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4sympj5h5tMyles Textbook for Midwives
SIXTEENTH EDITION
Jayne E Marshall PhD MA PGCEA ADM RM RGN
Head of School of Midwifery and Child Health, Faculty of Health, Social Care and Education,
St Georges, University of London/Kingston University, UK
Former Associate Professor in Midwifery, Director for Postgraduate Taught Studies in
Midwifery University of Nottingham, Academic Division of Midwifery, School of Health
Sciences, Faculty of Medicine and Health Sciences, Postgraduate Education Centre,
Nottingham, UK
Maureen D Raynor MA PGCEA ADM RMN RN
RM
Lecturer and Supervisor of Midwives, University of Nottingham, Academic Division of
Midwifery, School of Health Sciences, Faculty of Medicine and Health Sciences, Postgraduate
Education Centre, Nottingham, UK
Foreword by
Emeritus Professor Diane M Fraser
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2014
Table of Contents
Instructions for online access
Cover image
Title page
Copyright
Contributors
Foreword
Reference
Preface
Acknowledgements
Section 1 The midwife in context
Chapter 1 The midwife in contemporary midwifery practice
Internationalization/globalization
The emotional context of midwifery
The social context of pregnancy, childbirth and motherhood
Research
Evidence
Discussion
References
Further reading
Useful websites
Chapter 2 Professional issues concerning the midwife and midwifery practice
Statutory midwifery regulation
Self-regulation
Historical context
The nursing and midwifery council
Legal issues and the midwife
Ethical issues and the midwife
The statutory supervision of midwives
Clinical governance
References
Cases
Statutes, orders and directives
Further reading
Useful websites
Section 2 Human anatomy and reproduction
Chapter 3 The female pelvis and the reproductive organs
Female external genital organs
The perineum
The pelvic floor
The pudendal nerve
The pelvis
The female reproductive system
The male reproductive system
Further reading
Chapter 4 The female urinary tract
The kidneys
Urine
The ureters
The bladder
The urethra
Micturition
Changes to the urinary tract in pregnancy and childbirth
Conclusion
References
Further reading
Chapter 5 Hormonal cycles
Introduction
The ovarian cycle
The menstrual or endometrial cycle
Fertilization
Development of the zygote
References
Further reading
Chapter 6 The placenta
Early development
The placenta at term
Conclusion
References
Further reading
Chapter 7 The fetus
Time scale of development
Fetal growth and maturation
The fetal circulation
Adaptation to extrauterine life
The fetal skull
Conclusion
References
Further reading
Section 3 Pregnancy
Chapter 8 Antenatal education for birth and parenting
Parent education: the research and policy background
Antenatal education: the evidence
Leading antenatal sessions: aims and skills
Content of antenatal education in groups
Defining learning outcomes
Maximizing attendance at antenatal sessions
Conclusion
References
Further reading
Chapter 9 Change and adaptation in pregnancy
Physiological changes in the reproductive system
Changes in the cardiovascular system
Changes in the respiratory system
Changes in the central nervous system
Changes in the urinary system
Changes in the gastrointestinal system
Changes in metabolism
Maternal weight
Musculoskeletal changes
Skin changes
Changes in the endocrine system
Diagnosis of pregnancy
Common disorders arising from adaptations to pregnancy
References
Chapter 10 Antenatal care
The aim of antenatal care
The initial assessment (booking visit)
Physical examination
The midwife's examination
Ongoing antenatal care
References
Further reading
Useful websites
Chapter 11 Antenatal screening of the mother and fetus
Screening principles
How screening is set up and the midwife's role and responsibilities
Individual screening test considerations
Fetal screening tests
Screening for maternal conditions
Conclusion
References
Further reading
Useful websites
Chapter 12 Common problems associated with early and advanced pregnancy
The midwife's role
Abdominal pain in pregnancy
Bleeding before the 24th week of pregnancy
Other problems in early pregnancy
Bleeding after the 24th week of pregnancy
Hepatic disorders and jaundice
Skin disorders
Abnormalities of the amniotic fluid
Conclusion
References
Further reading
Useful websites
Chapter 13 Medical conditions of significance to midwifery practice
Hypertensive disorders
Metabolic disorders
Endocrine disorders
Cardiac disease
Respiratory disorders
Thromboembolic disease
Haematological disorders
Neurological disorders
Infection/sepsis
References
Further reading
Useful websites
Chapter 14 Multiple pregnancy
Incidence
Twin pregnancy
The pregnancy
Labour and the birth
Complications associated with multiple pregnancy
Postnatal period
Triplets and higher order births
Disability and bereavement
Multifetal pregnancy reduction (MFPR)
Selective feticide
Sources of help
References
Further reading
Useful websites and Contact Details
Section 4 Labour
Chapter 15 Care of the perineum, repair and female genital mutilation
Factors associated with reduced incidence of perineal trauma
Definition of perineal trauma
Episiotomy
Diagnosis of perineal trauma
Female genital mutilation/genital cutting/female circumcision
Repair of perineal trauma
Obstetric anal sphincter injuries (OASIS)
Postoperative care after OASIS
Follow-up
Medicolegal considerations
Training
References
Further reading
Useful websites
Chapter 16 Physiology and care during the first stage of labour
Defining labour
The onset of spontaneous physiological labour
Physiology of the first stage of labour
Recognition of the first stage of labour
Initial meeting with the midwife
Subsequent care in the first stage of labour
Assessing the wellbeing of the fetus
Women's control of pain during labour
First stage of labour: vaginal breech at term
Prelabour rupture of fetal membranes at term (PROM)
Preterm prelabour rupture of the membranes (PPROM)
The responsibilities of the midwife
References
Further reading
Useful websites
Chapter 17 Physiology and care during the transition and second stage phases of
labour
The nature of the transition and second stage phases of labour
Recognition of the commencement of the second stage of labour
Phases and duration of the second stage
Maternal response to transition and the second stage
The mechanism of normal labour (cephalic presentation)
Midwifery care in transition and the second stage
Vaginal breech birth at term
Record-keeping
Conclusion
References
Further reading
Useful websites
Chapter 18 Physiology and care during the third stage of labour
Physiological processes
Caring for a woman in the third stage of labour
Completion of the third stage
Complications of the third stage
Conclusion
References
Further reading
Useful website
Chapter 19 Prolonged pregnancy and disorders of uterine action
Prolonged pregnancy
Incidence
Plan of care for prolonged pregnancy
Induction of labour (IOL)
Failure to progress and prolonged labour
Obstructed labour
Precipitate labour
Making birth a positive experience
References
Further reading
Useful websites
Chapter 20 Malpositions of the occiput and malpresentations
Introduction
Occipitoposterior positions
Face presentation
Brow presentation
Shoulder presentation
Unstable lie
Compound presentation
References
Further reading
Chapter 21 Operative births
Assisting a vaginal birth
Indications for ventouse or forceps
Contraindications to an instrumental vaginal birth
Prerequisites for any operative vaginal birth
Birth by ventouse
Birth by forceps
Caesarean section
Acknowledgement
References
Further reading
Useful websites
Chapter 22 Midwifery and obstetric emergencies
Introduction
Communication
Vasa praevia
Presentation and prolapse of the umbilical cord
Shoulder dystocia
Rupture of the uterus
Amniotic fluid embolism
Acute inversion of the uterus
Basic life support measures
Shock
Drug toxicity/overdose
References
Further reading
Useful websites
Section 5 Puerperium
Chapter 23 Physiology and care during the puerperium
The postnatal period
Historical background
Framework and regulation for postnatal care
Midwives and postpartum care
Physiological changes and observations
Transition to parenthood
References
Further reading
Useful websites
Chapter 24 Physical health problems and complications in the puerperium
The need for women-focused and family-centred postpartum care
Potentially life-threatening conditions and morbidity after the birth
Immediate untoward events for the mother following the birth of the baby
Postpartum complications and identifying deviations from the normal
Practical skills for postpartum midwifery care after an operative birth
Emotional wellbeing: psychological deviation from normal
Self-care and recovery
Talking and listening after childbirth
References
Further reading
Useful websites
Chapter 25 Perinatal mental health
Part A: Pregnancy, childbirth, puerperium: the psychological context
Part B: Perinatal psychiatric conditions
References
Further reading
Useful websites
Chapter 26 Bereavement and loss in maternity care
Introduction
Grief and loss
Forms of loss
Loss in healthy childbearing
Care
The death of a mother
Conclusion
References
Further Reading
Useful Websites
Chapter 27 Contraception and sexual health in a global society
The role of the midwife
Hormonal contraceptive methods
Long acting reversible contraception (LARC)
Barrier methods of contraception (male and female methods)
Emergency contraception
Coitus interruptus
Fertility awareness (natural family planning)
Male and female sterilization
The future of contraception and sexual health services
Ongoing developments
References
Further reading
Useful websites/contacts
Section 6 The neonate
Chapter 28 Recognizing the healthy baby at term through examination of the newborn
screening
The first examination after birth
The daily examination screen
The neonatal and infant physical examination (NIPE)
References
Further reading
Useful websites
Chapter 29 Resuscitation of the healthy baby at birth
Drying the baby
Airway management and breathing
Difficulties in establishing an open airway
Parental support through effective communication
References
Further reading
Chapter 30 The healthy low birth weight baby
Classification of babies by gestation and weight
Small for gestational age (SGA)
The preterm baby
Care of the healthy LBW baby
Optimizing the care environment for the healthy LBW baby
References
Further reading
Useful websites
Chapter 31 Trauma during birth, haemorrhages and convulsions
Trauma during birth
Haemorrhages
Convulsions
Support of parents
References
Further reading
Useful websites
Chapter 32 Congenital malformations
Communicating the news
Palliative care
Definition and causes
Chromosomal abnormalities
Gastrointestinal malformations
Malformations relating to respiration
Congenital cardiac defects
Central nervous system malformations
Musculoskeletal deformities
Abnormalities of the skin
Genitourinary system
Disorders of sex development (DSD)
Teratogenic causes
Support for the midwife
References
Further reading
Useful websites
Chapter 33 Significant problems in the newborn baby
Introduction
Initial examination and recognition of problems
Recognition of problems at the time of resuscitation, including neonatal encephalopathy
Infection in the newborn
Respiratory problems
Congenital heart disease (CHD)
Jaundice
Haematological problems
Metabolic problems
Electrolyte imbalances in the newborn
Inborn errors of metabolism in the newborn
Endocrine problems
Effects on the newborn of maternal drug abuse/use during pregnancy
References
Further reading
Websites
Chapter 34 Infant feeding
Introduction
The breast and breastmilk
Management of breastfeeding
Choosing breast or formula milk
Feeding with formula milk
The baby friendly hospital initiative
References
Further reading
Useful websites and contact details
Glossary of terms and acronyms
Index
Copyright
© 2014 Elsevier Ltd. All rights reserved.
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This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
First edition 1953 Ninth edition 1981
Second edition 1956 Tenth edition 1985
Third edition 1958 Eleventh edition 1989
Fourth edition 1961 Twelfth edition 1993
Fifth edition 1964 Thirteenth edition 1999
Sixth edition 1968 Fourteenth edition 2003
Seventh edition 1971 Fifteenth edition 2009
Eighth edition 1975 Sixteenth edition 2014
ISBN 9780702051456
International ISBN 9780702051463
2 British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
3 Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notices
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds,
or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to
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practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment
for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage
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Printed in China
Contributors
Jenny Bailey BN MedSci/ClinEd DANS RM RGN
Midwife Teacher, University of Nottingham, Faculty of Medicine and Health Sciences, School of Health Sciences,
Academic Division of Midwifery, Nottingham, UK
Chapter 5 Hormonal cycles: fertilization and early development
Chapter 6 The placenta
Chapter 7 The fetus
Helen Baston BA(Hons) MMEdSci PhD ADM RN RM
Consultant Midwife, Public Health, Supervisor of Midwives, Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
Chapter 10 Antenatal care
Cecily Begley MSc MA PhD RGN RM RNT FFNRCSI FTCD
Professor of Nursing and Midwifery, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
Chapter 18 Physiology and care during the third stage of labour
Jenny Brewster MEd(Open) BSc(Hons) PGCert RM RN
Senior Lecturer in Midwifery, College of Nursing, Midwifery and Health Care, University of West London, Brentford,
UK
Chapter 12 Common problems associated with early and advanced pregnancy
Susan Brydon BSc(Hons) MSc PGDip(Mid) DipApSsc, CertHP RN RM
Supervisor of Midwives, Nottingham University Hospitals NHS Trust, Nottingham, UK
Chapter 16 Physiology and care during the first stage of labour
Kinsi Clarke
Advocacy Worker, Nottingham, UK
Chapter 15 Care of the perineum, repair and female genital mutilation
Terri Coates MSc ADM DipEd RN RM
Freelance Lecturer and Writer; Clinical Midwife, Salisbury NHS Trust, Salisbury, UK
Chapter 20 Malpositions of the occiput and malpresentations
Chapter 22 Midwifery and obstetric emergencies
Helen Crafter MSc ADM PGCEA FPCert RGN RM
Senior Lecturer in Midwifery/Course Leader, College of Nursing, Midwifery and Health Care, University of West
London, Brentford, UK
Chapter 12 Common problems associated with early and advanced pregnancy
Margie Davies RGN RM
Midwifery Advisor, Multiple Births Foundation, Queen Charlotte's and Chelsea Hospital, London, UK
Chapter 14 Multiple pregnancy
Rowena Doughty PGDE BA(Hons) MSc ADM RM RN
Senior Lecturer – Midwifery, School of Nursing and Midwifery, De Montfort University, Leicester, UK
Chapter 13 Medical conditions of significance to midwifery practice
Soo Downe BA(Hons) MSc PhD RM
University of Central Lancashire, School of Health, Research in Childbirth and Health (ReaCH group), Preston,
Lancashire, UK
Chapter 17 Physiology and care during the transition and second stage phases of labour
Carole England BSc(Hons) ENB405 CertEd(FE) RGN RM
Midwife Teacher, Academic Division of Midwifery, School of Health Sciences, University of Nottingham, Derby, UK
Chapter 28 Recognizing the healthy baby at term through examination of the newborn screening
Chapter 29 Resuscitation of the healthy baby at birth: the importance of drying, airway management and
establishment of breathing
Chapter 30 The healthy low birth weight baby
Chapter 33 Significant problems in the newborn baby
Angie Godfrey BSc(Hons) RM RN
Midwife/Antenatal and NewbornScreening Coordinator, Nottingham University Hospitals NHS Trust, Nottingham,
UK
Chapter 11 Antenatal screening of the mother and fetus
Claire Greig ADM MTD Neonatal Certificate BN MSc PhD RGN SCM
Senior Lecturer (retired), Lecturer (part time), Edinburgh Napier University, Edinburgh, UK
Chapter 31 Trauma during birth, haemorrhages and convulsions
Jenny Hassall BSc(Hons) MSc MPhil RN RM
School of Nursing and Midwifery, University of Brighton, Eastbourne, UK
Chapter 9 Change and adaptation in pregnancy
Richard Hayman BSc MB BS DFFP DM FRCOG
Consultant Obstetrician and Gynaecologist, Gloucestershire Hospitals NHS Trust, Gloucester, UK
Chapter 21 Operative births
Sally Inch RN RM
Honorary Research Fellow, Applied Research Centre Health and Lifestyles Interventions, Coventry University,
Coventry, UK
Chapter 34 Infant feeding
Karen Jackson BSc (Hons) MPhil ADM RN RM
Midwife Lecturer, University of Nottingham, Faculty of Medicine and Health Sciences, School of Health Sciences,
Academic Division of Midwifery, University of Nottingham, UK
Chapter 16 Physiology and care during the first stage of labour
Chapter 27 Contraception and sexual health in a global society
Lucy Kean BM BCh MD FRCOG
Consultant Obstetrician, Subspecialist in Fetal Medicine, Nottingham University Hospitals NHS Trust, Nottingham,
UK
Chapter 11 Antenatal screening of the mother and fetus
Rosemary Mander MSc PhD MTD RGN SCM
Emeritus Professor of Midwifery, School of Health in Social Science, University of Edinburgh, Edinburgh, UK
Chapter 1 The midwife in contemporary midwifery practice
Chapter 26 Bereavement and loss in maternity care
Jayne E Marshall PhD MA PGCEA ADM RM RGN
Head of School of Midwifery and Child Health, Faculty of Health, Social Care and Education, St Georges, University
of London/Kingston University, UK
Chapter 1 The midwife in contemporary midwifery practice
Chapter 2 Professional issues concerning the midwife and midwifery practice
Chapter 13 Medical conditions of significance to midwifery practice
Chapter 16 Physiology and care during the first stage of labour
Chapter 17 Physiology and care during the transition and second stage phases of labour
Carol McCormick BSc(Hons) PGDL ADM RN RM
Specialist Midwife (FGM), Nottingham University Hospitals NHS Trust (City Campus), Hucknall Road, Nottingham,
UK
Chapter 15 Care of the perineum, repair and female genital mutilation
Moira McLean RGN RM ADM PGCEA PGDIP SOM
Senior Lecturer – Midwifery and Supervisor of Midwives, School of Nursing and Midwifery, De Montfort University,
Leicester, UK
Chapter 13 Medical conditions of significance to midwifery practice
Irene Murray BSc(Hons) MTD RN RM
Teaching Fellow (Midwifery), Department of Nursing and Midwifery, University of Stirling, Centre for Health
Science, Inverness, UK
Chapter 9 Change and adaptation in pregnancy
Mary Louise Nolan BA(Hons) MA PhD RGN
Professor of Perinatal Education, Institute of Health and Society, University of Worcester, Worcester, UK
Chapter 8 Antenatal education for birth and parenting
Margaret R Oates OBE MB ChB FRCPsych FRCOG
Consultant Perinatal Psychiatrist and Clinical Lead, Strategic Clinical Network for Mental Health, Dementia and
Neurological Conditions, NHS England, Nottingham, UK
Chapter 25 Perinatal mental health
Kathleen O'Reilly MB ChB MA MRCPCH
Consultant Neonatologist, Neonatal Intensive Care Unit, Royal Hospital for Sick Children, Glasgow, UK
Chapter 32 Congenital malformations
Jean Rankin BSc(Hons) MSc PhD PGCert LTHE RN RSCN RM
Senior Lecturer in Research (Maternal, Child and Family Health)/Supervisor of Midwives, University of the West of
Scotland, Paisley, UK
Chapter 4 The female urinary tract
Maureen D Raynor MA PGCEA ADM RMN RN RM
Lecturer and Supervisor of Midwives, Academic Division of Midwifery, School of Health Sciences, Faculty of
Medicine and Health Sciences, University of Nottingham, Nottingham, UK
Chapter 1 The midwife in contemporary midwifery practice
Chapter 2 Professional issues concerning the midwife and midwifery practice
Chapter 15 Care of the perineum, repair and genital mutilation
Chapter 25 Perinatal mental health
Annie Rimmer BEd(Hons) ADM RM RN
Senior Lecturer – Midwifery, School of Nursing and Midwifery, University of Brighton, Eastbourne, UK
Chapter 19 Prolonged pregnancy and disorders of uterine action
S. Elizabeth Robson MSc ADM Cert(A)Ed MTD RGN RM FHEA
Principal Lecturer – Midwifery, School of Nursing and Midwifery, De Montfort University, Leicester, UK
Chapter 13 Medical conditions of significance to midwifery practice
Judith Simpson MB ChB MD MRCPCH
Consultant Neonatologist, Neonatal Intensive Care Unit, Royal Hospital for Sick Children, Glasgow, UK
Chapter 32 Congenital malformations
Mary Steen BSc PhD MCGI PGDipHE PGCRM RM RGN
Professional Editor, RCM Journal, Professor of Midwifery, University of Chester, Chester, UK, Adjunct Professor of
Midwifery, University of South Australia (UniSA), Adelaide, Australia
Chapter 23 Physiology and care during the puerperium
Chapter 24 Physical health problems and complications in the puerperium
Amanda Sullivan BA(Hons) PGDip PhD RM RGN
Director of Quality and Governance for NHS Nottinghamshire County, NHS Nottinghamshire County, Mansfield,
Nottinghamshire, UK
Chapter 11 Antenatal screening of the mother and fetus
Abdul H Sultan MD FRCOG
Consultant Obstetrician and Gynaecologist, Croydon University Hospital, Croydon, UK
Chapter 3 The female pelvis and the reproductive organs
Chapter 15 Care of the perineum, repair and female genital mutilation
Ranee Thakar MD MRCOG
Consultant Obstetrician and Urogynaecologist, Department of Obstetrics and Gynaecology, Croydon University
Hospital, Croydon, UK
Chapter 3 The female pelvis and the reproductive organs
Chapter 15 Care of the perineum, repair and female genital mutilation
Mary Vance MPhil PGCert TLT BSc(Hons) RM RGN
LSA Midwifery Officer, North of Scotland LSA Consortium, Inverness, UK
Chapter 2 Professional issues concerning the midwife and midwifery practice
Stephen P Wardle MB ChB MD FRCPCH
Consultant Neonatologist, Neonatal Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham,
UK
Chapter 33 Significant problems in the newborn baby
Julie Wray ONC MSc PhD PGCHE ADM RM RN
Joint Editor, The Practising Midwife Journal; Senior Lecturer, User and Carer Lead, School of Nursing, Midwifery and
Social Work, University of Salford, Salford, UK
Chapter 23 Physiology and care during the puerperium
Chapter 24 Physical health problems and complications in the puerperium
Foreword
The strength and longevity of Myles Textbook for Midwives lies in its ability to juxtapose
continuity and change from the first edition in 1953 to this sixteenth edition, over 60
years later. I n continuity, some of the excellent early illustrations have been replicated
throughout the editions. These provide clarity of understanding of essential anatomy
for students. Changes of and additional colours in this edition have made a dramatic
improvement to this clarity. I n addition the clearly set out sections, chapter titles and
index, aid systematic learning as well as facilitating easy reference when a new
situation is encountered in practice. Of equal importance is how this text demonstrates
the changes that have taken place in midwifery practice.
Unlike the early editions, when midwives relied on one textbook and teachers alone,
this sixteenth edition draws together theory, current practices, research and best
evidence. I n contrast to the first edition where Myles, in the Preface,wrote:‘No
bibliographical references have been given because of the vast number of sources which have
been tapped in compiling the text (by Margaret Myles herself)and because pupil midwives
become confused when they study from more than one or two textbooks’, this edition
signposts students to further resources to increase their depth and breadth of
knowledge. This is essential as no textbook can capture all the information needed for
contemporary midwifery practice.
I n all editions the needs of women and their families have been central and this
edition continues to emphasize the emotional, socio-economic, educational and
physical needs of women during the life changing experience of pregnancy and
parenthood, or bereavement. These events have a lasting impact on women's lives. O f
importance is always how well women are listened to and involved in making
decisions about their or their babies' care. Running through this edition is an
emphasis on the need for midwives to be emotionally aware and develop good
communication and interpersonal relationships with women, their partners and
colleagues in the interdisciplinary team. The midwife has a key role to play in assisting
women to make choices and feel in control, even when presented with difficult options
and dilemmas. This text demonstrates the midwife's role as lead professional when
pregnancy is straightforward and co-ordinator of care when others need to be
involved.
The maternity services have seen major changes in recent years, in particular the
massive increase in the birth rate, the changing demographics of women who become
pregnant and the politics surrounding childbirth. S ection O ne effectively brings
together the issues that midwives need to understand, not just during their education
programme, but also as part of their future responsibility in helping to bring about
improvements in maternity care both in the UK and internationally. The vision for UK
midwifery set out in Midwifery 2020 (Midwifery 2020 UK Programme, 2010) and the
global initiatives of the International Confederation of Midwives are well summarized.
W hilst Margaret Myles in her first 10 editions drew upon the knowledge of
obstetricians and paediatricians in England and S cotland, she wrote the entire book
herself. Recent edited editions demonstrate the need to draw upon the expertise of
other midwives and health professionals in chapter writing. Thakar's and S ultan's
inclusion of diagrams and photographs of perineal anatomy and trauma in chapter
three are very timely given the increasing number of students who now learn to
suture. These will help understanding of the importance of accurate diagnosis and
effective perineal repair to aid women's physical and emotional recovery.
The value of antenatal education has been emphasized since the inception of this
textbook, yet today not all women or their partners a end. Mary N olan stresses the
importance of sessions to be women-centred and expertly facilitated, not lecture
based. S he reminds readers that many women are not being provided with sufficient
opportunity to a end, yet classes can make a big difference to women's experiences of
birth and parenting. I n addition she draws a ention to the value they have in giving
women social networks. This has been evident in my daughter's experience of classes
in Germany. W hilst she was critical of some of the content of the classes, she and four
other women who birthed one to 10 days apart, have supported each other in
parenting. Two years on they remain good friends.
Chapter 13 skilfully draws together the most significant medical conditions a
midwife is likely to encounter in her practice. Much a ention is given to obesity. The
authors qualify that although obesity is not in itself a disease it is considered
abnormal in western cultures and is now a key health concern affecting society. They
discuss the additional risks to pregnant women who are obese and the association of
obesity with poor socioeconomic status. Midwives have a key role in educating these
women and their families to develop healthier life styles, but the women will only be
receptive if they do not experience judgemental attitudes.
Myles advice to midwives in the 1960s that, ‘nature is capable of performing her function
without aid in most instances; meddlesome midwifery increases the hazards of birth’, is still
as relevant today. I n this edition, given all the technological advances in the maternity
services, S ection 4 on labour begins by reminding students that: ‘birth is a physiological
process characterized by non-intervention, a supportive environment and empowerment of the
woman’. However, an appropriate reflection of multi-cultural changes in UK society is
the inclusion of female genital mutilation in chapter 15. W hilst many students will not
be involved in the care of women who have undergone such a procedure, it is essential
that all midwives understand the mutilation some young women have undergone and
the special care they will need in childbirth. The inclusion of Kinsi's poignant and
brave story of her own experiences should help midwives develop the empathy they
will need when caring for women who have been subject to similar mutilation.
Perinatal mental health has figured since the early days of the textbook but only in
recent editions have students been provided with the necessary information to
understand the complexity of the psychology of childbearing and psychiatric
disorders. A useful inclusion in this edition is tocophobia, fear of giving birth.
S tudents need to take this fear seriously in supporting women and they cannot afford
to trivialize these very real phobias.
A s ever this textbook includes a comprehensive section on the newborn baby, often
neglected in other general texts for midwives. This is so important when parents turn
to midwives for advice and reassurance or explanations. With many midwifery
curricula including a module on the specialist education for the N ewborn and I nfant
Physical Examination, chapter 28 clearly differentiates between the midwife's and the
doctor's responsibilities when undertaking this examination. The publishers have
brought about major improvements also, through locating the colour photographs in
these newborn baby chapters close to where they are described in the text rather than
as a separate colour plate section.
Midwifery is the best career you can have. I t is a privilege to work with women and
their families as they experience pregnancy, birth and parenting. The knowledge, skills
and a itudes that students need to be competent midwives and professional friends
to women have been skilfully interwoven in this sixteenth edition. The chapter authors
and editors have summarized where appropriate, elaborated when needed, referenced
liberally and used illustrations effectively to enhance understanding. Given the
infinite depth and breadth of information available in wri en and electronic forms,
they have succeeded in producing a textbook that remains invaluable for the next
generation of midwives.
Diane M Fraser Bed MPhil PhD MTD RM RGN Emeritus Professor of Midwifery University of Nottingham
Reference
Midwifery 2020 UK Programme. Midwifery 2020: Delivering expectations.
Midwifery 2020 UK Programme: Edinburgh; 2010.
Preface
I t is a great privilege to have been approached by Elsevier to undertake the editorship
of the sixteenth edition of M yles Textbook for M idwives. I t is over 60 years since the
S co ish midwife Margaret Myles wrote the first edition and this book remains highly
regarded as the seminal text for student midwives and practising midwives alike
throughout the world. O ver the ensuing decades, many changes have taken place in
the education and training of future midwives alongside increasing demands and
complexities associated with the health and wellbeing of childbearing women, their
babies and families within a global context. Furthermore, the development of
evidence-based practice and advances in technology have also contributed to major
reviews of how undergraduate midwifery curricula are delivered to ensure that today's
graduate midwives are able to rise to the many challenges of the midwife's multi-
faceted role: being fit for both practice and purpose. I t is with these issues in mind that
the sixteenth edition of Myles has been developed as, without a doubt, women expect
midwives to provide safe and competent care that is tailored to their individual needs,
with a professional and compassionate attitude.
The content and format of this edition of Myles has been developed in response to
the collated views from students and midwives regarding the fifteenth edition.
Midwifery practice clearly should always be informed by the best possible up-to-date
evidence and, whilst it is acknowledged that it is impossible to expect any new text to
contain the most contemporary of research and systematic reviews, this edition
provides the reader with annotated further reading and appropriate websites in
addition to comprehensive reference lists.
There has been a major revision of chapters, which have been streamlined and
structured into reflect similar themes and content. Throughout its history, Myles
Textbook for M idwives has always included clear and comprehensible illustrations to
compliment the text. I n this sixteenth edition, full colour has been used throughout
the book, and new diagrams have been added where appropriate.
I t is pleasing that a number of chapter authors have continued their contribution to
successive editions of this pivotal text and we also welcome the invaluable
contributions from new authors. W hilst it is vital to retain the ethos of the text being a
textbook for midwives that is wri en by midwives with the appropriate expertise, it is also
imperative that it reflects the eclectic nature of maternity care and thus, some of the
chapters have been wri en in collaboration with members of the multi-professional
team. This clearly demonstrates the importance of health professionals working and
learning together in order to enhance the quality of care women and their families
receive, especially when complications develop in the physiological process
throughout the childbirth continuum. The presence of the midwife is integral to all
clinical situations and the role is significant in ensuring the woman always receives the
additional care required from the most-appropriate health professional at the most-
appropriate time.
A significant change has been to the first section of the text where content from the
final section has been included. From an international perspective, we believe that
issues such as the globalization of midwifery education and practice, best depicted by
the Millennium D evelopment Goals, professional regulation and midwifery
supervision, legal and ethical issues as well as risk management and clinical
governance are fundamental to every midwife practising in the twenty-first century
and should therefore be given more prominence. We acknowledge that medicalization
and the consequential effect of a risk culture in the maternity services have eroded
some aspects of the midwife's role over time. I t is our aim to challenge midwives into
thinking outside the box and to have the confidence to empower women into making
choices appropriate for them and their personal situation. A n example is the decision
to incorporate breech presentation and vaginal breech birth at term into the first and
second stage of labour chapters rather than within the malpresentations chapter.
Recognizing that midwives increasingly care for women with complex health needs
within a multicultural society and taking on specialist or extended roles, significant
topics have been added to make the text more contemporary. Chapter 13 incorporates
the dilemmas faced by midwives when caring for women who have a raised body mass
index and chapter 15 is a new chapter that addresses how care of the perineum can be
optimized alongside the physiological and psychosocial challenges when women
present with some degree of female genital mutilation. Furthermore, as an increasing
number of midwives are undertaking further training to carry out the neonatal
physiological examination and neonatal life support, specific details have been
included in chapter 28 and a new chapter 29 dedicated to basic neonatal resuscitation
respectively, to provide a foundation for students to build upon.
A dditional online multiple-choice questions have been updated and revised to
reflect the focus of the chapters in this edition, as readers appreciate their use in
aiding self-assessment of learning.
We hope that this new edition of M yles Textbook for M idwives will provide midwives
with the foundation of the physiological theory and underpinning care principles to
inform their clinical practice and support appropriate decision-making in partnership
with childbearing women and members of the multi-professional team. We recognize
that knowledge is boundless and that this text alone cannot provide everything
midwives should know when undertaking their multi-faceted roles, however, it can
afford the means to stimulate further enquiry and enthusiasm for continuing
professional development.
London and Nottingham, 2014
Jayne E Marshall
Maureen D Raynor
Acknowledgements
The editors of the sixteenth edition are indebted to the many authors of earlier
editions whose work has provided the foundations from which this current volume
has evolved. From the fifteenth edition, these contributors include the volume editors,
Diane M Fraser and Margaret A Cooper, and chapter authors:
Robina Aslam
Jean E Bain
Diane Barrowclough
Kuldip Kaur Bharj OBE
Susan Dapaah
Victor E Dapaah
Jean Duerden
Philomena Farrell
Alison Gibbs
Adela Hamilton
Pauline Hudson
Billie Hunter
Beverley Kirk
Judith Lee
Carmel Lloyd
Sally Marchant
Christine McCourt
Sue McDonald
Christina McKenzie
Alison Miller
Salmon Omokanye
Lesley Page
Patricia Percival
Lindsay Reid
Nancy Riddick-Thomas
Jane M Rutherford
Iolanda G J Serci
Della Sherratt
Norma Sittlington
Nina Smith
Ian M Symonds
Ros Thomas
Denise Tiran
Tom Turner
Anne Viccars
W hilst the support and guidance from the production team at Elsevier has been
invaluable in the culmination of an exciting and much improved illustrated text, the
editors must also acknowledge the support of family, friends and colleagues in
enabling them to accomplish the task amidst their full-time academic roles.
S E CT I ON 1
The midwife in context
OU T LIN E
Chapter 1 The midwife in contemporary midwifery practice
Chapter 2 Professional issues concerning the midwife and midwifery practice
C H AP T E R 1
The midwife in contemporary midwifery
practice
Maureen D Raynor, Rosemary Mander, Jayne E Marshall
CHAPTER CONTENTS
Internationalization/globalization 4
Definition and scope of the midwife 4
The ICM Global Midwifery Education Standards 4
The ERASMUS Programme 8
The Millennium Development Goals (MDGs) 8
The emotional context of midwifery 8
What is ‘emotion work’? 9
Sources of emotion work in midwifery practice 9
Managing emotions in midwifery 11
Challenges 12
Developing emotional awareness 12
The social context of pregnancy, childbirth and motherhood 13
Disadvantaged groups 13
Women from disadvantaged groups 14
Midwives meeting the needs of women from disadvantaged groups 17
Research 18
Evidence 18
The stated rationale for evidence-based practice (EBP) 18
The randomized controlled trial (RCT) 18
Discussion 19
References 20
Further reading 23
Useful websites 23
In the United Kingdom (UK) midwives are encouraged to broaden their
toolkit of skills and knowledge in an effort to strengthen their public health
remit and leadership potential in order to work collaboratively with women
as equal partners in their care. Midwifery 2020 (Department of Health [DH]
2010a) outlines the future vision for midwifery. This initiative is a unique UK-
wide collaborative programme where the four countries of Great Britain
share a common purpose and ideology that can benchmark their midwifery
planning and provision. It is envisaged that each country will be able to
identify their own priorities to deliver care that is woman-centred, safe and
fulfilling within existing resources. There are parallels here to be drawn with
wider global initiatives such as the United Nations [UN] (2010, 2013)
Millennium Development Goals (MDGs) and the International Confederation
of Midwives (ICM 2011) international definition of the midwife.
The chapter aims to:
• explore the midwife in context, taking a number of influential social and global issues
into consideration; the key factors are –
• globalization and internationalization with due consideration of the Millennium
Development Goals, the European (EU) Directives and International Confederation of
Midwives Education Standards
• the emotional context of midwifery
• working with women from socially disadvantaged groups
• evidence-based practice.
Internationalization/globalization
Globalization and internationalization against the background of midwifery practice
are difficult terms to define, compounded by the fact that the terms are often used
interchangeably and synonymously, even though they are construed as distinctly
separate entities. Globalization is not a new phenomenon (Baumann and Blythe 2008)
with a number of varying definitions evident in the literature. The definition with the
greatest resonance for midwives is that provided by the W orld Health O rganization
(2013), who states that globalization is:
the increased interconnectedness and interdependence of people and countries, is
generally understood to include two interrelated elements: the opening of borders
to increasingly fast flows of goods, services, finance, people and ideas across
international borders; and the changes in institutional and policy regimes at the
international and national levels that facilitates or promote such flows.
Globalization is not without its critics but it is acknowledged that the consequences
of globalization are not predetermined and can have both positive and negative
outcomes (Baumann and Blythe 2008). I t is essential therefore to have an awareness of
both the good and harm globalization may impose on a society.
C onversely, internationalization has no agreed definition but from a midwifery
perspective it can be defined as the international process of planning and
implementing midwifery education and services in order that there is a shared vision
that can easily be translated or adapted to meet the local and national needs of
individual nations in both resource-rich and resource-poor countries.
I nternationalization is important for the midwifery profession because in a global
society midwives are required to have a broad understanding of cross-cultural issues.
They need to be flexible and adaptable in order to provide care that is sensitive and
responsive to women's dynamic healthcare needs. This requires the midwife to be an
effective change agent, and the onus is very much on the midwife to keep pace with
change. This means having a good comprehension of internationalization, learning to
deal with uncertainty, embracing the ethos of life-long learning as well as the gains
and challenges of interprofessional or multidisciplinary collaboration, contributing to
quality assurance issues such as audit, research, risk assessment and the wider clinical
governance agenda. Even though skills of problem-solving, clinical judgement,
decision-making and clinical competence in the practical assessment, planning,
implementation, evaluation and documentation of care are all crucial for midwifery
practice, human factors also ma er. I n England, the Francis Report (M id S taffordshire
N HS Foundation Trust Public I nquiry 2013 ) was the outcome of a public inquiry into
failings at Mid S taffordshire and relevant regulatory bodies. I t represents a watershed
moment in the history of the UK N ational Health S ervice (N HS ). The scale of th
problems highlighted by the report relates to the unusually high death rates amongst
the sick and vulnerable at Mid S taffordshire in the late 2000s. The key lessons learnt
convey the importance of transparent, compassionate, commi ed, competent and
confident caring premised on strong leadership. I t can be argued therefore that
common standards and a shared vision established through global initiatives such as
the MD Gs and the I CM definition of a midwife are essential for midwives working
within a global community. N ot least because there is a strong correlation between
outcomes for mothers and babies and the specific professional competencies the
midwife possesses.
Definition and scope of the midwife
Midwives should be informed about the legal framework in which their role and scope
of practice are enshrined. A definition of the midwife was developed by the I CM in
1972, which was later adopted by the I nternational Federation of Gynaecology and
O bstetrics (FI GO ) followed by the W orld Health O rganization (W HO ). I n 1990, at th
Kobe Council meeting, the I CM amended the definition, later ratified in 1991 and 1992
by FI GO and W HO respectively. I n 2005 and 2011 it was amended slightly by the I CM
Council (Box 1.1).
Box 1.1
A n I nt e rna t iona l de finit ion of t he m idwife
A midwife is a person who has successfully completed a midwifery
education programme that is duly recognized in the country where it is
located and that is based on the I CM Essential Competencies for Basic
Midwifery Practice and the framework of the I CM Global S tandards for
Midwifery Education; who has acquired the requisite qualifications to be
registered and/or legally licensed to practice midwifery and use the title
‘midwife’; and who demonstrates competency in the practice of midwifery.
Scope of practice
The midwife is recognized as a responsible and accountable professional
who works in partnership with women to give the necessary support, care
and advice during pregnancy, labour and the postpartum period, to
conduct births on the midwife's own responsibility and to provide care for
the newborn and the infant. This care includes preventative measures, the
promotion of normal birth, the detection of complications in mother and
child, the accessing of medical care or other appropriate assistance and the
carrying out of emergency measures. The midwife has an important task in
health counselling and education, not only for the woman, but also within
the family and the community. This work should involve antenatal
education and preparation for parenthood and may extend to women's
health, sexual or reproductive health and child care. A midwife may
practice in any se ing including the home, community, hospitals, clinics or
health units.
Revised and adopted by ICM Council 15 June 2011; due for review 2017
www.internationalmidwives.org
At the European level, member states of the EU (known at the time as the European
Community [EC]) prepared a list of activities (B ox 1.2) that midwives should be
entitled to take up within its territory (EC Midwives D irective 1980; W HO 2009).
A lthough midwives must learn about all of these activities, in the UK, where there is
skilled medical care available to all pregnant women, it is recognized that it is highly
unlikely that midwives would be expected to be proficient in all the activities
identified by the EU. The manual removal of the placenta, for example, would
routinely be carried out by a doctor unless no doctor is available and the mother's life
is at risk.
Box 1.2
E urope a n U nion S t a nda rds for N ursing a nd
M idwife ry
Article 42 – Pursuit of the professional activities of a midwife
The provisions of this section shall apply to the activities of midwives as
defined by each Member S tate, without prejudice to paragraph 2, and
pursued under the professional titles set out in Annex V, point 5.5.2.
The Member S tates shall ensure that midwives are able to gain access to
and pursue at least the following activities:
(a) provision of sound family planning information and advice;
(b) diagnosis of pregnancies and monitoring normal pregnancies; carrying
out the examinations necessary for the monitoring of the development of
normal pregnancies;
(c) prescribing or advising on the examinations necessary for the earliest
possible diagnosis of pregnancies at risk;
(d) provision of programmes of parenthood preparation and complete
preparation for childbirth including advice on hygiene and nutrition;
(e) caring for and assisting the mother during labour and monitoring the
condition of the fetus in utero by the appropriate clinical and technical
means;
(f) conducting spontaneous deliveries including where required
episiotomies and in urgent cases breech deliveries;
(g) recognizing the warning signs of abnormality in the mother or infant
which necessitate referral to a doctor and assisting the latter where
appropriate; taking the necessary emergency measures in the doctor's
absence, in particular the manual removal of the placenta, possibly
followed by manual examination of the uterus;
(h) examining and caring for the newborn infant; taking all initiatives which
are necessary in case of need and carrying out where necessary immediate
resuscitation;
(i) caring for and monitoring the progress of the mother in the postnatal
period and giving all necessary advice to the mother on infant care to
enable her to ensure the optimum progress of the new-born infant;
(j) carrying out treatment prescribed by doctors;
(k) drawing up the necessary written reports.
Source: WHO (World Health Organization) 2009 European Union Standards for Nursing and
Midwifery: information for accession countries, 2nd edn.
www.euro.who.int/__data/assets/pdf_file/0005/102200/E92852.pdf
The ICM Global Midwifery Education Standards
The I CM acknowledges that all midwifery programmes should be accountable to the
public, mothers and their families, the profession, employers, students as well as one
another. I t is therefore the responsibility of the provider education institution to
ensure that the undergraduate or preregistration curricula they provide have a stated
philosophy, transparent, realistic, achievable goals and outcomes that prepare
students to be fully qualified competent and autonomous midwives. The Global
S tandards for Midwifery Education 2010 as developed, outlined and amended by the
I CM (2013) are deemed as the mainstays to strengthen midwifery education and
practice. These standards, outlined in Box 1.3, were developed alongside two further
documents: Companion Guidelines and Glossary, which are all available on the I CM
website. I n order to meet the needs of childbearing women and their families, the ICM
(2013) highlights that these publications are ‘living’ documents subjected to continual
scrutiny, evaluation and amendment as new evidence regarding midwifery education
and practice unfolds. Therefore it is recommended by the I CM (2013) that all three
documents should be reviewed together in the following order: the Glossary followed
by the Global Standards for Education and concluding with the Companion Guidelines.
Box 1.3
G loba l S t a nda rds for M idwife ry E duca t ion 2 0 1 0
I Organization and administration
1. The host institution/agency/branch of government supports the
philosophy, aims and objectives of the midwifery education
programme.
2. The host institution helps to ensure that financial and public/policy
support for the midwifery education programme are sufficient to
prepare competent midwives.
3. The midwifery school/programme has a designated budget and budget
control that meets programme needs.
4. The midwifery faculty is self-governing and responsible for developing
and leading the policies and curriculum of the midwifery education
programme.
5. The head of the midwifery programme is a qualified midwife teacher
with experience in management/administration.
6. The midwifery programme takes into account national and
international policies and standards to meet maternity workforce
needs.
II Midwifery faculty
1. The midwifery faculty includes predominantly midwives (teachers and
clinical preceptors/clinical teachers) who work with experts from other
disciplines as needed.
2. The midwife teacher
a. has formal preparation in midwifery;
b. demonstrates competency in midwifery practice, generally
accomplished with 2 years full scope practice;
c. holds a current licence/registration or other form of legal recognition to
practise midwifery;
d. has formal preparation for teaching, or undertakes such preparation as
a condition of continuing to hold the position; and
e. maintains competence in midwifery practice and education.
3. The midwife clinical preceptor/clinical teacher
a. is qualified according to the ICM definition of a midwife;
b. demonstrates competency in midwifery practice, generally
accomplished with 2 years full scope practice;
c. maintains competency in midwifery practice and clinical education;
d. holds a current licence/registration or other form of legal recognition to
practice midwifery; and
e. has formal preparation for clinical teaching or undertakes such
preparation.
4. Individuals from other disciplines who teach in the midwifery
programme are competent in the content they teach.
5. Midwife teachers provide education, support and supervision of
individuals who teach students in practical learning sites.
6. Midwife teachers and midwife clinical preceptors/clinical teachers
work together to support (facilitate), directly observe and evaluate
students' practical learning.
7. The ratio of students to teachers and clinical preceptors/clinical
teachers in classroom and practical sites is determined by the
midwifery programme and the requirements of regulatory authorities.
8. The effectiveness of midwifery faculty members is assessed on a
regular basis following an established process.
III Student body
1. The midwifery programme has clearly written admission policies that
are accessible to potential applicants. These policies include:
a. entry requirements, including minimum requirement of completion of
secondary education;
b. a transparent recruitment process;
c. selection process and criteria for acceptance; and
d. mechanisms for taking account of prior learning.
2. Eligible midwifery candidates are admitted without prejudice or
discrimination (e.g., gender, age, national origin, religion).
3. Eligible midwifery candidates are admitted in keeping with national
health care policies and maternity workforce plans.
4. The midwifery programme has clearly written student policies that
include:
a. expectations of students in classroom and practical areas;
b. statements about students' rights and responsibilities and an
established process for addressing student appeals and/or grievances;
c. mechanisms for students to provide feedback and ongoing evaluation
of the midwifery curriculum, midwifery faculty, and the midwifery
programme; and
d. requirements for successful completion of the midwifery programme.
5. Mechanisms exist for the student's active participation in midwifery
programme governance and committees.
6. Students have sufficient midwifery practical experience in a variety of
settings to attain, at a minimum, the current ICM Essential
Competencies for basic midwifery practice.
7. Students provide midwifery care primarily under the supervision of a
midwife teacher or midwifery clinical preceptor/clinical teacher.
IV Curriculum
1. The philosophy of the midwifery education programme is consistent
with the ICM philosophy and model of care.
2. The purpose of the midwifery education is to produce a competent
midwife who:
a. has attained/demonstrated, at a minimum, the current ICM Essential
Competencies for basic midwifery practice;
b. meets the criteria of the ICM Definition of a Midwife and regulatory
body standards leading to licensure or registration as a midwife;
c. is eligible to apply for advanced education; and
d. is a knowledgeable, autonomous practitioner who adheres to the ICM
International Code of Ethics for Midwives, standards of the profession
and established scope of practice within the jurisdiction where legally
recognized.
3. The sequence and content of the midwifery curriculum enables the
student to acquire essential competencies for midwifery practice in
accord with ICM core documents.
4. The midwifery curriculum includes both theory and practice elements
with a minimum of 40% theory and a minimum of 50% practice.
a. Minimum length of a direct-entry midwifery education programme is 3
years;
b. Minimum length of a post-nursing/health care provider (post-
registration) midwifery education programme is 18 months.
5. The midwifery programme uses evidence-based approaches to
teaching and learning that promote adult learning and competency
based education.
6. The midwifery programme offers opportunities for multidisciplinary
content and learning experiences that complement the midwifery
content.
V Resources, facilities and services
1. The midwifery programme implements written policies that address
student and teacher safety and wellbeing in teaching and learning
environments.
2. The midwifery programme has sufficient teaching and learning
resources to meet programme needs.
3. The midwifery programme has adequate human resources to support
both classroom/theoretical and practical learning.
4. The midwifery programme has access to sufficient midwifery practical
experiences in a variety of settings to meet the learning needs of each
student.
5. Selection criteria for appropriate midwifery practical learning sites are
clearly written and implemented.
VI Assessment strategies
1. Midwifery faculty uses valid and reliable formative and summative
evaluation/assessment methods to measure student performance and
progress in learning related to:
a. knowledge;
b. behaviours;
c. practice skills;
d. critical thinking and decision-making; and
e. interpersonal relationships/communication skills.
2. The means and criteria for assessment/evaluation of midwifery student
performance and progression, including identification of learning
difficulties, are written and shared with students.
3. Midwifery faculty conducts regular review of the curriculum as a part
of quality improvement, including input from students, programme
graduates, midwife practitioners, clients of midwives and other
stakeholders.
4. Midwifery faculty conducts ongoing review of practical learning sites
and their suitability for student learning/experience in relation to
expected learning outcomes.
5. Periodic external review of programme effectiveness takes place.
Source: ICM 2013
The purpose of the I CM (2013) global education standards is to establish
benchmarks so that internationally all countries, with or without such standards, can
educate and train midwives to be competent and autonomous practitioners who are
equipped to work within global norms. A dditionally, it is envisaged that not only can
the standards be expanded to meet the needs of individual countries but they can be
achieved within the context of these individual countries' norms and cultural mores,
thus embracing the whole ethos of globalization previously outlined. The core aims of
the ICM (2013) Global Standards for Midwifery Education are three-fold:
1. Essentially, to assist countries that do not have robust training programme(s) but
are striving to meet the country's needs for outputs of qualified midwives to
establish basic midwifery.
2. To support countries striving to improve and/or standardize the quality of their
midwifery programme(s), ensuring that midwives are fit for both practice and
purpose.
3. Offer a framework to countries with established programme(s) for midwifery
education who may wish to compare the quality of their existing standards of
midwifery education against the ICM minimum standards. This can be achieved
during the design, implementation and evaluation of the ongoing quality of the
midwifery programme.
The I CM expects that the global standards for midwifery education outlined inBox
1.3 will be adopted by all those with a vested interest in the health and wellbeing of
mothers, babies and their families. This requires engagement from policy-makers,
governments/health ministers, midwives and wider healthcare systems. The standards
not only promote an education process that prepares midwives with all the essential
I CM competencies, it also supports the philosophy of life-long learning through
continuing education. This approach it is hoped will foster and promote safe
midwifery practice alongside quality and evidence-based care. A further goal is to
strengthen and reinforce the autonomy of the midwifery profession as well as uphold
the virtue of midwives as well-informed, reflective and autonomous practitioners.
To ensure students are educated and prepared to be responsible global citizens,
Tucke and Crompton (2013) stress that undergraduate programmes for student
nurses and midwives should expose learners to global health systems within a
culturally diverse society. Maclean (2013) concurs with this view, highlighting that
global health issues are much more mainstream in contemporary midwifery practice
as a direct consequence of elective placements abroad. Elective placements enable
students from high-income countries to gain an invaluable insight into the health
challenges faced by resource-poor countries. Furthermore, the importance of global
strides to reduce disadvantages and health inequalities, such as Millennium
D evelopment Goals 4 and 5 (see below), and the principles on which the safe
motherhood initiative is based, have greater significance when students have first-
hand experience of the struggles encountered on a daily basis by those who are
socially and economically disadvantaged.
The ERASMUS programme
ERA S MUS is an acronym for EuRopean A ction S cheme for the Mobility of Universi
S tudents. S alient aspects of globalization have led to this initiative in Europe, incepted
in 1987 to allow international mobility for university student exchange between
European countries (Papatsiba 2006) . Milne and Cowie (2013) extol the virtues of the
ERA S MUS scheme in preparing the future generation of healthcare professionals to
provide culturally diverse and competent care. However, for a multiplicity of reasons,
only a minority of students undertake the ERASMUS exchange.
The Millennium Development Goals (MDGs)
D espite its detractors, globalization has resulted in a rich tapestry of skills, knowledge
and research to inform midwifery practice and help deliver culturally sensitive and
responsive care to mothers, babies and their families. Having undertaken global travel
as a consultant with the W HO to promote safer childbirth through the safe
motherhood initiative, Maclean (2013) acknowledges the importance of both
globalization and internationalization for midwives. S he states that this is pivotal in
developing a shared philosophy and building a strong alliance, especially from a cross-
cultural perspective in the quest to achieve the MDGs by 2015.
A lthough the MD Gs have placed poverty reduction, gender and wider social
inequalities on the international agenda, some would argue that the blueprint or
framework has its flaws (Waage et al 2010; S ubramanian et al 2011) given that the
goals must be achieved by 2015 and much work is still needed as the deadline looms.
However, the targets outlined in Fig. 1.1 have assisted in the cooperation and
collaboration of international agencies and government in addressing many of the
major moral challenges of modern day society and healthcare provision for mothers
and babies in the quest to realize a healthier nation.
FIG. 1.1 The eight Millennium Development Goals. Reproduced with permission from
www.un.org/millenniumgoals/.
The emotional context of midwifery
I n a dynamic health service, midwives need to have an emotional awareness in order
to deliver care sensitively, as well as to ensure that these feelings are acknowledged
and responded to. To do this effectively, midwives should be aware not only of their
own feelings but of how the delivery of the care meted out to women may impact on
women's affective state (see Chapter 25). Much of midwifery work is emotionally
demanding, thus an understanding by midwives of why this is so, and exploration of
ways to manage feelings, can only benefit women and midwives. How midwives ‘feel’
about their work and the women they care for is important. I t has significant
implications for communication and interpersonal relationships with not only women
and families but also colleagues. I t also has much wider implications for the quality of
maternity services in general.
By its very nature, midwifery work involves a range of emotions. A ctivities that
midwives perform in their day-to-day role are rarely dull, spanning a vast spectrum.
W hat may appear routine and mundane acts to midwives are often far from ordinary
experiences for women – the recipients of maternity care. W hile birth is often
construed as a highly charged emotional event, it may be less obvious to appreciate
why a routine antenatal ‘booking’ history or postnatal visit can generate emotions.
However, women's experience of maternity care conveys a different picture (Goleman
2005; Redshaw and Heikkila 2010). There is clear evidence from research studies that
women do not always receive the emotional support from midwives that they would
wish (Beech and Phipps 2008; Redshaw and Heikkila 2010).
What is ‘emotion work’?
O ver the past three decades there has been increased interest in how emotions affect
the work professionals do (Fineman 2003). This interest was stimulated by an
A merican study undertaken by Hochschild (1983), which drew a ention to the
importance of emotion in the workplace, and to the work that needs be done when
managing emotions. This study focused on A merican flight a endants, who identified
that a significant aspect of their work was to create a safe and secure environment for
passengers, and in order to do so they needed to manage the emotions of their
customers and themselves.
Consequently, emotional labour can be defined as the work that is undertaken to
manage feelings so that they are appropriate for a particular situation (Hochschild
1983; Hunter and D eery 2009). This is done in accordance with ‘feeling rules’, social
norms regarding which emotions it is considered appropriate to feel and to display.
This is best depicted by Hunter and D eery (2005), who note how midwives describe
suppressing their feelings in order to maintain a reassuring atmosphere for women
and their partners.
Hochschild (1983) used the term ‘emotional labour’ to mean management of
emotion within the public domain, as part of the employment contract between
employer and employee; ‘emotion work’ referred to management of emotion in the
private domain, i.e. the home. The research focused particularly on commercial
organizations, where workers are required to provide a veneer of hospitality in order
to present a corporate image, with the ultimate aim of profit-making (e.g. the ‘switch-
on smile’ of the flight a endants or the superficial enjoinders to ‘have a nice day’ from
shop assistants). This requires the use of ‘acting’ techniques, which Hochschild (1983)
argues may be incongruent with what workers are really feeling. Hunter (2004a)
suggests that the emotion management of midwives is different to this. Midwives are
more able to exercise autonomy in how they control emotions, and emotion
management is driven by a desire to ‘make a difference’, based on ideals of caring and
service.
Sources of emotion work in midwifery practice
Research studies suggest that there are various sources of emotion work in midwifery
(Hunter 2004a, 2004b; Hunter and D eery 2005, 2009). These can be grouped into three
key themes, which are discussed in turn:
1. Midwife–woman relationships
2. Collegial relationships
3. The organization of maternity care.
I t is important to note that these themes are often interlinked. For example, the
organization of maternity care impacts on both midwife–woman relationships and on
collegial relationships.
Midwife-woman relationships
The nature of pregnancy and childbirth means that midwives work with women and
their families during some of the most emotionally charged times of human life. The
excited anticipation that generally surrounds the announcement of a pregnancy and
the birth of a baby may be tempered with anxieties about changes in role identity,
altered sexual relationships and fears about pain and altered body image (Raphael-
Leff 2005). Thus it is important to remember that even the most delighted of new
mothers may experience a wide range of feelings about their experiences (see Chapter
25).
Pregnancy and birth are not always joyful experiences: for example, midwives work
with women who have unplanned or unwanted pregnancies, who are in unhappy or
abusive relationships, and where fetal abnormalities or antenatal problems are
detected. I n these cases, midwives need to support women and their partners with
great sensitivity and emotional awareness. This requires excellent interpersonal skills,
particularly the ability to listen. I t is easy in such distressing situations to try to help
by giving advice and adopting a problem-solving approach. However, the evidence
suggests that this is often inappropriate, and that what is much more beneficial is a
non-judgemental listening ear (Turner et al 2010).
Childbirth itself is a time of heightened emotion, and brings with it exposure to
pain, bodily fluids and issues of sexuality, all of which may prove challenging to the
woman, her partner and also to those caring for her. A ending a woman in childbirth
is highly intimate work, and the feelings that this engenders may come as a surprise to
new students. For example, undertaking vaginal examinations is an intimate activity,
and needs to be acknowledged as such (S tewart 2005). I n the past, the emotional
aspects of these issues have tended to be ignored within the education of midwives.
Relationships between midwives and women may vary considerably in their quality,
level of intimacy and sense of personal connection. S ome relationships may be intense
and short-lived (e.g. when a midwife and woman meet on the labour suite or birth
centre for the first time); intense and long-lived (e.g. when a midwife provides
continuity of care throughout pregnancy, birth and the postnatal period via models of
care such as caseholding). They may also be relatively superficial, whether the contact
is short-lived or longer-standing. There is evidence that a key issue in midwife–woman
relationships is the level of ‘reciprocity’ that is experienced (Hunter 2006; McCourt and
S tevens 2009; Pairman et al 2010; Raynor and England 2010). Reciprocity is defined as
‘exchanging things with others for mutual benefit’ ( O xford English D ictionary 2013).
W hen relationships are experienced as ‘reciprocal’ or ‘balanced’, the midwife and
woman are in a harmonious situation. Both are able to give to the other and to receive
what is given, such as when the midwife can give support and advice, and the woman
is happy to accept this, and in return affirm the value of the midwife's care. A chieving
partnership with women requires reciprocity. Pairman et al (2010: viii) defines
partnership as a relationship of trust and equity ‘through which both partners are
strengthened’. This implies that the power in the mother–midwife relationship is
diffused. There is no imposition of ideas, values and beliefs, but rather the midwife
uses skills of negotiation and effective communication to ensure the woman remains
firmly in the driving seat of all decision-making relating to her care.
I n contrast, relationships may become unbalanced, and in these situations emotion
work is needed by the midwife. For example, a woman may be hostile to the
information provided by the midwife, or alternatively, she may expect more in terms
of personal friendship than the midwife feels it is appropriate or feasible to offer.
S ome midwives working in continuity of care schemes have expressed concerns about
‘ge ing the balance right’ in their relationships with women, so that they can offer
authentic support without overstepping personal boundaries and becoming burnt out
(Hunter 2006; McCourt and S tevens 2009; Pairman et al 2010). However, establishing
and maintaining reciprocal relationships can prove challenging at times.
Intelligent kindness
I n their thought-provoking book, Balla and Campling (2011) assert that in the
modern N HS that has undergone relentless structural and regulatory reforms,
healthcare professionals need to find a way to return to a way of working and being
based on ‘intelligent kindness’, kinship and compassion. ‘I ntelligent kindness’, they
claim, is being kind while acting intelligently. This approach not only results in
individual acts of kindness but it promotes a sense of wellbeing, helps to reduce stress
and leads to increased satisfaction with care. I t is also liberating to the individual,
team and organization as it promotes a harmonious way of working and being. Thus
the interest of the individual woman, the midwife and the maternity care organization
are inextricably bound together. Measures should be in place to mitigate against
inhibiting factors such as a culture of negativity and blame. However, kindness alone
is not sufficient. W omen want care from a midwife that is not only kind but is also
a entive, intelligent and competent in her clinical skills to make the woman feels safe.
E qually, Balla and Campling (2011) state that kindness should be genuine and not
contrived, which results in congruence.
Collegial relationships
Relationships between midwives and their colleagues, both within midwifery and the
wider multidisciplinary and multiagency teams are also key sources of emotion work.
Much of the existing evidence a ests to relationships between midwifery colleagues,
which may be positive or negative experiences.
Positive collegial relationships provide both practical and emotional support
(Sandall 1997). Walsh (2007) provides an excellent example of these in his ethnography
of a free-standing birth centre. He observed a strong ‘communitarian ideal’ (Walsh
2007: 77), whereby midwives provided each other with mutual support built on trust,
compassion and solidarity. He a ributes this to the birth centre model, with its
emphasis on relationships, facilitation and cooperation.
S adly, however, such experiences are not always universal. There is also evidence
that intimidation and bullying exists within contemporary UK midwifery (Leap 1997;
Kirkham 1999; Hadikin and O 'D riscoll 2000; Hunter and D eery 2005). The concept of
‘horizontal violence’ ( Leap 1997) is often used to explain this problem. Kirkham (1999)
explains how groups who have been oppressed internalize the values of powerful
groups, thereby rejecting their own values. A s a result, criticism is directed within the
group (hence the term ‘horizontal violence’), particularly towards those who are
considered to have different views from the norm. This type of workplace conflict
inevitably affects the emotional wellbeing of the midwifery workforce (Hunter and
Deery 2005).
The organization of maternity care
I n the UK the way in which maternity care is organized may also be a source of
emotion work for midwives. The fragmented, task-orientated nature of much hospital-
based maternity care creates emotionally difficult situations for midwives ( Ball et al
2002; D eery 2005; D ykes 2005; Hunter 2004a, 2005; Kirkham 1999), as it reduces
opportunities for establishing meaningful relationships with women and colleagues,
and for doing ‘real midwifery’. The study by Ball et al (2002) identified frustration with
the organization of maternity care as one of the key reasons why midwives leave the
profession. A study by Lavender and Chapple (2004) explored the views of midwives
working in different se ings. They found that all participants shared a common model
of ideal practice, which included autonomy, equity of care for women and job
satisfaction. However, midwives varied in how successful they were in achieving this.
S trong midwifery leadership and a workplace culture that promoted normality are
deemed to be facilitative rather than inhibiting factors. Free-standing birth centres
were usually described as being more satisfying and supportive environments, which
facilitated the establishing of rewarding relationships with women and their families.
Conversely, consultant-led units were often experienced negatively; this was partly the
result of a dominant medicalized model of childbirth, a task-orientated approach to
care and a culture of ‘lots of criticism and no praise’ (Lavender and Chapple 2004: 9).
I n general, it would appear that midwives working in community-based practice,
continuity of care schemes or in birth centre se ings are more emotionally satisfied
with their work (Sandall 1997; Hunter 2004a; Walsh 2007; S andall et al 2013). A lthough
there is the potential for continuity of care schemes to increase emotion work as a
result of altered boundaries in the midwife–woman relationship, there is also evidence
to suggest that when these schemes are organized and managed effectively, they
provide emotional rewards for women and midwives.
A key reason underpinning these differing emotion work experiences appears to be
the co-existence of conflicting models of midwifery practice (Hunter 2004a). A lthough
midwifery as a profession has a strong commitment to providing woman-centred care,
this is frequently not achievable in practice, particularly within large institutions. A n
approach to care that focuses on the needs of individual women may be at odds with
an approach that is driven by institutional demands to provide efficient and equitable
care to large numbers of women and babies 24 hours a day, 7 days a week. W hen
midwives are able to work in a ‘with woman’ way, there is congruence between ideals
and reality, and work is experienced as being emotionally rewarding. W hen it is
impossible for midwives to work in this way, as is often the case, midwives experience
a sense of disharmony. This may lead to anger, distress and frustration, all of which
require emotion work (Hunter 2004a).
Managing emotions in midwifery
Hunter (2004a) and Hunter and D eery (2005) found that midwives described two
different approaches to emotion management: affective neutrality and affective
awareness. These different approaches were often in conflict and presented mixed
messages to student midwives.
Affective neutrality
A ffective neutrality, described as ‘professional detachment’, suggests that emotion
must be suppressed in order to get the work done efficiently. By minimizing the
emotional content of work, its emotional ‘messiness’ is reduced and work becomes an
emotion-free zone. This approach fits well within a culture that values efficiency,
hierarchical relationships, standardization of care and completion of tasks. Personal
emotions are managed by the individual, in order to hide them as much as possible
from women and colleagues. Coping strategies, such as distancing, ‘toughening up’
and impression management are used in order to present an appropriate ‘professional
performance’, i.e. a professional who is neutral and objective. W hen dealing with
women, there is avoidance of discussing emotional issues and a focus on practical
tasks. This is clearly not in the best interests of women.
A lthough this may appear to be an outdated approach to dealing with emotion in
contemporary maternity care, there is ample evidence that this approach continues,
particularly within hospital se ings. This can be problematic for midwives who wish
to work in more emotionally aware ways, and can detract from the quality of care.
Affective awareness
I n contrast, affective awareness fits well with a ‘new midwifery’ approach to practice
(Page and McCandlish 2006). I n this approach it is considered important to be aware
of feelings and express them when possible. This may be in relation to women's
emotional experiences, or when dealing with personal emotions. S haring feelings
enables them to be explored and named. I t also provides opportunities for developing
supportive and nurturing relationships between midwives and women, and between
midwives and colleagues.
A ffective awareness fits within a wider contemporary Western culture, which
emphasizes the benefits of the ‘talking cure’, that is the therapeutic value of talking
things through (e.g. via counselling or psychotherapy). However, it is important that
midwives recognize the limits of their own expertise, so they do not find themselves
out of their depth. W orking in partnership with women, particularly in continuity of
care schemes, means that midwives are more likely to develop close connections with
women and their families. If emotionally difficult events occur, midwives ‘feel’ more.
Challenges
I t is also important not to be overly critical of midwives who adopt an ‘affectively
neutral’ approach, but to try to understand why this may be occurring. I n Hunter and
D eery's (2005) study, most participants did not consider this to be the best way of
dealing with emotion, believing that ‘affective awareness’ was the ideal way to
practise. But when they felt ‘stressed out’, they described ‘retreating’ emotionally and
‘pu ing on an act’ to get through the day. S tress may be the result of unsustainable
workloads, staff shortages, conflicts with colleagues or difficulties in personal lives. I n
order to understand emotion work in midwifery, midwives need to be aware of the
broader social and political context in which maternity care is provided.
Understanding emotion work requires careful thought and reflection, not just about
individual midwives, but also about the complexities of the maternity services. I n
order to move away from a blame culture in midwifery, we need to work at developing
empathy, in order to better understand each others' behaviour.
I t is also important to ensure cultural sensitivity in relation to emotion. The ways
that emotions are displayed, and the types of emotion that are considered appropriate
for display will vary from culture to culture, as well as within cultures (Fineman 2003).
Midwives need to develop skills in reading the emotional language of a situation and
avoid ethnocentricity.
Developing emotional awareness
I t is possible to develop emotional skills in the same way as it is possible to develop
any skills. I n other words, individuals can develop ‘emotional awareness’ (Hunter
2004b) or ‘emotional intelligence’, according to (Goleman 2005). He claims that
emotionally intelligent people: know their emotions, manage their emotions, motivate
themselves, recognize the emotions of others and handle relationships effectively.
Goleman (2005) suggests ways that emotional intelligence can be developed, so that an
individual can have a high ‘EQ ’ (emotional intelligence quotient) in the way that they
may have a high IQ (intelligence quotient).
The idea of emotional intelligence has caught the public imagination, although
some would argue that Goleman's ideas are rather simplistic and lack a substantive
research base (e.g. Fineman 2003: 52). I nstead, Fineman (2003: 54) prefers the notion of
‘emotional sensitivity’, which he claims can be developed through ‘processes of
feminization, emotionally responsive leadership styles, valuing intuition, and
tolerance for a wide range of emotional expression and candour’. W hatever the
preferred terminology, it would seem that these ideas have particular relevance to
midwifery, given the emotionally demanding nature of this work. Midwives need to
develop emotional awareness so that they know what it is they are feeling, why they
are feeling it, and how others may be feeling. They also need to develop a language to
articulate these feelings, in a manner that is authentic.
S o how can midwives develop their emotional awareness? There are a number of
options that may be helpful. A endance on counselling and assertiveness courses can
help to develop insights into personal feelings, which by extension provide insights
into the possible feelings of others. S upervision may also provide opportunities for
exploration of the emotions of both self and others, with the aim of recognizing and
responding appropriately to these.
I t is particularly important that emotional issues are given careful and sensitive
a ention during pre-registration education. This could take the form of role-play, or
by making use of participative theatre. D rama workshops have been used effectively
with student midwives (Baker 2000) to explore various aspects of their clinical
experience, including a range of emotional issues, in a safe and supportive
environment. O ne advantage of such an approach is that participants realize that they
are not alone in their experiences. With a skilled workshop facilitator, difficult
situations can be considered in a broader context, so that they are understood as
shared rather than personal problems. These methods could also be beneficial for
qualified midwives, especially clinical mentors, as part of their continuing professional
development.
Emotional issues also need a ention within clinical practice, if they are not to be
seen as something that is explored only ‘in the classroom’. A s previously discussed,
there may be ‘mixed messages’ about what emotions should be felt and displayed.
These mixed messages are not helpful in creating an emotionally a uned
environment. S upervision could have a role to play here, having the potential to
provide a supportive environment for understanding emotion, particularly if a ‘clinical
supervision’ approach is taken. This is a method of peer support and review aimed at
creating a safe and non-judgemental space in which the emotional support needs of
midwives can be considered (Kirkham and S tapleton 2000; D eery 2005). The
importance of ‘caring for the carers’ is crucial, but often underestimated.
Finally, as Fineman (2003) recommends, those in leadership positions within
midwifery need to set the scene by adopting leadership styles that are emotionally
responsive. In this way, a ripple effect through the whole workforce could be created.
The social context of pregnancy, childbirth and
motherhood
A number of influential social policies have resulted in radical reforms of the
maternity services in the UK over many years. Consequently, the twenty-first century
has heralded the transformation of the N HS at systems and at organizational level to
provide be er care, enhanced experience for mothers and their families and improved
value for money. The reforms are to deliver excellence and equity in the N HS (DH
2010b). S ince 2009, the policy reforms have ensured that women and their families are
provided with a greater choice in the services they want and need, and guaranteed a
wider choice in the type and place of maternity care, including birth (D H 2007a,
2007b).
A s key public health agents midwives are at the forefront of social change and act as
the cornerstone to the delivery of maternity service reforms. Their roles and
responsibilities will increasingly focus to deliver greater productivity and best value
for money, offering real choice and improvement in women's maternity experiences.
These reforms are creating opportunities for midwives to work in new ways and
undertake new and different roles. Midwives are required to be much more oriented
towards public health and the reforms provide increased opportunities to work in
more diverse teams to provide integrated services. The working environment is
changing where midwives are increasingly accountable for the care they provide,
creating a new form of ownership.
Disadvantaged groups
Many of the reasons given by women for dissatisfaction with maternity services
include fragmented care, long waiting times, insensitive care, lack of emotional
support, inadequate explanations, lack of information, medical control, inflexibility of
hospital routines and poor communication (Redshaw and Heikkila 2010).
Universally, there is no agreed definition of vulnerability, however, the term
‘vulnerable groups’ is often used to refer to groups of people who are at risk of being
socially excluded and marginalized in accessing maternity services. These groups of
people or communities are more likely to experience social marginalization as a result
of a number of interrelated factors such as unemployment, poor or limited skills, low
income, poor housing, poverty, high crime environment, poor or ill health and family
breakdown. W omen from these vulnerable groups may experience disadvantage either
due to mental or physical impairment, or particular characteristics no longer
a ributed to mental or physical impairment but that have historically led to
individuals experiencing prejudice and discrimination, for example ethnicity or
disability. Box 1.4 provides examples of some of the groups of women who may be
disadvantaged in the maternity service.
Box 1.4
W om e n who a re m ost like ly t o e x pe rie nce
disa dva nt a ge
• The very young
• Those with disability (physical, sensory or learning)
• Those living in poor socioeconomic deprived circumstances
• Those from black and minority ethnic backgrounds
• Those from travelling communities
• Those seeking refuge/asylum
• Those who misuse substances
• Those experiencing domestic abuse
• Lesbians
Providing woman-centred care is a complex issue, particularly in a diverse society
where individual's and families' health needs are varied and not homogeneous.
Listening and responding to women's views and respecting their ethnic, cultural,
social and family backgrounds is critical to developing responsive maternity services.
Persistent concerns have been expressed about the poor neonatal and maternal health
outcomes among disadvantaged and socially excluded groups (Lewis and D rife 2001,
2004; Lewis 2007; CMA CE [Centre for Maternal and Child Enquiries] 2011 ), suggesting
not all groups in society enjoy equal access to maternity services (Redshaw and
Heikkila 2010).
There is strong evidence that disadvantaged groups have poorer health and poorer
access to healthcare, with clear links between inequality in social life and inequality in
health, demonstrating that inequality exists in both mortality and morbidity (Marmot
2010). The W HO (2008) refers to the social determinants of health as conditions in
which people are born, live, develop, work and age. This includes the healthcare
system, which paradoxically is formulated and influenced by the distribution of
wealth, power and resources at all levels. Moreover, the social determinants of health
are largely responsible for health inequalities, i.e. the unfair and avoidable differences
in health status seen within and between countries (WHO 2008).
To facilitate care that is responsive to the needs of women, health professionals
need to understand women's social, cultural and historical backgrounds so that care is
tailored to meet their individual needs. A number of models of care have been
introduced to deliver culturally congruent care, including some examples of
midwifery-led caseloading teams developed around the needs of vulnerable groups,
e.g. Blackburn Midwifery Group Practice B ( yrom 2006) and the Wirrall one-to-one care
scheme (McGarrity Dodd 2012).
Women from disadvantaged groups
Young mothers
Previously the UK had the unenviable reputation for the highest rate of teenage
pregnancy and teenage parenthood in Europe. However, recent figures from the Office
of N ational S tatistics (O N S 2013)reveal that in England and Wales the tide is finally
changing: teenage pregnancy rates are actually declining. Recent statistical data from
ONS (2013) reveals that pregnancies in young women <18 years old in 2011 was 31 051
compared to 45 495 in 1969 when records began, a decrease of 32%. I n contrast, the
figure for conceptions to all women in 2011 was 909 109 compared to 832 700 in 1969,
signalling an overall increase of 9.2%
Why teenage pregnancy matters
I t is important to acknowledge that some young mothers do achieve a successful
outcome to their pregnancy and parenting with appropriate social support (Olds 2002).
N onetheless, it is widely understood that there is a strong association between
teenage pregnancy resulting in early motherhood and poor educational achievement
and wider health inequalities and social deprivation, e.g. poor physical and mental
health, social isolation, and poverty and wider related factors (A rai 2009). I t should
also be recognized that mortality and morbidity among babies born to these mothers
is increased and that the mothers show a higher risk of developing complications,
such as hypertensive disorders and intrapartum complications (Lewis and D rife 2004).
Many young teenage mothers tend to present late for antenatal care and are
disproportionately likely to have some risk factors associated with poor antenatal
health (e.g. poverty and smoking). Moreover, there is a growing recognition that
socioeconomic disadvantage can be both a cause and effect of teenage parenthood.
Consequently, in the UK the former government led by the Labour party established a
target to half the teenage pregnancy rate by 2010, when compared with 1998. This
signified a radical shift in the position of local authorities, who set a 10-year target that
aimed to reduce the local teenage conception rate between 40% and 60%. S uch an
ambitious goal was meant to contribute to the national 50% reduction target. However,
although the Teenage Pregnancy S trategy ended in 2010, the actual teenage pregnancy
rate has remained an area of policy interest and contentious debate. The current
Coalition government (Conservatives and Liberal D emocrats) places teenage
pregnancy rate to young women <18 as one of its three sexual health indicators in its
Public Health O utcomes Framework 2013–2016 D ( H 2013). I n fact this emboldened
approach is one of the national measures of progress on child poverty, which aims to
ensure a continued focus on preventing teenage conceptions as well as the social
impact upon teenage mothers (ONS 2013).
With appropriate support, young mothers and young fathers can make an effective
transition to parenthood. They can be assisted to develop good parenting and life
skills to prevent a potential downward spiral and break the cycle of social deprivation
and health inequalities by early intervention schemes such as the Family N urse
Partnership developed by Olds (2002).
Women with disability
W omen with disability are increasingly engaged with the maternity services as they
seek to live full and autonomous lives. A UK national survey on disabled women's
experiences of pregnancy, labour and postpartum care compared to non-disabled
women was conducted by Redshaw et al (2013). The study found that while in many
areas there were no differences in the quality of care disabled women received there
was evidence for areas of improvement. This includes infant feeding and be er
communication if women are to experience truly individualized care. Thus the midwife
needs to allow sufficient time to assess how the disability may impact on the woman's
experience of childbirth and parenting and to work with her in identifying helpful
ways to make reasonable adjustment, including the assistance of multiagency
departments as required.
The woman will probably be be er informed about her disability than the midwife.
However, she may need the midwife to provide information and guidance on the
impact that the physiological changes of pregnancy and labour may have on her, for
example the increased weight and change in posture. S ome women and their partners
may raise concerns regarding the inheritance pa ern of a genetic condition, and may
need referral to specialist services such as a genetic counsellor. Midwives and other
healthcare professionals should recognize the need to approach antenatal screening in
a sensitive manner (see Chapter 11). Midwives need to be aware of local information
pertaining to professional and voluntary organizations and networks and adopt a
multidisciplinary approach to planning and provision of services. The Common
A ssessment Framework may be an appropriate tool for the midwife to use to ensure a
coordinated multiagency approach to care (DfES 2006).
A birth plan is a useful communication tool providing the woman with scope to
identify her specific needs alongside the issues that most pregnant women are
concerned with, such as coping strategies for labour and birth and views on any
medical intervention that might be deemed necessary. A ssisting women with a
disability to make informed choices about all aspects of their antenatal, intrapartum
and postnatal care (Royal College of Midwives [RCM] 2008 ) is empowering. I f the
woman is to give birth in hospital it may be helpful for her to visit the unit, meet some
of the staff and assess the environment and resources in relation to her special needs,
e.g. if she is planning to have a waterbirth a thorough risk assessment of the
environment will be needed. A single room should be offered to her to facilitate the
woman's control over her immediate environment and, where appropriate, to adapt it
to accommodate any equipment that she may wish to bring with her. A woman who is
blind or partially sighted may prefer to give birth at home where she is familiar with
the environment. I f she has a guide dog then consideration needs to be given to its
presence in the hospital environment.
W omen with learning difficulties may need a friend or carer to help with the birth
plan but the midwife should remember that the woman must remain at the centre of
care. Midwives need to understand the worldview of women with disabilities in order
to shape the maternity services to meet the individual needs of these women, and
work within an ethical framework that values key principles of rights, independence,
choice and inclusion (Chapter 2).
Women living in poverty
I t is well documented that women living in poverty are more likely to suffer health
inequalities and have a higher rate of maternal and perinatal mortality (Lewis 2007;
Marmot 2010; CMACE 2011; UN 2013). Tackling inequality is high on the public health
agenda and the midwife has an important role in targeting women in need.
Women from black and minority ethnic (BME) communities
The UK has continued to see major demographic changes in the profile of its
population and is more ethnically diverse now than ever before (ONS 2012). According
to the 2011 census, England and Wales are more ethnically diverse, with rising
numbers of people identifying with minority ethnic groups. N evertheless, although
the white ethnic group is decreasing in size, it remains the majority ethnic group that
people identify with. Furthermore, there are regional variations for ethnic diversity.
London has the most concentrated and rich ethnic mix while Wales remains largely
white, despite pockets of minority ethnic groups (ONS 2012).
W hen referring to multiethnic societies, a basic understanding of the culture is
often assumed to mean the way of life of a society or a group of people and is used to
express social life, food, clothing, music and behaviours. The concept of culture has
been defined by many, such as Helman (2007), providing a variety of insights into the
concept. However, the commonalities are that culture is learned, it is shared and it is
passed on from generation to generation. Members of the society learn a set of
guidelines through which they a ain concepts of role expectancies, values and
a itudes of society; it is therefore not genetically inherited but is socially constructed
and the behaviour of individuals is shaped by the values and a itudes they hold as
well as the physical and geographical surroundings in which they interact. I ndividuals
perceive and respond to stimuli from economic, social and political factors in different
ways and they will be affected differently according to age, gender, social class,
occupation and many other factors. Culture is very much a dynamic state, it is not a
group phenomenon, and to treat it as homogeneous is foolhardy as it can lead to
generalizations and negative stereotypes. S ome aspects can be true for some and not
for others belonging to the same cultural group.
A n understanding of some of the cultural differences between social groups is
essential in ensuring that professional practice is closely matched to meet the needs of
individual women, promoting the delivery of culturally congruent care. A n
understanding of the role culture plays in determining health, health behaviours and
illness is essential when planning and delivering services that meet the health needs
of the local population. However, caution is needed as the role of culture in explaining
pa erns of health and health-related behavior is somewhat simplistic. Placing
emphasis on culture diverts attention away from the role of broad structural process in
discrimination and the role that racism plays in health status (A hmad 1993, 1996;
Stubbs 1993).
Ethnic diversity in the UK has created major challenges for maternity services
(Lewis 2007; CMA CE 2011 ). S uccessive reports of the Confidential Enquiries into
Maternal D eaths in the UK have demonstrated that the inability to respond
appropriately to the individual needs of women from different backgrounds is
reflected in persistent poor communication practice and ineffective care culminating
in poor health outcomes for both mother and baby (Lewis and D rife 2001, 2004; Lewis
2007; CMACE 2011).
W omen from the BME population experience disadvantage and are socially excluded
for two main reasons. First, some women are more likely to be categorized into lower
socioeconomic status; they are predominantly residents of deprived inner city areas,
have poor housing, are at risk of high unemployment, and have low-paid occupations,
poor working conditions, poor social security rights and low income, all of which lead
to poverty. O ften factors such as lifestyle, environmental factors and genetic
determinants are cited as indicators of poor health outcomes, dismissing key social
determinants of poverty, poor housing and poor education (Nazroo 1997; Platt 2007).
S econd, because their skin colour and ethnic origin make them visible minorities,
they are more likely to experience racial harassment, discrimination and social
inequalities (N azroo 2001). I nstitutionalized racism and general reluctance by
organizations and individuals to address the sensitive issue of ethnicity are likely
contributors to inequalities of health and access to maternity services (RCM 2003). I t is
important to understand concepts of discrimination and racism and how this can
marginalize women.
Ethnicity has largely replaced the term ‘race’, encompassing all of the ways in which
people from one group seek to differentiate themselves from other groups. ‘Ethnicity
is an indicator of the process by which people create and maintain a sense of group
identity and solidarity which they use to distinguish themselves from “others” ' (Smaje
1995: 16). Ethnicity is a self-claimed identity and is socially constructed; people of a
particular group have a common sense of belonging, and have shared beliefs, values
and cultural traditions as well as biological characteristics. I n general, people use
these terms to identify the ‘other’ groups but it must be remembered that all people
have a culture and ethnicity.
W hen people value their own culture more highly, perceiving their cultural ways to
be the best, they devalue and beli le other ethnic groups, perceiving ‘others’ culture
as bizarre and strange; this is referred to as ethnocentrism. Ethnocentric behaviour, in
particular when other individuals' cultural requirements may be ignored or dismissed
as unimportant, would do very li le to meet the tenets of woman-centred care and
hinders the delivery of responsive care. Many maternity services are still based on an
ethnocentric model, e.g. education for parenthood is not culturally sensitive where
women and their partners are positively encouraged to attend jointly (Katbamna 2000).
BM E groups as users of the maternity service:The majority of women from BME groups
express satisfaction with maternity services. W hile some argue that ethnicity is not a
marker for good or poor quality (Hirst and Hewison 2001, 2002), others have reported a
plausible relationship between ethnicity and women's proficiency in speaking and
reading English with poor quality of care (Bharj 2007). Many women assert that their
ability to access maternity services is impaired because they are offered li le or no
information regarding options of care during pregnancy, childbirth and the postnatal
period (Katbamna 2000; Bharj 2007). W omen are therefore not aware of the range of
maternity services and choices available to them.
Evidence indicates that lack of proficiency to speak and read English adversely
impacts on women's experience and their ability to access and utilize maternity
services, also adversely affecting the quality of maternity services and maternity
outcomes (Lewis 2007; CMA CE 2011 ). O ften lack of interventions to overcome
communication and language barriers, such as qualified interpreters, is cited as a
major challenge in accessing maternity services (Lewis 2007; CMA CE 2011 ).
Furthermore, use of relatives or friends as interpreters during sensitive consultations
is not recommended (Lewis 2007) and is viewed by women as inappropriate. I n some
studies, women reported that their requests to see a female doctor were dismissed and
they were distressed when treated by a male doctor, particularly when they observed
purdah (Sivagnanam 2004).
Women seeking refuge/asylum
Midwives need to be aware of the complex needs of this group of vulnerable women
who, in addition to the problems described above, have often experienced traumatic
events in their home country, may be isolated from their family and friends and face
uncertainty regarding their future domicile.
Women from travelling families
Travelling families are not a homogeneous group. Travellers may belong to a distinct
social group such as the Romanies, their origins may lie in the UK or elsewhere such
as I reland or Eastern Europe, or they may be part of the social grouping loosely
termed ‘N ew A ge’ travellers or part of the S howman's Guild travelling community. A s
with all social groups, their cultural background will influence their beliefs about and
experience of health and childbearing.
A common factor, which may apply to all, is the likelihood of prejudice and
marginalization. Midwives need to examine their own beliefs and values in order to
develop their knowledge to address the needs of travelling families with respect, plus
provide a caring and non-judgemental service. A n informed approach to lifestyle
interpretation may stop the midwife identifying the woman as an antenatal defaulter
with the negative connotations that accompany that label. Moving on may be through
choice related to lifestyle, but equally it may be the result of eviction from unofficial
sites.
S ome health authorities have designated services for travelling families that
contribute to uptake and continuity of care. These carers understand the culture and
are aware of specific health needs; they can also access appropriate resources, for
example a general practitioner (GP) who is receptive to travellers' needs. A trusting
relationship is important to people who are frequently subjected to discrimination.
Handheld records contribute to continuity of care and communication between care
providers, but the maternity service also needs to address communication challenges
for individuals who do not have a postal address or who have low levels of literacy.
Women who are lesbian
Evidence suggests that an increasing number of women are seeking motherhood
within a lesbian relationship. The exact numbers are unclear as it is the woman's
choice as to whether she makes her sexual orientation known. The midwife can,
however, create an environment in which she feels safe to do so. Communication and
careful framing of questions can reduce the risk of causing offence and assist the
midwife in the provision of woman-centred care.
Wilton and Kaufmann (2001) identify the booking interview as the first time, as a
user of the maternity service, that the woman must consider how she will respond to
questions such as ‘when did you last have sex?’ or ‘what is the father’s name?’ I ssues
such as parenting, sex and contraception may have different meanings for the midwife
and the woman and therefore careful use of non-heterosexist language by the midwife
will help to promote a climate for open communication (Hastie 2000). S he argues that
the ‘realities of lesbian experiences are hidden from the mainstream heterosexist
society and so stereotypes are rife among health practitioners’; Hastie (2000) also
states that oppression and invisibility damage health. The RCM (2000) suggest that
midwives should take a lead in challenging discriminatory language and behaviour,
both positively and constructively.
Midwives meeting the needs of women from
disadvantaged groups
Midwives are in a unique position to exploit the opportunities created by the N HS
reforms to deliver equitable services, and to create responsive organizations and
practices. They have a moral, ethical, legal and professional responsibility to provide
individualized care and to develop equitable service provision and delivery (Nursing
and Midwifery Council [N MC] 2008 ). They play a key role in bringing about change.
They also have a responsibility to facilitate an environment that provides all women
and their families with appropriate information and encourages more active
participation in the decision-making process, including ensuring ‘informed consent’.
Meeting information needs
W omen from disadvantaged backgrounds often lack knowledge and understanding of
the maternity services. They are not always given adequate information about the full
range of maternity services and options of care available to them during pregnancy,
labour and the postnatal period. O ften information is not available in appropriate
formats to reach women who have visual or hearing impairment or who lack
proficiency in speaking and reading English. Therefore, they are unaware of the range
of maternity services and choices available to them. Midwives can play an important
role in facilitating two-way communication to enable women to participate in making
decisions about the care they want, need and receive.
Midwives recognize that communication and language difficulties may be addressed
by making use of professional qualified interpreters or liaison workers or signers. I n
practice, the use of qualified interpreters is intermi ent and fragmented. Financial
resources, midwives' beliefs and a itudes, time constraints and the nature of
employment of qualified interpreters determine the availability of qualified
interpreters (Bharj 2007).
Advocacy
I n circumstances where women cannot effectively communicate with their midwives,
they are unable to fully participate in decisions made about their care. These women
feel that professionals and hospitals ‘take over’ and make decisions about them
without first discussing all the options, or informing them of their rights. Having a
strong advocate is therefore important.
Working in partnership
A s identified earlier in the chapter, for midwives to work in partnership with women,
they need to cultivate a meaningful relationship with them. Partnership working and
its impact in promoting woman-centred care should take account of trust and power
(Calvert 2002; Kirkham 2010). A relationship based on trust builds confidence and
makes women feel safe and respected.
S tereotyping and discrimination on the other hand play a major role in hindering
the development of meaningful relationships. There is well-documented evidence
illustrating the detrimental effect of discrimination and racism on people's health
(Virdee 1997). S everal studies confirm that midwives commonly use stereotypes of
women in determining their needs and preferences and utilize these to make
judgements about the kind of care women deserve, as well as what a particular woman
is likely to want during labour and birth (Kirkham and S tapleton 2004). O ften these
stereotypes and prejudices have detrimental effect on women's maternity experiences
(Redshaw and Heikkla 2010).
D iscriminatory a itudes and hostility coupled with their adverse impact on women
will do li le towards the development of a meaningful relationship. Consequently,
partnership working will be rhetoric for women from disadvantaged background as
will issues of continuity, choice and control. Midwives need to consider such issues
and where possible draw upon transcultural models to provide anti-oppressive care
promoting the tenets of woman-centred care for women from disadvantaged groups.
Research
W hen she provides care during childbearing, the midwife does so by virtue of her
expert knowledge. This knowledge distinguishes her from all the people who offer
opinions to the childbearing woman. The midwife's unique knowledge which
determines her practice derives from many sources. Traditionally, the midwife drew
on her personal experience of childbearing. More recently, the midwife's occupational
experience has assumed greater significance. Precedent has been quoted as an
important influence (Thomson 2000), which may have been enforced by authority
figures. Ritual has also influenced midwifery practice (Rodgers 2000). Relatively
recently research and research evidence have been required to determine midwifery
practice.
The term ‘research’ carries many implications, so a dictionary definition is useful:
‘systematic investigation towards increasing the sum of knowledge’ (Macdonald 1981:
1148).
Clearly, research is about asking questions, but not haphazardly. S ystematic
questioning is crucial, making planning, in the form of the ‘research process’, the basis
of research activity. The purpose of this activity is encompassed in the dictionary
definition, as research into the improvement or increase in knowledge in midwifery is
intended to ensure more effective care.
Evidence
The term ‘evidence’ refers to a particular form of research, which is considered by
some to be particularly strong and crucial to effective practice (Chalmers 1993: 3). The
need for ‘evidence’ began with observations by Cochrane (1972). He identified the lack
of scientific rigour in medical decisions, and singled out obstetricians for withering
criticism of their want of rigour. S ome obstetricians, with other maternity
practitioners, responded by a empting to correct the deficiency. To develop material
for practitioners who lacked inclination, ability and opportunities to search and
evaluate the literature, this group began reviewing research systematically. This
resulted, first, in the publication of two significant volumes ( Chalmers et al 1989) and
later, the ongoing development of the Cochrane database. Unsurprisingly, evidence is
intended to facilitate evidence-based practice, defined as:
The conscientious, explicit and judicious use of current best evidence in making
decisions about the care of individual patients. (Sackett et al 1996: 71)
As well as evidence, other forms of research are used in healthcare, such as audit.
The stated rationale for evidence-based practice (EBP)
Research-based practice has long been said to ensure high-quality care. A dditionally,
professions' status may be enhanced by such intellectual activity. EBP has been
advocated by many UK policy documents which have argued that it may facilitate
more appropriate resource allocation, by increasing effectiveness and efficiency. W hile
midwifery has long benefited from strong evidence relating to episiotomy (Sleep
1991), other aspects of care are seriously deficient; these include contentious issues
such as the location of uncomplicated childbirth (Olsen and Clausen 2012), continuous
electronic fetal monitoring (CEFM) in labour A ( lfirevic et al 2013) and routine
ultrasound examination in pregnancy (Bricker and Neilson 2007; Bricker et al 2008).
The randomized controlled trial (RCT)
The research design usually regarded as most likely to ensure good quality evidence is
the RCT. The RCTovercomes bias inherent in using other approaches without
comparison groups to decide between alternative forms of care (D onnan 2000). The
power of the RCT lies in its objectivity or freedom from bias, possibly arising from the
sampling or selection of subjects for the experimental treatment and control (no/usual
treatment) group, who receive a placebo or standard care. I mplemented
conscientiously, the RCT is regarded as ‘the gold standard for comparing alternative
forms of care’ ( Enkin et al 2000: 10). The data collected are analysed statistically to
assess whether differences in outcomes are due to chance, rather than the
experimental intervention. D espite the RCT's power, the practitioner should scrutinize
research reports to ensure relevance. I n maternity care, where systems of care differ
and culture ma ers, scrutiny takes account of the context, the woman, her personal
and clinical experience and her intuition.
Discussion
A s with other forms of quantitative research, RCTs have been criticized as being
reductionist. This is because, to make sense of the subjects' behaviour or responses,
the researcher must simplify or reduce events to their basic component parts. Those
who undertake or use research should consider carefully the effect of reductionism in
a field such as childbearing. I t is possible that some important aspect of the
phenomenon may be neglected because the researcher is unaware of it, or it is too
complicated, or challenging, to address.
The midwifery evidence base has been criticized for its lack of completeness; as
evidence, obviously, exists only on aspects of care already subjected to research. The
result is that the evidence base is inadequate to permit comprehensive evidence-based
midwifery care. This incomplete evidence base is being addressed by ongoing
research, to produce new evidence which may conflict with or contradict existing
knowledge. To utilize current best evidence, the practitioner should assess or critique
the research, which means its careful examination or criticism. Critique, though,
carries no negative overtones, comprising a fair, balanced judgement, seeking
strengths and limitations.
The appropriateness of EBP in an activity as uniquely human as childbearing
deserves a ention. EBP may reduce the humanity of care, not only through
reductionism, but also through ‘routinization’ or even ‘cookbook care’ (Kim 2000).
This argument about reducing care's humanity has been extended to include the
effects of EBP on midwiferyper se. These effects are reflected in concerns that have
been expressed regarding the relevance of RCT-based evidence to the care decisions
made by midwives (Page 1996; Clarke 1999). The possibility has been raised of EBP
constituting a threat to midwifery through its prescriptive medical orientation
(Bogdan-Lovis and S ousa 2006). EBP's relevance to midwifery continues to be
questioned. This applies particularly to the widely accepted need for the active input
of the childbearing woman in any decisions about her care (Munro and S piby 2010).
The likelihood exists that research evidence that is RCT-based may be less than
appropriate to midwifery practice; this likelihood has also cast doubt on the EBP
agenda more generally (McCourt 2005).
These concerns about the uncertain relevance of EBP to midwifery have resulted in
the need for a more woman-centred framework to inform decision-making (Wickham
1999). What may be a compromise position, termed ‘evidence-informed practice’ (EIP),
is intended to utilize the strengths of EBP at the same time as avoiding dogmatic and
prescriptive approaches. W hile interventions based solely on prejudice or superstition
are unacceptable, the knowledge and judgement of the midwife practitioner and the
childbearing woman form an equal triangular foundation with research-based
evidence (N evo and S lonim-N evo 2011). Thus, the woman and the midwife enjoy a
dynamic relationship which is recognized and encouraged in EI P. The dialogue into
which they enter through this caring relationship becomes constructively transparent.
The pressure on midwives to adhere to the EBP agenda, though, has been both
profound and enduring. This has been demonstrated by the early and ongoing efforts
by medical practitioners to direct midwives along the path of EBP. Such direction came
from authorities such as Chalmers (1993: 3) in his requirement that midwives use only
‘strong research’. D irection of midwives towards EBP, however, has brought with it an
element of medical hypocrisy which has taken the form of ‘do as I say and not as I do’.
W hile there may be many examples of such hypocrisy, a familiar one would be the
continuing, and possibly increasing, medical reliance on routine ultrasound during
pregnancy, the benefits of which have yet to be established (Bricker and N eilson 2007;
Bricker et al 2008).
The issue that underpins the adherence of the midwife to EBP is the question of
knowledge or knowledges. Knowledge of theory must precede practice, in a
relationship that ideally develops as a virtuous and escalating cycle; but a cycle which
is affected by a range of factors. S uch influence means that practice enhances not just
knowledge, but knowledges. These differing knowledges arise out of a multiplicity of
belief systems within one health culture. The result is that the authority or dominant
nature of a certain set of beliefs may serve to limit, threaten or undermine other belief
systems which, though equally legitimate, are accepted to the same extent and do not
carry equal kudos. The dominant knowledge system in maternity has been identified
as the ‘medical model’, as characterized by EBP, and the other knowledges as
midwifery, social or woman-centred. The existence of these discrete knowledges may
give rise to tension and conflict between different disciplines, practitioners and the
childbearing woman.
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Paper No. 22] RCM: London; 2000.
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Health Committee. Inequalities in access to maternity services. [Eighth Report of
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Further reading
Association of Radical Midwives. New vision for maternity care.
www.midwifery.org.uk; 2013.
Acknowledges the centrality of the mother–midwife relationship and identifies some of
the policy and cultural changes needed to protect and support this dyad..
Heath I. Kindness in health care: what goes around. BMJ. 2012;344:e1171.
A thought-provoking review in how simple acts of kindness can be healing for both
recipients of care and caregivers..
Useful websites
Association of Radical Midwives. www.midwifery.org.uk.
Department of Health. www.gov.uk.
International Confederation of Midwives. www.internationalmidwives.org.
National Perinatal Epidemiology Unit. www.npeu.ox.ac.uk.
Office of National Statistics. www.ons.gov.uk.
Royal College of Midwives. www.rcm.org.uk.
United Nations. www.un.org.
World Health Organization. www.who.int.
C H AP T E R 2
Professional issues concerning the
midwife and midwifery practice
Jayne E Marshall, Mary Vance, Maureen D Raynor
CHAPTER CONTENTS
Statutory midwifery regulation 26
Self-regulation 26
Historical context 27
Statutory instruments (SI) 28
The Nursing and Midwifery Council 29
Functions of the NMC 29
Membership 29
Committees 29
Practice Committees 29
Decisions made by the Practice Committees 30
Consensual panel determination 30
Voluntary removal from the Register 31
Restoration to the Register following a striking off order 31
Responsibility and accountability 31
Legal issues and the midwife 32
Legislation 32
The Human Rights Act 1998 32
Legal frameworks: rules and standards 32
Litigation 35
Consent 35
Negligence 36
Vicarious liability 37
Ethical issues and the midwife 37
Ethical frameworks and theories 37
The statutory supervision of midwives 39
Historical context 39
Supervision of midwives in the 21st century 40
Statutory supervision in action 42
Clinical governance 44
The key components of clinical governance 44
Policies, protocols, guidelines and standards 44
Audit 46
Risk management 47
Clinical Negligence Scheme for Trusts 47
Clinical governance, risk management and statutory supervision of midwives 47
References 50
Cases 51
Statutes, Orders and Directives 51
Further Reading 52
Useful Websites 52
This chapter affords the student with the frameworks governing the
midwifery profession and underpinning the professional practice of the
midwife. It emphasizes how the statutory supervision of midwives
framework is a vital element of leadership and clinical governance
supporting risk management by monitoring the development of maternity
services and standards of midwifery practice. Having knowledge of these
various frameworks is essential to every midwife so they are able to
function effectively as autonomous, accountable practitioners and provide
care to all childbearing women and their families that follows legal and
ethical principles and is also contemporary, safe and of a high quality.
The chapter aims to:
• identify the purpose of regulation of healthcare professionals in protecting public safety
• explain the role and functions of the regulatory body governing midwifery practice
within the United Kingdom – the Nursing and Midwifery Council
• review the legal framework midwives should work within to maximize safety and
minimize risk to women, their babies and families
• raise awareness of ethical frameworks and principles in supporting midwifery practice
and empowering childbearing women
• describe the statutory supervision of midwives
• promote the supervision of midwives as a mechanism for quality assurance, sensitive
to the needs of mothers and babies
• review the various aspects of clinical governance and demonstrate how statutory
supervision supports the clinical governance framework.
Statutory midwifery regulation
S tatutory regulation provides structure and boundaries that can be understood and
interpreted by both professionals and the public: it is the basis of a contract of trust
between the public and the profession. A lthough the primary purpose of regulation is
protection and safety of the public, the same mechanism also protects and supports
midwives in their practice.
Regulation of midwifery should play a key part in helping to improve women's
experiences of the maternity services and preventing harm from occurring in
midwifery practice. I t is essential that women and their families can be assured they
are being cared for by competent and skilled midwives who are effectively educated
and knowledgeable in contemporary midwifery practice. Consequently, midwifery
regulation should not be viewed as an abstract concept but from how it is perceived in
ordinary everyday healthcare terms, that is: supporting the standard of care that women
want or what midwives would want for themselves and their families.
Midwife is a title protected in statute in the United Kingdom (UK). This means that
no one can call themselves a midwife or practise as a midwife unless they are
registered on the N ursing and Midwifery Council's (N MC) Register. This registration
must be active, in that the midwife has met the continuing professional development
and practice requirements to remain on the Register and has paid the renewal of
registration fee (every three years supported by a signed notification of practice form
[N O P]) or a retainer fee (every interim first and second year of active registration).
There are over 35 000 midwives on the NMC Midwives Register (NMC 2013).
Self-regulation
I n the UK, midwives are members of a self-regulating profession. This is a privilege in
that the standards for education and practice of any midwife are set by midwives
themselves. S elf-regulating professions have regulatory bodies that are funded by
their own professionals. I n the case of midwives and nurses, their initial and
subsequent retaining/renewal of registration payments is the sole funding that pays
for all the functions of their regulatory body, the NMC.
S elf-regulation of midwives is achieved through a statutory Midwifery Commi ee of
the N MC which advises the N ursing and Midwifery Council (The Council) about wha
is required to ensure safe and competent midwives. The powers of the Midwifery
Commi ee are defined under S ection 41 of The N ursing and Midwifery O rder (2001).
The term statutory means that the role and scope of the commi ee is enshrined in law
and cannot be reduced or disbanded unless there is a change in the legislation to allow
it to happen. A ny rule or standards for midwifery education or practice set by the
Midwifery Commi ee are subsequently approved by the Council before they can come
into effect.
S elf-regulation of midwifery, however, does not exist in all countries and
consequently regulations for midwifery education or practice are set by the national
government or by another professional group who may be perceived as
senior/superior. However, it is acknowledged that the midwifery profession, as other
health professions in the UK, is affected to varying degrees by national regulations
that are set by others who are not part of the profession: for example, legislation for
safeguarding vulnerable children or adults (Safeguarding Vulnerable Groups Act 2006;
D epartment of Health [D H] 2011; HM Government 2013); medicines legislation
(Human Medicines Regulations 2012); health and safety in the workplace regulations
(Health and S afety at W ork A ct 1974). A ll midwives are bound by these national laws
in the same way as others.
Protection of the public cannot be achieved by the regulatory body alone and thus it
involves a combination of statutory regulation, personal self-regulation, employment
practices, professional organizations, education and working in an effective and
collaborative way with others. I t can, however, be difficult for individuals to act
ethically and escalate concerns about practices within their organizations. I t is here
where the regulator and regulation can support the midwife by offering appropriate
guidance. The N MC can also work actively with other service regulators such as the
Care Q uality Commission (CQ C) in England, Healthcare I mprovement S cotland, th
Regulator and Q uality I mprovement Authority in N orthern I reland and Healthcare
I nspectorate Wales, to ensure early action is taken to prevent unnecessary harm to
women and their families.
O verseeing the N MC and other healthcare regulators and working with them to
improve the way the professions are regulated is the Professional S tandards Authority
(PS A), which was previously known as the Council for Healthcare Regulatory
Excellence (CHRE). This organization is accountable to Parliament for the health
safety and wellbeing of patients and other members of the public. The PS A is also
required to undertake research, develop policy and provide advice to the four
governments of the UK on regulating healthcare professionals and consequently
provides an annual review of each of the healthcare regulators.
There has been, and still remains, a degree of public concern in the UK about self-
regulation of the healthcare professions as a result of some high profile media cases
where patient care was severely compromised (Bristol Royal I nfirmary I nquiry 2001;
Clothier et al 1994; HM Government 2007; Mid S taffordshire N HS Foundation Trust
Public I nquiry 2013). Consequently, a number of reviews of professional regulation
have been undertaken to improve safety and quality of care, the maintenance of
professional standards and public assurance that poor practice or bad behaviour will
be identified and promptly dealt with (D H 2007; CHRE 2008). The outcome of these
reports and the introduction of the Health and S ocial Care A ct 2012 have led to a
major reorganization of the structure and function of the NMC.
Historical context
W hilst it is appreciated that the establishment of legislation governing the practice of
midwifery had been taken by the governments in Austria, N orway and S weden as
early as 1801, it was not until a century later, in 1902, that the first Midwives A ct
sanctioned the establishment of a statutory body – the Central Midwives Board (CMB)
in England and Wales, followed by the Midwives (Scotland) Act 1915 and the Midwives
(I reland) A ct 1918. The first A ct in 1902 was promoted by individual members of
Parliament through Private Members' Bills in the House of Lords and by others who
supported midwife registration rather than being initiated by the government of the
time. A ll three A cts of the UK prescribed the constitution and function of the CMBs in
each of the four countries and laid down their statutory powers that included the
development of systems for licensing midwives and prohibiting unqualified practice.
The CMB had the responsibility for regulating the issue of certificates, keeping a
central roll of midwives and providing a means for the suspension of practitioners
through Local S upervising Authorities (LS A) and the supervision of midwives. I t also
had the responsibility for regulating any courses of training and examinations and
generally supervising the effective running of the profession. A series of further A cts
of Parliament in 1926, 1934, 1936 and 1950 amended this initial legislation and were
consolidated in the Midwives A ct 1951 and Midwives (S cotland) A ct 1951. However all
midwifery statutory bodies of the UK were dominated by doctors who also held the
chairmanships and there was no requirement for even one midwife to be included on
the Council of any CMB. This remained the case until the dissolution of the CMBs in
1983.
T he N urses, Midwives and Health Visitors A ct 1979established the framework of
the United Kingdom Central Council for N ursing, Midwifery and Health Visiting
(UKCC) and the N ational Boards for England, S cotland, N orthern I reland and Wale
to regulate education and practice, leading to the abolition of the CMBs in 1983. This
was the first time that midwives had been amalgamated in law with other professional
groups as up to this point midwifery had remained independent of any nursing
infrastructure with the regulation of the nursing profession being undertaken by the
General N ursing Councils (GN C). However, a separate Midwifery Commi ee was se
up in S tatute after much campaigning by the Royal College of Midwives (RCM) and
the A ssociation of Radical Midwives (A RM) who feared that the voice of midwifery
would be over-ruled by that of nursing. N evertheless, in 1987, the profession-specific
education officers were replaced by generic education officers, over-ruling the
Midwifery Commi ee and protests from members of the midwifery profession at the
time.
A decade later, an external review of the N urses, Midwives and Health Visitors A ct
1979 was commissioned by the D H which resulted in a smaller, directly elected central
council with smaller national boards. Regional Health Authorities (RHA) were
assigned the responsibility of funding nursing and midwifery education, whilst the
national boards retained responsibility for course validation and accreditation. This in
essence established the purchaser–provider model, where hospitals were expected to
contract with education providers for a requisite number of training places for nurses
and midwives to fulfil their local workforce planning. These arrangements and the
new streamlined structure of the UKCC and national boards were incorporated into
the 1992 N urses, Midwives and Health Visitors A ct. Further consolidation of the 1979
and 1992 A cts incorporating all the reforms, resulted in the 1997 N urses, Midwives
and Health Visitors Act.
D uring the 1990s, the government devolved power away from the UK Parliament
based in Westminster to the other three countries of the UK to enable them to
establish their own parliaments or assemblies. This devolution has not impacted
greatly on the regulation of midwives as midwifery is one of the established
professions of which the power to regulate remains with the UK Parliament at
Westminster, advised by the D epartment of Health England. O nly new health-related
professions that are established in the future will be exempt from this approach.
Further reform of the health professions was included in the Health A ct 1999 that
repealed the Nurses, Midwives and Health Visitors Act 1997. This resulted in replacing
primary legislation with a S tatutory I nstrument by O rder, which meant a departure
from the normal practice of parliamentary procedure experienced during the previous
century, involving professional scrutiny through all the earlier stages, including the
publication of Green and W hite Papers. S ection 62 (9) of theHealth A ct 1999 set out
the O rder for the establishment of the N ursing and Midwifery Council (N MC) which
commenced operating in 2002. The N MC took over the quality assurance functions of
the UKCC and the four national boards, although some of the functions of the national
boards in S cotland, N orthern I reland and Wales are provided by N HS Education
S cotland, the N orthern I reland Practice and Education Council for N ursing and
Midwifery, and Healthcare I nspectorate Wales. This development reunited standards
for education with standards for practice and supervision of midwives on a UK basis.
However, the creation of this UK-wide regulatory body, the N MC, was contrary to the
trend of devolution.
Statutory Instruments (SI)
The Nursing and Midwifery Order 2001: SI 2002 No: 253
This is the main legislation that established the N MC and was made under S ection 60
of the Health Act 1999: it is generally known as The Order. The Order sets out what the
Council is required to do (shall) and provides permissive powers for things that it can
choose to do (may). The numbered paragraphs within The O rder are referred to as
Articles.
The structure of registration was set up according to Part I I I of The O rder, resulting
in three parts of the Register being opened from August 2004:
• Nurses
• Midwives
• Specialist Community Public Health Nurses: namely health visitors, school nurses,
occupational health nurses, health promotion nurses and sexual health nurses.
Part I V set up Education and Training; Part V set up Fitness to Practise; Part VI I
relates to Midwifery.
Midwifery-specific Articles established the following:
• Article 41: The Midwifery Committee
• Article 42: Rules specific to midwifery practice
• Article 43: Regulation of the LSA and supervisors of midwives
• Article 45: Regulation of attendance in childbirth.
The O rder has been subject to a number of amendments, which are detailed in Box
2.1.
Box 2.1
N ot a ble a m e ndm e nt s t o t he N ursing a nd M idwife ry
O rde r S I 2 0 0 1
No. 253
Statutory instrument Title
SI 2006 No. 1914 The Medical Act 1983 (Amendment) and Miscellaneous Amendments Order 2006
Part 16: Paragraph
82
SI 2007 No. 3101 The European Qualifications (Health and Social Care Professions) Regulations 2007
Part 10: Paragraphs
155–173
SI 2008 No. 1485 The Nursing and Midwifery (Amendment) Order 2008
SI 2009 No. 1182 The Healthcare and Associated Professions (Miscellaneous Amendments) and Practitioner
Schedule 4: Part 2 Psychologists Order 2009
Paragraph 22
Part 6 Paragraphs
38, 41
Schedule 5: Part 2
Paragraph 12
SI 2009 No. 2894 The Nursing and Midwifery Council (Midwifery and Practice Committees) (Constitution)
(Amendment) Rules 2009
SI 2011 No. 17 Nursing and Midwifery Council (Fitness to Practise) (Amendment) Rules 2011
SI 2011 No. 2297 The Nursing and Midwifery Council (Fees and Education, Registration and Registration
Appeals) (Amendment) Rules 2011
SI 2012 No. 2754 The Nursing and Midwifery Council (Education, Registration and Registration Appeals)
(Amendment) Rules 2012
SI 2012 No. 3025 The Nursing and Midwifery Council (Midwives) Rules 2012
SI 2013 No. 235 The National Treatment Agency (Abolition) and the Health and Social Care Act 2012
Schedule 2: Part 1 (Consequential, Transitional and Savings Provisions) Order 2013
Paragraphs 51, 177
The nursing and midwifery council
Being the UK-wide regulator for two professions, namely nursing and midwifery, the
N ursing and Midwifery Council (N MC) has two key functions: se ing the strategic
direction for the N MC and overseeing the work of senior N MC staff. The Counci
ensures that the N MC complies with all relevant legislation governing nursing and
midwifery practice, including the N ursing and Midwifery O rder 2001(The O rder) and
adheres to the Charities A ct 1993. Having charitable status, the N MC should use all
funds received from its registrants purely for the benefit of the public, i.e. in the
regulation of nursing and midwifery to safeguard the public's health and wellbeing.
Functions of the NMC
The powers of the N MC are specified within The O rder and, as was the case with the
CMB and UKCC, its primary function is to establish and improve standards o
midwifery and nursing care in order to safeguard the public by:
• Establishing and maintaining a Register of all qualified nurses, midwives and
specialist community public health nurses
• Setting standards for the education and practice of all nurses, midwives and
specialist community public health nurses to ensure they have the right skills and
qualities at the point of registration which continue to develop throughout their
professional careers
• Regulating fitness to practise, conduct and performance through rules, codes and
statutory supervision of midwives.
W here a registrant does not meet the standards for skills, education and behaviour,
the N MC has the power to remove them from the Register permanently or for a set
period of time.
Membership
The N MC comprises of 12 lay and registrant members, including one member from
each of the four UK countries who are appointed by the Privy Council. Each registrant
member is from either a nursing or midwifery background with the lay members
selected for their expertise in various areas and strategic experience. These members
also sit on various Committees within the framework of the NMC.
Committees
Following the N MC Governance review N ( MC 2013), a number of the Council
Commi ees were disbanded: the A ppointments Board, the Education Commi ee, the
Finance and I nformation Technology Commi ee and the Fitness to Practise
Commi ee. A s a result only three main Council Commi ees remain: the Audit
Commi ee, the Midwifery Commi ee and the Remuneration Commi ee. There are,
however, three further statutory commi ees: the I nvestigating Commi ee, the
Conduct and Competence Commi ee and the Health Commi ee, known collectively
as the Practice Commi ees, which are responsible for considering allegations under
Part 5 of the Order.
The Audit Committee
This commi ee is responsible for ensuring that Council business is conducted with
the highest integrity, probity and efficiency in addition to guaranteeing that there are
appropriate systems in place for managing risk.
The Midwifery Committee
The role of the Midwifery Commi ee is to advise Council on any ma er affecting
midwifery, such as policy issues and standards influencing midwifery practice,
education and statutory supervision of midwives, responding to policy trends,
research and ethical issues concerning all registrants. The Midwifery Commi ee
recommendations and subsequent Council decisions influence midwifery
developments in the UK affecting the lives of individual women and their families for
whom the midwife provides care.
The Remuneration Committee
The responsibility of this Commi ee is to determine and agree with Council the
framework for the remuneration of the N MC's Chief Executive and Registrar, directors
and other such members of the executive team as it is designated to consider.
Practice Committees
A ny allegations of impaired Fitness to Practise referred to the N MC are considered by
Panels of the I nvestigating Commi ee, with a possible referral to the Conduct and
Competence Commi ee or the Health Commi ee, depending on the outcome of the
Panel's decision. I n 2014 a system of professional case examiners is to be introduced to
make decisions at the investigation stage of the process as to whether cases should
proceed to a final public hearing stage. The N MC expects this will improve the
consistency of decisions and develop a faster and more cost-effective process.
Furthermore, the introduction of a new power to review decisions to close cases at the
investigation stage is also being considered. The final stage of a Fitness to Practise
case, however, will still be heard by an independent panel, comprising of at least one
nurse or midwife and at least one lay member advised by a legal expert.
The Investigating Committee
The responsibility of the panels of the I nvestigating Commi ee is to consider any
allegations of a registrant being unfit to practise. I f the registrant's health is in question,
it is usual for a medical practitioner to be present. These hearings take place in private
and the Panel decides if there is a case to answer. I f there is, then a referral is made to
either the Conduct and Competence Commi ee or the Health Commi ee. However, if
the registrant is thought to be an immediate risk to the public, the Panel may refer the
case immediately to an I nterim O rders hearing. The Panel can then impose the
following:
• An interim suspension order: registration is suspended to prevent the registrant from
working during investigation of the case. This can be imposed for up to 18 months,
but must be reviewed after 6 months and every 3 months thereafter.
• An interim conditions of practice order: the panel imposes conditions on the registrant
for up to 18 months. According to the situation, this order can be revoked, modified
or replaced with a different order.
• Removal from the Register: can be authorized by the Investigating Committee should
there be fraudulent or incorrect entries in the register (NMC 2012a).
The Conduct and Competence Committee
This commi ee considers cases where a registrant's fitness to practise is alleged to be
impaired due to:
• misconduct
• lack of competence
• a criminal offence
• a finding by any other health or social care regulator or licensing body that fitness to
practise is impaired, or
• a barring under the arrangements provided by the Safeguarding Vulnerable Groups
Act 2006 (Controlled Activity and Miscellaneous Provisions) Regulations 2010, the
Safeguarding Vulnerable Groups (Northern Ireland) Order 2007 or the Protection of
Vulnerable Groups (Scotland) Act 2007.
Panel hearings are held in public, reflecting the N MC's public accountability,
although the Panel may agree to hold parts of the case in private, to protect the
anonymity of the alleged victim, or if disclosure of confidential medical evidence is
involved.
The Health Committee
This commi ee decides whether a registrant's fitness to practise is impaired by
physical or mental ill health and, if so, determines the appropriate sanction required
to protect the public. Because of the confidential nature of the medical evidence
considered, Panel hearings are held in private.
Decisions made by the Practice Committees
Hearings follow a four stage process:
• establishing whether the facts are proved
• establishing whether the person's fitness to practise is impaired
• receiving information about the person's previous professional and employment
history and in mitigation, and
• deciding the sanction.
S ince 2008, Panels have used the Civil S tandard of Proof to decide whether the facts
of an allegation are proved (Health and S ocial Care A ct 2007, 2008). Evidence is
therefore based on the balance of probabilities, rather than the Criminal S tandard of
Proof where facts previously needed to be proved beyond reasonable doubt. W hen
deciding on impairment, panels look for the level of conduct and competence expected
of the average registrant, not for the highest possible level of practice. Even if there has
been a breach of a standard set out in The Code (NMC 2008), it does not automatically
follow that a registrant's fitness to practise is impaired. That is a judgement for the
Panel to make.
A range of sanctions is available and the Panel uses the Council's indicative sanctions
guidance to determine the one that is most appropriate for the particular case. The
Panel must first consider whether, taking account of all the circumstances of the case,
it is appropriate to take no further action. I f the Panel decides this option is not
appropriate, the following sanctions are available:
• to issue a caution order for a specified period of between one and five years
• to impose a conditions of practice order for a specified period up to three years
• to impose a suspension order for up to one year
• to impose a striking off order of the nurse or midwife from the Register (in lack of
competence cases, this option is available only if the registrant has been continuously
suspended or under conditions of practice for the previous two years).
Consensual panel determination
From 2013, the N MC have introduced consensual panel determination, which enables
a registrant who is subject to a fitness to practise allegation to agree a provisional
sanction with the N MC before it is put before a panel for consideration. This option is
offered to a registrant following a full investigation and who has readily admi ed all
the charges against them in that their fitness to practise is impaired and a sanction is
then provisionally agreed. The agreement is then put before a Conduct and
Competence Committee or Health Committee Panel who will decide to accept or reject
it. I f rejected, the case is put before a new panel to conduct a full hearing and decide
an appropriate outcome. This new arrangement reduces the need for witnesses to
a end hearings, the length of hearings and enables the N MC to concentrate their
resources on cases where there are significant matters in dispute.
Voluntary removal from the Register
Voluntary removal allows a registrant who admits that their fitness to practise is
impaired, and who does not intend to continue practising, to apply to be permanently
removed from the N MC Register without a full public hearing. This development was
introduced in J anuary 2013 to enable the N MC to take swift action in protecting the
public following its investigation and liberating resources that can be used in more
significant cases.
Voluntary removal is allowed in only limited circumstances where there is no public
interest in holding a full hearing and where the public is best protected by a nurse or
midwife's immediate removal from the Register. S uch registrants would be those who
accept that they are no longer fit to practise due to a serious or long-term health
condition or are near retirement age. Voluntary removal will not be allowed where the
allegations are so serious that public confidence in professional standards would
suffer if they were not dealt with at a public hearing. This includes cases where the
actions of a registrant have caused the death of a patient or other significant harm,
including sexual misconduct.
W hile an application for voluntary removal can be made at any time, it is not
allowed until a full investigation into the allegation has been completed. W here
possible, the Registrar should consider the views of the person who made the initial
allegation before making a decision. I f an application is allowed, the registrant will
appear on the N MC website with the status ‘Voluntarily removed’ adjacent to their
name. The admissions made by the registrant may be made available to relevant
enquirers, including potential employers, other regulators and overseas medical
authorities.
Restoration to the Register following a striking off order
A registrant's name is removed from the N MC Register for five years during which
time they are not allowed to work as a nurse or midwife in the UK. The application
process to be restored to the Register can be made five years after the striking off
order was made, as this is not done automatically. The process is as follows:
• The nurse or midwife must make an application to the NMC Registrar for the
process to begin.
• A NMC committee will then decide at a hearing whether or not to allow the former
nurse or midwife to be readmitted to the Register.
• They will take into consideration the initial charge, the nurse or midwife's
understanding and insight into their past behaviour, and any action they may have
taken with regard to the reasons for which they were struck off.
I f the registrant can demonstrate they have achieved the additional education,
training and experience required and once the registration fee has been paid, their
name can be restored to the Register. However, if the application is unsuccessful, an
appeal may be made within 28 days of the decision date. The individual may be
suspended indefinitely should subsequent applications be made while the striking off
order is in place and they are also unsuccessful.
Responsibility and accountability
A lthough midwives practise in a wide range of se ings, they are all unified by
underlying values and responsibilities. Each midwife has a personal responsibility for
their own practice by being aware of their personal strengths and limitations and is
therefore required to continually develop their knowledge and skills to maintain
competence. S elf-regulation and professional freedom are based on the assumption
that each professional can be trusted to work without supervision and, where
necessary, take action against colleagues should their practice not be up to the
appropriate standards. Furthermore midwives share a collective responsibility in how
women and their families are treated and cared for. This means that each midwife
should highlight instances where individual practices or where the systems or
processes within organizations providing maternity services, are compromising safe
and appropriate care to women and their babies.
Accountability is more than having responsibility, although the concepts are used
interchangeably and means that midwives are answerable for their actions and
omissions, regardless of advice or directions by another professional. To be
accountable, a midwife is required to have the ability, responsibility and authority for
their actions (Bergman 1981). Each registrant is professionally accountable for their
actions and omissions to the N MC,legally accountable to the law and contractually
accountable to their employer. They must always act in the best interests of the
individuals to whom they are providing care. I n the case of midwives this would be the
childbearing woman, her baby and family. There may be occasions when midwives
have difficulty appreciating their own accountability, especially when carrying out the
instructions of medical staff, but it is clear from The Code (NMC 2008) that registrants'
accountability cannot be delegated to or borne by others. Midwives can gain greater
clarity and understanding of their accountability through discussions with their
supervisor of midwives.
D ifferent levels of individual and corporate accountability exist in relation to
professional practice and management structures. D uty of care and the advice
contained in The Code (N MC 2008) provide further clarity around a registrant's
professional accountability.
Legal issues and the midwife
Contemporary midwifery practice is characterized by increasing complexities in
respect of the health needs of childbearing women, their babies and families as well as
increasing uncertainties about what is right and wrong. Midwives can find themselves
faced with dilemmas and have to make decisions where there may not be evidence of
any robust clinical evidence. I t is therefore important each midwife is fully aware of
the legislation and legal framework in which they should practise as accountable
practitioners within the context of normal midwifery for which they have been duly
trained and have the appropriate expertise.
Legislation
T he N ursing and Midwifery O rder 2001 (S I 2002 N o: 253) is the statutory legislation
that currently governs the midwifery profession and endorsed the formation of the
regulatory body, the NMC.
Primary legislation is enshrined in A cts of Parliament, which have been debated in
the House of Commons and House of Lords before receiving Royal A ssent. S uch
legislation is expected to last at least a couple of decades before being revised. With
the pressure on Parliamentary time, A cts of Parliament are frequently designed as
enabling legislation in that they provide a framework from which statutory rules may be
derived: known as secondary or subordinate legislation. A ll secondary legislation is
published in Statutory Instruments.
S tatutory rules/secondary legislation can in theory be implemented or amended
much more quickly as it is the Privy Council which lays the rules before the House of
Commons for formal and generally automatic approval rather than is the case for
primary legislation that requires endorsement by the S ecretary of S tate. However, this
may still take several weeks or months to occur.
The Human Rights Act 1998
The European Convention for theProtection of Human Rights and Fundamental
Freedoms (1951) set out to protect basic human rights and the UK was the first
signatory to the Convention. The Convention is enforced through the European Court
of Human Rights in S trasbourg. TheHuman Rights A ct was passed in 1998 and came
into force on 2 O ctober 2000, since when most of the articles of the convention have
been directly enforceable in the UK courts in relation to public authorities and
organizations, such as the N ational Health S ervice (N HS ). I t is important tha
midwives are aware of, and encouraged to work within, the boundaries of this A ct. O f
particular importance to midwives and those working in health care are the following
Articles of the Act:
• Article 2: The right to life (e.g. continuing treatment of the life of a severely disabled
baby).
• Article 3: The right not to be tortured or subjected to inhumane or degrading
treatment (e.g. chaining a pregnant prisoner to a bed during labour would contravene
this Article).
• Article 5: The right to liberty and security (e.g. safe and competent care during
childbirth).
• Article 6: The right to a fair trial (e.g. civil hearings and tribunals as well as criminal
proceedings).
• Article 8: The right to respect privacy and family life (e.g. supports a woman's right
to give birth at home).
• Article 12: The right to marry (e.g. found a family, including fertility and assisted
fertility).
• Article 14: The right not to be discriminated against (e.g. women with a disability,
from a different ethnic/cultural background).
O ne benefit of this A ct is that it has placed the public at the centre of health care.
The individual's experience has become an important measure of quality and
effectiveness in health care and as a consequence of this A ct the N HS complaints
system has been reviewed. Midwives should be aware that when someone has a right
to something, there is usually a corresponding duty on someone else to facilitate the
right (Beauchamp and Childress 2012). I t could be said that women have a right to safe
and competent care during childbirth, fi ing in with A rticle 5. I t would therefore follow
that as midwives are educated to provide midwifery care, they have an obligation that
the care is both safe and competent. S imilarly, the UK Government via the N MC has an
obligation in regulating its practitioners to ensure they practise safely and
competently. The N MC does this by se ing theM idwives Rules and Standards (NMC
2012b), via the Post Registration Education and Practice (PREP) Standards(N MC 2011)
and the statutory supervision of midwives framework.
Legal frameworks: rules and standards
Each midwife must meet S tandard 17 of the S tandards for Pre-registration Midwifery
Education (N MC 2009a), which stipulate the competencies and Essential S kills
Clusters (ES Cs) required of all midwives and which also comply with A rticle 42 of the
European Union D irective on professional qualifications (2005/36/EC). I n addition, the
role and sphere of a midwife's practice are clearly defined in the Midwives Rules and
S tandards (N MC 2012b), the la er of which supplement the standards set out in The
Code (N MC 2008) and thus provides the midwife with the legal frameworks in which
to practise. Furthermore, the midwife's role is also embodied in the International
Confederation of Midwives (I CM) D efinition of the Midwife (I CM 2011)(see Chapter
1).
Midwives Rules and Standards
The Midwives Rules and S tandards N ( MC 2012b) are specific to the midwifery
profession and relate to midwifery practice and the supervision of midwives. They are
developed through the Midwifery Commi ee and approved by the Council. The
current Midwives Rules and S tandards are organized into five parts:preliminaries,
requirements for practice, obligations and scope of practice, supervision and reporting and
action by the local supervising authority. They provide detail about the specific rule, the
LS A standard and the midwifery standard. D etails of the rules contained within these
parts can be seen in Box 2.2. Midwives need to be mindful that as the Midwives Rules
are established by legislation set out in The O rder, they are a legal requirement for
midwifery registration and practice, whereas the Standards provide each midwife with
guidance as to how each rule can be met in practice.
Box 2.2
M idwive s R ule s a nd S t a nda rds
Source: Midwives Rules and Standards (NMC 2012b)
Rule 5: Scope of practice
Rule 5 (N MC 2012b) clarifies the midwife's responsibility in that she should refer to
other appropriately qualified health or social care professionals whenever any
emergency or deviation from the norm occurs in a woman or baby which is outside of
her current scope of practice. I t is imperative that a midwife is fully aware that Rule 5
also states that a midwife should not permit anyone else or arrange for anyone else to
act as their substitute other than another practising midwife or a registered medical
practitioner. Permi ing maternity support workers (MS W ) to undertake activities
associated with the role of the midwife would therefore be contravening Rule 5 and
the midwife would be fully accountable for the consequences of the actions or
omissions of the MS W . S imilarly, the midwife remains professionally accountable for
what a student midwife does or fails to do in clinical practice, but the subtle difference
is that this delegation is permi ed as the student is training to become a midwife and
thus will be developing the underpinning knowledge and skills expected of a
practising midwife.
Rule 6: Records
Rule 6 (N MC 2012b) outlines the midwife's responsibilities in respect of the safe
storage of records relating to the advice and care provided to women and babies
following their discharge from that care, including situations where the midwife is
self-employed and when a midwife ceases to be registered with the N MC. The LS A
standard relates to guidance concerning transfer of midwifery records from self-
employed midwives. The midwife standards specify that all records relating to the care
of a woman and baby should be kept securely for 25 years, including work diaries. Self-
employed midwives should also ensure that women are able to access their records
and inform them of the location of the records if they are transferred to the LS A .
Claims can arise up to 25–30 years after a baby's birth and, if the documentation is
lost, it is difficult for the case to be successfully defended. The guidance for storage
and access to records is in accordance with the D ata Protection A ct 1998 that covers
both computerised and manually held records.
I n addition, the N MC guidance onrecord keeping (N MC 2009b) provides the
principles that support good record keeping that should be integral to the practice of
every registrant and includes details relating to confidentiality, access to records and
information disclosure. I t also stresses the importance of registrants keeping up to
date with relevant legislation, case law and national and local policies relating to
information and record keeping as well as undertaking audits to assess the quality and
standard of the record keeping and communications.
The Code: Standards of Conduct, Performance and Ethics for Nurses
and Midwives
The Code (NMC 2008) provides the registrant with the foundation of good nursing and
midwifery practice and is a vital mechanism in safeguarding the health and wellbeing
of the public. I t highlights four standards that each registrant must clearly
demonstrate through their professional practice in order to meet public trust. These
are identified in Box 2.3.
Box 2.3
N M C C ode
Public trust
The people in your care must be able to trust you with their health and
wellbeing. To justify that trust you must:
• Make the care of people your first concern, treating them as individuals
and respecting their dignity
• Work with others to protect and promote the health and wellbeing of
those in your care, their families and carers, and the wider community
• Provide a high standard of practice and care at all times
• Be open and honest, act with integrity and uphold the reputation of your
profession
Source: The Code: standards of conduct, performance and ethics for nurses and midwives (NMC 2008)
These four standards are further expanded upon in The Code and include gaining
consent, adhering to professional boundaries, working effectively as part of a team
and delegation appropriately to others, keeping knowledge and skills up to date,
maintaining clear and accurate records and upholding the reputation of the profession
at all times. The Code reaffirms the registrant's personal accountability for their
actions and omissions and being able to justify their decisions. Furthermore, the
registrant's actions should always be lawful whether these relate to their professional
or personal life. A registrant who does not practise according to these standards could
find themselves before the N MC's Practice Commi ees with a possible suspension
from practice and/or removal from the professional Register.
The increase in social networking has necessitated further guidance from the NMC
(2012c) in that conduct online should be judged in the same way as conduct in the real
world. The consequences of improper action or behaviour when posting information
on such sites could put a nurse's or midwife's registration at risk or could jeopardize a
student from being eligible to join the professional Register.
The Post Registration Education and Practice (PREP) Standards
I n order for all registrants to retain their name on the professional Register, they have
to fulfil the requirements of the Post Registration Education and Practice S tandards
(NMC 2011), which are as follows:
• undertake a minimum of 450 hours in clinical practice during the previous three
years (practice standard)
• undertake a minimum of 35 hours study relevant to their practice every three years
(continuing professional development standard)
• maintain a professional portfolio of their learning activity
• complete a notification of practice (NOP) form every three years
• undertake a return to practice programme if they have been out of practice for three
years or more.
From a legal perspective it is every midwife's responsibility to ensure they remain
professionally up to date with developments in practice, are clinically competent to
fulfil their role and their practice is evidence-based. I t is no defence for the midwife to
disregard developments in practice and continue to use out-of-date policies, protocols
and guidelines. A ll employers are required to provide regular education and training
programmes either within the workplace or alternative educational institutions to
support midwives in meeting their professional development needs. The supervisor of
midwives can also support midwives in this respect through the annual supervisory
meetings with each supervisee.
Standards for Medicines Management
Medicines management and prescribing in the UK are governed by a complex
framework of legislation, policy and standards of which the N MC standards are only
one part. However, the Human Medicines Regulations 2012 have a empted to simplify
medicines legislation while maintaining effective safeguards for public health. The
regulations replaced much of the Medicines A ct 1968, repealing most of the obsolete
law in the process to ensure the legislation is fit for purpose. I n the S tandards for
Medicines Management (N MC 2007a) there are 26 standards detailed that stress the
importance of the responsibility all nurses and midwives should have towards safe
administration of medicines, including being conversant with local and national
policies to maximize public protection. A useful source in providing information
about medicines legislation and regulation in the UK that midwives can access is the
Medicines Healthcare Products Regulatory A gency (MHRA). The N MC has als
published guidance for those registrants who have undertaken further training to
become nurse or midwife prescribers (NMC 2006a).
Litigation
This is the term used for the process of taking a case through the courts, where a
claimant brings a charge against a defendant to seek some form of redress. I n
healthcare terms, this may be as a consequence of the claimant experiencing an act of
trespass to their person by the defendant or suffering harm from the defendant's
actions/omissions that could be proven as negligence. The N ational Health S ervice
Litigation Authority (N HS LA) manages litigation and other claims against the N HS in
England on behalf of member organizations and is responsible for providing advice on
human rights case law and handling equal pay claims.
Consent
The concept of consent is complex and this section is intended as only a brief
introduction. I t is important the midwife or doctor obtains consent from a woman
before undertaking any procedure to avoid any future allegations of trespass to the
person that may be made against them. O btaining consent is therefore the legal
defence to trespass to the person.
I nformed consent is taken to mean the reasonable person standard or the Bolam
standard (Bolam v Friern Hospital Management Committee 1957) whereby an individual is
given as much information as any reasonable person could be expected to understand in
order to make a decision about their care/treatment (D H 2009a). This implies that the
person is mentally competent to make such a decision (is legally an adult: 18 years or
over) or is not mentally incapacitated in any way. The purpose and significance or
potential complication of any procedure or treatment should also be discussed with
the childbearing woman by the midwife or doctor. W here possible, the woman should
be given time to consider her options before making a decision. This should be done
voluntarily and without any duress or undue influence from health professionals,
family or friends for it to be valid. O nly the woman can give consent for treatment or
intervention and although it is desirable if the partner or other relatives are in
agreement, ultimately the woman's views are the only ones that should be taken into
consideration (DH 2009a).
I ncapacity may be temporary, for example as a result of shock, pain, fatigue,
confusion, or panic induced by fear. However, it would not usually be reasonable to
consider that a woman in labour, experiencing the pain of contractions, would be so
affected that she lacked capacity. I f a healthcare professional fears that a woman's
decision-making (capacity) is impaired they should seek assistance in assessing
capacity, which is usually provided by the courts. I f a woman requires emergency
treatment to save her life, and she is unable to give consent due to being unconscious,
treatment can be carried out if it is in her best interests and according to the
reasonable standard of the profession (Mental Capacity A ct 2005). O nce the woman
has recovered, the reasons why treatment was necessary must be fully explained to
her.
I n the case of minors (children under 16 years), it is important to carefully assess
whether there is evidence that they have sufficient understanding in order to give
valid consent, i.e. considered to be Gillick competent (Gillick v West N orfolk and Wisbech
AHA 1985). A lthough Gillick competence was originally intended to decide whether a
child under 16 years can receive contraception without parental knowledge it has,
since 1986, had wider applications in health provision and is also referred to as Fraser
competence (D H 2009a). I t is also advisable that the child's parents or other
accompanying adults are kept informed of any clinical decisions that are made. W here
there is a conflict of opinion regarding consent between child and parent, the health
professional should always act in the child's best interest which in some instances may
involve the courts determining whether it is lawful to treat the child (DH 2009a).
I t is good practice that the health professional who is to perform the procedure
should be the one to obtain the woman's consent. S uch details of the discussion and
decision should be clearly documented in the woman's records for colleagues to see
that consent has been duly obtained or declined.
Consent can be implied, verbal or written. I t is a common misconception that wri en
consent is more valid than verbal consent when in fact wri en consent merely serves
as evidence of consent. I f appropriate information has not been provided, the woman
feels that she is under duress or undue influence or she does not have capacity, then a
signature on a form will make the consent invalid. I t is advised that wri en consent for
significant interventions such as surgery should always be obtained ( D H 2009a) but
for many procedures such as vaginal examination or phlebotomy verbal consent is
sufficient. I n an absolute emergency, it may be more appropriate to take witnessed
verbal consent for caesarean section rather than spending time on paperwork.
A lthough the law protects the rights of the woman, the fetus does not have any
rights until it is born. A mentally competent woman cannot be legally forced to have a
caesarean section because of risks to the fetus. However, whilst accepting the law and
respecting the woman's right to refuse such an intervention that may further endanger
the life of the fetus, such a situation will be very uncomfortable for any midwife or
obstetrician to sit back and allow a fetus to die. Cases such as this can be referred to
court for an emergency application to determine whether the intervention can proceed
lawfully.
Negligence
I t is recognized that the most significant claims in obstetrics arise from birth trauma
resulting in cerebral palsy. These are usually based on the allegation that there was
negligence on the part of the health professionals involved in the intrapartum care and
management, resulting in fetal asphyxia and consequently neurological damage to the
baby.
T he Congenital D isabilities (Civil Liability) A ct 1976enables a child who is born
disabled as a result of negligence prior to birth to claim compensation from the
person(s) responsible for the negligent act. A mother can only be sued for negligence
to her unborn baby if this occurred through dangerous driving. I n such cases, the
child would sue the mother's insurance company. There has been an amendment to
the A ct so that children who have suffered damage during in vitro fertilization (I VF)
treatment may also obtain compensation. A s with all medicolegal cases, for the
claimant to be successful, the following need to be proved:
• the health professional owed the woman a duty of care
• there was a breach of duty of care to the woman by the health professional such that
the standard of care afforded to her was below the standard that she could reasonably
have expected
• the harm/injury sustained was caused by the breach of duty and
• damages or other losses such as psychiatric injury (post-traumatic stress
disorder/nervous shock, anxiety disorder or adjustment disorder), financial loss (loss
of earnings) and future healthcare provision, recognized by the courts as being
subject to compensation, have resulted from that harm.
I n many cases where a baby suffers neurological damage and develops cerebral
palsy, although it may be accepted that the care was substandard, proving causation is
more difficult. i.e. whether the substandard care actually resulted in the disability. The
situation is complicated by the fact that only a small percentage of babies born with
significant neurological damage acquire their disability as a result of events that took
place during labour and birth. However, parents will seek to assign the damage to
issues of management during the intrapartum period when the health and wellbeing
of some babies may have already been chronically compromised before this time.
Experts are therefore required to assess the case on behalf of the claimant (the
woman or mother on behalf of the baby) and the defendant (usually the hospital
Trust) to consider the issues of causation. This may mean that many medicolegal
expert opinions are obtained from neonatologists, paediatric neurologists and
obstetricians before finally reaching a conclusion.
T he burden of proof of negligence is on the claimant to prove that on the balance of
probabilities it is more likely than not that the defendant was negligent in order for
them to be awarded any compensation by the courts. I n cases of negligence,
compensation is determined by agreeing the liability and the amount (quantum).
However, if as a result of negligence the baby has died, then the parents can only
recover bereavement costs. W here a fetus dies there is no bereavement costs as the
unborn child does not have any legal rights.
Vicarious liability
I n the event of an employed midwife being negligent, it would be usual for her
employer to be sued. The doctrine of vicarious liability exists to ensure that any
innocent victim obtains compensation for injuries caused by an employee. Under this
doctrine the employer is responsible for compensation payable for the harm. For
vicarious liability to be established the following elements must exist:
• there must be negligence: a duty of care has been breached and as a reasonably
foreseeable consequence has caused harm/other failure by the employee
• the negligent act, omission or failure must have been by an employee
• the negligent employee must have been acting in the course of their employment.
I t is worth noting that even where the employer is held to be vicariously liable, the
midwife who is responsible for harm, such as death of a woman or baby, could be
found guilty of manslaughter for their gross negligence which led to the death, could
lose their job following disciplinary action and also be struck off the Register following
a hearing by the NMC Conduct and Competence Committee.
The doctrine of vicarious liability does not necessarily deprive the employer of their
rights against the negligent employee. I f a midwife has been negligent then they are in
breach of their contract of employment that requires them to take all reasonable care
and skill. This breach gives the employer a right to be indemnified against the
negligent midwife.
From 2013 the Health Care and A ssociated Professions (I ndemnity A rrangements)
O rder 2013 (referred to as The I ndemnity O rder) specifies that all healthcare
professionals, including midwives and nurses, are expected to have indemnity
arrangements in place as a condition of their registration. The Clinical N egligence
S cheme for Trusts (CN S T) fulfils this requirement so each midwife should be covered
via their employer's membership to CNST.
I n the case of independent midwives who are self-employed, they have no vicarious
liability or indemnity by an employer and are personally liable for the health and safety
of themselves and others. However, from O ctober 2013 all independent midwives in
the UK are unable to practise without indemnity cover (The I ndemnity O rder 2013). I t
is therefore advisable they secure their own personal indemnity insurance cover as
even though they have to have a supervisor of midwives, the supervisor is not liable;
neither is supervisor's employer vicariously liable for the negligence of the
independent midwife. However due to the increase in compensation paid out to
maternity cases and subsequent rising costs of insurance premiums, many
independent midwives are no longer able to function alone. They have either
established social enterprise schemes where they commission care from maternity
care providers with whom they negotiate professional indemnity insurance cover, or
have returned to employment in the NHS.
Ethical issues and the midwife
A lthough the area of ethics is complex and perceived as difficult and daunting, it is a
major part of midwifery education and practice and should be seen as a daily tool to
support a midwife's decision-making with childbearing women. Being ethically aware
is a step towards being an autonomous practitioner: taking responsibility,
empowering others and facilitating professional growth and development. The
language and terminology, however, can be hard to comprehend and need greater
explanation (see Box 2.4).
Box 2.4
T e rm inology
Informed consent Information regarding options for care/treatment
Rights Justified claim to a demand
Duty A requirement to act in a certain manner
Justice Being treated fairly
Best interests Deciding on best course for an individual
Utilitarian Greatest good for greatest number
Deontological Duty of care
Beneficence Doing good
Non-maleficence Avoiding harm
Ethics is often about exploring values and beliefs and clarifying what people
understand, think and feel in a certain situation, often from what they say as much as
what they do – such actions being underpinned by morality. Beliefs and values are
very personal and dependent on many things, such as a person's background, the
society they have been brought up in and the principles and concepts learned since
early childhood, such as veracity (truth telling). I t is important to reflect on these
issues and be open and honest about dilemmas faced in practice. A potential area of
conflict is that of law, as law and ethics are often seen as complementary to one
another, yet they can also be placed at opposite ends of the spectrum, either creating
overlap or creating conflict. Exploring ethics provides a framework to aid resolution of
such dilemmas.
Ethical frameworks and theories
There are many ethical frameworks that could be adopted to use in clinical situations
and Edwards (1996) advocates a four-level system of moral thinking based on the work
o f Melia (1989) that can assist in formulating arguments and discussions and
ultimately solving moral dilemmas (see Box 2.5).
Box 2.5
E dwa rds' le ve ls of e t hics
Level one Judgements
Level two Rules
Level three Principles
Level four Ethical theories
Source: After Edwards 1996
Level one: Judgements
J udgements are usually readily made, based on information on individual gains. S uch
judgements may have no real foundation except the belief of the individual who made
it. They may therefore be biased and not necessarily well thought through or based on
all the available evidence. W hat informs a judgment is often linked to personal values
and beliefs, societal influences as well as experiences of similar past events. I t is
important that midwives reflect on past judgements to consider if in retrospect they
were well founded or based on personal bias or prejudice.
Level two: Rules
Rules govern our daily lives and are determined by the society or culture in which we
live. I n terms of ethics, rules are what guide the midwife's practice and control their
actions. According to Beauchamp and Childress (2012) rules come in different forms:
• Substantive rules: cover issues such as privacy, confidentiality or truth telling
• Authority rules: are determined by those in power and enforced on a country or
section of society
• Procedural rules: define a set course of action or line that should be followed.
The midwife should recognize that rules can be enabling in that they define clear
limits or boundaries of practice, allowing freedom to act knowing the safe limits of
those actions. The N MC (2012b) Midwives Rules and S tandards are statutory rules
bound by legal processes but can guide and enable practice when used appropriately
and as a consequence ease any ethical dilemmas. The Code (N MC 2008) is less formal
or obligatory than rules and is viewed as a set of guidelines to support safe practice
among midwives as well as nurses.
Level three: Principles
There are four main principles which are usually applied specifically within health
care and midwifery practice:
• Respect for autonomy: respecting another's right to self-determine a course of action:
e.g. placing women at the centre of maternity care where their views and wishes are
seen as key to the decision-making process in care delivery.
• Non-maleficence: Primum non nocere – above all, do no harm or cause no hurt.
• Beneficence: compassion, taking positive action to do good or balance the benefits or
harm in a given situation. This principle can cause a particular dilemma when a
woman chooses a course of action that may not be in her and her fetus/baby's best
interests.
• Justice: to treat everyone fairly and as equals. This principle also encompasses fair
access for all women to the same level and options of health and maternity services,
including place of birth.
Level four: Ethical theories
There are a number of theories that could be explored and applied to healthcare and
midwifery practice, e.g. liberalism, ethical relativism, feminism and casuistry are just
some of them. The two main normative ethical theories that are at either end of the
spectrum are utilitarianism (consequentialism) and deontology.
Utilitarianism
This theory considers actions in terms of their probable consequences and originates
from the Greek telos meaning end or purpose, such that this theory is sometimes
referred to as teleological theory. A lthough the original theory's aim was for all actions
to create the greatest happiness for the greatest number of people, the word happiness
has been criticized, as for some individuals actions may result in a degree of
unhappiness. I t is therefore more apt to consider this theory as substituting happiness
for the word good or benefit: that is, the greatest good/benefit for the greatest number.
Many aspects of midwifery practice have been implemented on utilitarian
principles: e.g. antenatal and neonatal screening tests are offered to all women
irrespective of need or individual assessment to benefit society as a whole. However,
midwives do need to be mindful that whilst the majority of women may opt for the
testing to identify any potential health risks and consequential treatment, unhappiness
may be evoked for some women as fear and anxiety is associated with the choice to
accept or decline such a test.
There are two types of this theory: act utilitarianism and rule utilitarianism. Act
utilitarianism was developed by Bentham, Mill and S idgwick in the 18th and 19th
centuries and is the purer form of the two types. The theory expects every potential
action to be assessed according to its predicted outcomes in terms of benefit. I n
comparison, rule utilitarianism considers moral rules that are intended to ensure the
greatest benefit, such that each act is assessed to how it conforms to the rules.
Practically, utilitarianism theory is a ractive in that it can aid decision making for the
masses, such that an action is good if it provides benefits for the majority.
Deontology
This particular ethical theory derives from the Greek term deon, meaning duty, rule or
obligation, and was formulated around the right thing to do without regard to the
consequences by the German metaphysician, I mmanuel Kant. A ll health professionals
would appreciate they have a duty towards their patients/clients, but as shown in Box
2.6, they may have duties in other areas that they need to consider and balance in
order to make appropriate decisions to take the best course of action. How duty is
interpreted may vary according to the individual's personal situation, their values or
beliefs with some individuals basing their duty on natural laws, religion and the Ten
Commandments (traditional deontology).
Box 2.6
D ut y of ca re t o …
• Self
• Colleagues
• Women (mothers)/patients
• Relatives
• Fetus/baby
• Employer
• Profession (NMC)
The philosophy behind Kant's theory reflects that to act morally is concerned with
truth-telling and out of respect for duty, regardless of the circumstances. Kant believed
that the actions of an individual should always be rational and stem from good will,
that is to say, duty for its own sake, namely the categorical imperative, which is
expressed as follows:
• Act only according to that maxim by which you can also will that it would become a
universal law.
• Act in such a way that you always treat humanity, whether in your own person or in
the person of any other, never simply as a means, but always at the same time as an
end.
This highlights that an action can only be moral if it can be applied to everyone
universally: if everyone was to do it. Kant believed all individuals to be autonomous
and rational and should be treated with respect rather merely as a means to an end.
Beauchamp and Childress (2012) consider that if an action necessitates treating
someone without respect then it is the action that is wrong. I n maternity care, respecting
women as individuals with their own personal experiences is fundamental to the role
of the midwife.
A lthough the N HS and other healthcare providers are generally utilitarian,
midwifery, nursing, medicine and other such disciplines adopt a more deontological
approach. The duty of care which is the duty that health professionals are most familiar
with, is in essence embedded in the text of The Code (NMC 2008).
Conflicting duties can cause dilemmas in deciding the best course of action.
Casuistry is a system that can assist in prioritizing duties according to the
circumstances. However, most people deal with conflicts and dilemmas in their lives
without having an appreciation of these theories. N evertheless, whether midwives opt
to utilize formal or informal approaches to assist their ethical decision-making in
practice, to have knowledge of each of them is important in order to understand how
some decisions are made. Furthermore, having knowledge of ethical theories can help
midwives to appreciate why certain approaches are taken by the employing
organization/management when changes or implementation of innovations are
proposed in practice.
The statutory supervision of midwives
The purpose of supervision of midwives is to protect women and babies by actively
promoting safe standards of midwifery practice. S upervision is a statutory
responsibility that provides a mechanism for support and guidance to all midwives
practising in the UK, empowering them to work within the full scope of their role
(N MC 2013). The philosophy of midwifery supervision and the standards it develops
reflect the key themes of clinical governance described in N HS First Class S ervice DH
(
1998). These themes are:
• professional self-regulation
• clinical governance
• life-long learning.
Historical context
The concept of the supervision of midwives was established in the UK in Edwardian
times with the passing of the 1902 Midwives A ct (England and Wales), the Midwives
(Scotland) Act in 1915 and the Midwives (Ireland) Act in 1918 that led to the se ing up
of a Central Midwives Board (CMB) in the respective countries. Under these A cts, the
CMBs that initially had a medical majority had the power to frame the rules to govern
midwifery practice and the authority to enforce their compliance. Midwives who
disobeyed or ignored the rules or who were guilty of negligence, malpractice or
personal or professional misconduct were consequently disciplined or suspended
from practice. At this time, failure to submit an intention to practise (I TP) form or
submitting incomplete details would result in the midwife incurring a fine.
A lthough the CMBs had the responsibility for supervising the effective running of
the profession, much of the responsibility for the supervision of midwives lay with
Local Authorities (LA) that were under the control of county councils/county borough
councils. A s a consequence of the LA s acquiring extensive powers by the CMBs, they
eventually became known as Local S upervising Authorities (LS A). The extent of the
functioning powers of the LSA included:
• the supervision of midwives practising within their district in accordance with the
CMB rules;
• investigating allegations of malpractice, negligence or misconduct;
• reporting the names of any practising midwife convicted of an offence;
• suspending a midwife from practice if they were likely to be a source of infection;
• reporting the death of any midwife;
• receiving the notification of intention to practise from each practising midwife
within their district; and
• submitting a roll of midwives annually to the CMB.
The role of the LS A O fficer was undertaken by the Medical O fficer of Health (MO H
who passed on the bulk of their LS A work to non-medical inspectors. The first
inspectors were often clergymen's daughters, members of the local gentry, or relatives
of the MO H (Heagerty 1996). These individuals were used to supervising subordinates
and had domestic standards much higher than those of the working-class midwives.
A s a result, they were extremely critical of the poor environments in which many of
the midwives lived and practised at this time. The inspectors were at liberty to inspect
the midwives in any way they felt appropriate. They could follow them on their
rounds, visit their homes, question the women they had cared for and even investigate
their personal lives in addition to inspecting their equipment (Kirkham 1996). Records
could not be checked as they were rarely made due to the fact that many midwives
were illiterate, notwithstanding their immense practical knowledge and independence.
T h e Midwives A ct 1936 empowered the CMB to set rules requiring midwives to
a end refresher courses and determined the qualifications of medical and non-
medical inspectors: the la er being practising midwives. I n 1937, further expansion of
the 1936 Midwives A ct stated that inspectors of midwives were to be known as
‘supervisors of midwives’ with their role being more of a counsellor and friend.
I n 1974 the N ational Health S ervice (Reorganization) A ct 1973designated Regional
Health Authorities in England and A rea Health Authorities in Wales as LS A s. By 1977
the medical supervisor role had been abolished with all subsequent supervisors being
practising midwives. The reorganization also led to supervision being introduced into
the hospital environment as well as in the community.
T he Midwives A ct 1951 and Midwives (S cotland) A ct 1951 required LS A s, through
the supervisors of midwives, to ensure midwives a ended statutory postgraduate
courses (refresher courses). This statutory requirement continued until 2001 when
Rule 37 (UKCC 1998) was superseded by the Post Registration Education and Practice
(PREP) standards U ( KCC 1997) and the subsequent developments in midwives'
continuing professional development as a consequence of the N ursing and Midwifery
Order 2001 and its amendments.
The responsibility for monitoring the statutory supervision of midwives is through
the regulator, the N MC and detailed in the Midwives Rules and S tandards NMC (
2012b). The S tandards for the Preparation and Practice of S upervisors ofMidwives
(N MC 2006b) provides further detail and clarity about the statutory supervision of
midwives.
Supervision of midwives in the 21st century
Many of the historic functions of the statutory supervision of midwives continue
today, although they exist in a much more supportive fashion. The principal aim of
statutory supervision of midwives is still the protection of the public, however the
philosophy is centred on promoting best practice and excellence in care, preventing
poor practice and intervening in unacceptable practice. Effective use of the supervisory
framework leads to improvements in the standard of midwifery care and be er
outcomes for women. This endorses the need for midwives and supervisors of
midwives to work towards a common aim of providing the best possible care for
women and babies through a mutual responsibility for effective communication.
Consequently, there is much more emphasis placed on discussion, support and
continuing professional development needs with the supervisor of midwives
providing a confidential framework for a supportive relationship with the midwife.
Midwives are still required to give notice to each LS A in whose area they intend to
practise, before commencing to practise there. S ubsequently midwives must give
notice in respect of each 12 month period in which they intend to continue practising
within a specific location (N MC 2012b: Rule 3). The intention to practise (I TP)
documentation is now linked to the registrant's entry on the midwives part of the
N MC register. This confirms the midwife'seligibility to practise to an employer and the
public rather than the midwife merely having an effective registration.
Local Supervising Authorities
Local S upervising Authorities (LS A) are organizations within geographical areas,
responsible for ensuring that statutory supervision of midwives is undertaken
according to the standards set by the N MC under article 43 of theN ursing and
Midwifery O rder (The O rder) 2001: details of which are set out in the Midwives Rules
and Standards (NMC 2012b).
The Order states that each LSA shall:
1. exercise general supervision over all midwives practising in its area;
2. where it appears that the fitness to practise of a midwife in its area is impaired,
report it to the Council; and
3. have power in accordance with the rules made under Article 42 [of The Order] to
suspend a midwife from practice.
Local S upervising Authority arrangements differ across the UK. I n England the LS A
is N HS England, in Wales, it is Healthcare I nspectorate Wales, in S cotland it rests with
the Health Boards and in N orthern I reland, the LS A is the Public Health A gency .
A lthough the LS A role has no management responsibility to these organizations, it
does act as a focus for issues relating to midwifery practice with its strength lying in its
influence on quality in local maternity services.
Role of the LSA Midwifery Officer
Each LS A has an appointed LS A Midwifery O fficer (LS A MO ) employed to carry o
the LS A function who is professionally accountable to the N MC. The LS A MO is
practising midwife with experience in statutory supervision and who provides an
essential point of contact for supervisors of midwives to consult for advice on aspects
of supervision. Members of the public who seek help or support concerning the
provision of midwifery care can also contact the LSAMO directly.
The LS A MO provides leadership, support and guidance on a range of ma ers
including professional development and also contributes to the wider N HS agenda by
supporting public health and inter-professional activities at national level. I t is a
unique role in that it does not represent the interests of either the commissioners or
providers of N HS maternity services. A list of the functions of the LS A , as discharged
by the LSAMO, can be found in Box 2.7.
Box 2.7
D ut ie s of t he L oca l S upe rvising A ut horit y M idwife ry
O ffice r ( L S A M O )
Ensures that supervision is carried out to a satisfactory standard for all
midwives within the geographical boundaries of the LSA
Provides impartial, expert advice on professional matters
Provides a framework for supporting supervision and midwifery practice
Operates a system that ensures each midwife meets the statutory
requirements for practice
Selects and appoints supervisors of midwives and deselects if necessary
Ensures the supervisor of midwives to midwives ratio does not normally
exceed 1 : 15
Provides a formal link between midwives, their supervisors and the
statutory bodies
Implements the NMC's rules and standards for supervision of midwives
Provides advice and guidance to supervisors of midwives
Participates in the development and facilitation of programmes of
preparation for prospective supervisors of midwives
Provides initial training and continuing education opportunities for
supervisors of midwives
Provides advice on midwifery matters to maternity care providers
Works in partnership with other agencies and promotes partnership
working with women and their families
Provides a point of contact for women to discuss any aspect of their
midwifery care that they do not feel has been addressed through other
channels
Manages communications within supervisory systems with a direct link
between supervisors of midwives and the LSA
Conducts regular meetings with supervisors of midwives to develop key
areas of practice
Investigates cases of alleged misconduct or lack of competence
Determines whether to suspend a midwife from practice, in accordance
with Rule 14 of the Midwives Rules and Standards (NMC 2012b)
Conducts investigations and initiates legal action in cases of practice by
persons not qualified to do so under the Nursing and Midwifery Order
(2001)
Receives reports of maternal deaths
Leads the development of standards and audit of supervision
Maintains a list of current supervisors of midwives
Receives intention to practise data from every midwife practising in the
LSA
Prepares an annual report of supervisory activities within the report year,
including audit outcomes and emerging trends affecting maternity
services for the NMC, DH and Trusts
Publishes details of how to contact supervisors of midwives
Publishes details of how the practice of midwives will be supervised
Publishes the local mechanism for confirming any midwife's eligibility to
practise.
Having regular contact with supervisors of midwives and being part of the LS A MO
Forum UK ensures that each LS A Midwifery O fficer has detailed knowledge o
contemporary issues to enable the development of midwifery practice in meeting the
needs of women and their families (Bacon 2011). O ne of the many aims of the LS A MO
Forum UK is to ensure that it contributes to maintaining a consistent and equitable
approach to supervision through UK wide guidance.
Selection and preparation of supervisors of midwives
The statutory supervision of midwives is a valuable component of midwifery practice,
however its success reflects the ability of those who are appointed as supervisors of
midwives. I t is therefore important to have robust high-quality preparation and
ongoing assessment of performance. However, formal courses of instruction for
supervisors of midwives did not exist until 1978, and it was not until the English
N ational Board for N ursing, Midwifery and Health Visiting (EN B) developed an O pe
Learning Programme at D iploma level in 1992 (E N B 1992) that training to become a
supervisor of midwives prior to appointment became a requirement.
T he standards for the preparation and practice of supervisors of midwives (N MC 2006b)
outline the standards of competence that underpin the principles of statutory
supervision of midwives, in accordance with the Midwives Rules and S tandards (NMC
2012b: Rule 9). Programmes of education are now delivered at first degree or masters
level by Higher Education I nstitutions (HEI ) and are approved and monitored
annually by the N MC (N MC 2006b). Midwives must complete the course successfully
before being eligible for appointment as a supervisor of midwife.
Role and responsibilities of the supervisor of midwives
S upervisors of midwives are independent of the employer and often work in a team.
Their role is different from the midwifery manager, who is responsible to the
employer to make sure that maternity services run effectively. Supervisors of midwives
are accountable to the LS A and are supported in their role by the LS A MO . The
provide leadership and guidance to midwives that include a 24-hour service provision
for midwives and women (NMC 2007b; LSAMO Forum UK 2009).
Each supervisor has a professional and practice responsibility to ensure that the
practice within their own clinical area is evidence-based, to challenge and monitor
midwifery practice, set standards and carry out clinical audit. They must ensure that
their personal supervisees have access to the N MC statutory rules and standards
(NMC 2012b) and The Code (N MC 2008), and to local and national clinical guidelines.
A mong their many duties, a supervisor is responsible to audit records, arrange regular
meetings with their supervisees at least annually and work with them to identify any
areas of practice requiring development. A list of the responsibilities of a supervisor of
midwives is provided in Box 2.8.
Box 2.8
R e sponsibilit ie s of a supe rvisor of m idwive s include
Being accountable to the Local Supervising Authority for all supervisory
activities
Maintaining an awareness of local, regional and national health-related
issues
Providing professional leadership
Being an effective change agent
Liaising with clinicians, managers and educationalists
Providing practical advice, guidance and support on all midwifery matters,
including ethical issues
Supporting best practice and ensuring women-centred, evidence-based
midwifery care
Offering guidance and support to women accessing maternity services
Being a confident advocate for midwives and childbearing women
Empowering women and midwives
Being a professional role model to midwives and student midwives
Facilitating a supportive partnership with midwives in clinical practice
Being approachable and accessible to midwives
Supporting midwives through dilemmas
Facilitating midwives' reflection on critical incidents
Assisting midwives with their personal and professional development
plans
Undertaking annual supervisory reviews with personal supervisees
Supporting midwives undertaking LSA Practice Programmes [The
Programme]
Being a mentor to midwives undertaking preparation of supervisor of
midwives programmes
Maintaining records of all supervisory activities
Statutory supervision in action
Each supervisor of midwives is in an excellent position to identify good practice and
also to learn of examples of good practice in other maternity units through the
supervisory network that can be adopted within their own units. Where midwives have
ideas for changing and improving practice, supervisors should be able to empower
them to introduce such change and support them in their initiatives, acting as their
advocate with senior staff.
Partnership between supervisor and midwife/supervisee
To benefit from supervision, mutual respect between the supervisor of midwives and
their midwives/supervisees is essential. Midwives should work in partnership with
their supervisors and make the most of supervision (LS A MO Forum UK 2009 ), so that
it can be effective not only for themselves but also for the mothers and babies for
whom they care.
The primary responsibilities of a midwife are to ensure the safe and efficient care of
women and their babies, and to maintain personal fitness for practice to sustain their
registration with the N MC. The supervisory relationship enables, supports and
empowers midwives to fulfil these responsibilities. Figure 2.1 demonstrates how
midwives can make the most of supervision and the benefits of a professional
relationship with their named supervisor of midwives.
FIG. 2.1 Making the most of supervision. (From Modern supervision in action, a practical guide for
midwives, LSAMO Forum UK 2009, with permission from the Local Supervising Authority Midwifery Officers Forum
UK.)
Supervisory reviews
S upervisory reviews provide midwives with an opportunity to take time out with their
named supervisor of midwives to consider personal learning needs and professional
development requirements. These review meetings can be used to consider
mechanisms for gaining relevant experience in other areas and receiving the necessary
professional knowledge and skills.
Midwives are responsible for meeting their own PREP requirements before re-
registering with the N MC (2011) and these requirements can be discussed with the
supervisor of midwives during the review. The supervisor will be able to guide the
midwife if further academic study is being considered. The review also provides an
opportunity to evaluate practice and share any practice issues causing concern. I f it is
felt necessary, the supervisor will investigate the matter and take appropriate action.
A lthough it is customary for only one supervisory review a year, midwives are able
to access their supervisor as and when required. A s many supervisors hold clinical
posts, they often work alongside the midwives they supervise and have more regular
contact on an informal basis. Being valued and supported by supervisors and having
achievements recognized enhances midwives' professional confidence and practice.
The supervisory decisions perceived as empowering are those made by a consensus
between the supervisor and the midwife (S tapleton et al 1998). I f this relationship is
not recognized by either midwife or supervisor, then the opportunity to change
supervisor should be taken by the midwife to enable the necessary rapport and
confidence in the supervisory relationship for it to be successful. I t benefits some
midwives to change their supervisor every few years, while others feel the need for a
longer-term relationship.
Clinical governance
Clinical governance was introduced in British health policy as a term to describe the
accountability processes for the safety, quality and effectiveness of clinical care delivered
to service users (D H 1997; S co ish Executive 1997; Welsh O ffice 1998; D epartment of
Health, S ocial S ervices and Public S afety [D HS S PS ] 2001
). I t was originally defined in
First Class Service (DH 1998: 33) as
a framework through which NHS organizations are accountable for continuously
improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence in clinical care will flourish.
A ccording to J aggs-Fowler (2011), clinical governance has developed beyond simply
being a moral principle and is now a statutory duty for all N HS organizations to
address, forming part of the overall drive to improve quality. I t is just one component
of the management tools variously known as total quality management and continuous
quality improvement.
A s part of implementing the concept of clinical governance, two government-
appointed bodies, the N ational I nstitute for Health and Clinical Excellence [N I CE
(known as the N ational I nstitute for Health and Care Excellence from 2013) and the
N ational Commissioning Board (a peer and lay body), were initially introduced in
England to standardize, improve and assess the quality of clinical practice on a
national basis. However, with the extensive reorganization of the N ational Health
S ervice (N HS ) as a result of theHealth and S ocial Care A ct 2012, five key national
bodies have been assigned to coordinate consistent governance of the N HS in
England:
• The Department of Health
• The NHS Commissioning Board: NHS England
• The National Institute for Health and Care Excellence
• The Care Quality Commission
• The economic regulator Monitor.
Clinical Commissioning Groups (CCGs) now operate as statutory bodies replacing
Primary Care Trusts (PCTs) and S trategic Health Authorities (S HA s) and consequentl
have taken over the responsibility for commissioning the vast majority of N HS
services, including hospital care, community and mental health services. I n addition,
local CCGs are responsible for monitoring the quality of the care provided.
Within the context of local midwifery practice, the focus of clinical governance lies
in the effective partnership between women and health professionals and the
establishment of midwifery networks where the voice of service users assists in
shaping local maternity services, policies, protocols, guidelines and standards. I n
addition, professional bodies endorse the importance of health professionals working,
learning and collaborating to provide safe and effective care to childbearing women,
their babies and families (Royal College of O bstetricians and Gynaecologists [RCO G]
RCM, Royal College of A naesthetists [RCoA ], Royal College of Paediatrics and Chil
Health [RCPCH] 2007 ; RCO G, RCM, RCoA 2008 ; RCO G 2009). Regular monitoring
visits by the LS A Midwifery O fficer, and by national bodies such as the Care Q uality
Commission (CQ C) (England), Healthcare I mprovement S cotland, Healthcar
I nspectorate Wales, the Regulation and Q uality I mprovement Authority (N orthern
I reland) and periodical assessments by the N MC means that, from a clinical
governance perspective, there can be confidence in the standard of care provided in
each maternity unit.
The key components of clinical governance
Clinical governance should be an integrated process in all aspects of health care
delivery and the various processes underpinning it should in themselves be integrated
with each other (J aggs-Fowler 2011). With this in mind the key components of clinical
governance can be grouped into three main categories: clinical effectiveness, risk
management and patient focus and public involvement, all of which contribute to the
delivery of high-quality care as summarized in Box 2.9. However, it may also be
prudent to acknowledge that effective leadership and interpersonal skills are also vital
components to the successful governance of an organization.
Box 2.9
K e y com pone nt s of clinica l gove rna nce
Policies, protocols, guidelines and standards
A ll healthcare providers are required to have policies, protocols, guidelines and
standards in place to govern safe, effective and quality care to the public. I t is
important that midwives understand the differences between these definitions in
order to utilize them appropriately in their clinical practice.
Policies are general principles or directions, usually without the mandatory approach
for addressing an issue. They are a means of ensuring a consistent standard of care to
avoid any confusion over practice and are often set at national level, for example
M idwifery 2020 (D H 2010) and A Refreshed Framework for M aternity Services inScotland
(S co ish Government 2011). Policies should make clear the procedures that will be
followed by midwives, doctors and support staff. There are differing views about the
benefits of policies, ranging from ensuring safe practice and providing consistency, to
restricting midwives' autonomy. I ndeed, if a midwife's clinical judgement on an
individual woman's care is at odds with policy, she may be in breach of her contract of
employment unless she can justify her actions.
The term protocol is often used interchangeably with ‘guideline’. A protocol is
usually regarded as a local initiative that practitioners are expected to follow, but may
also vary in meaning, e.g. a wri en agreement between parties, a multidisciplinary
action plan for managing care, or an action plan for a clinical trial. Protocols therefore
determine individual aspects of practice and should be based on the latest evidence.
Most protocols are binding on employees as they usually relate to the management of
individuals with urgent, life-threatening conditions, for example antepartum
haemorrhage, such that if the practitioner does not work within the protocol they
would be deemed to be in breach of their employment contract. However, it would not
be expected to have protocols for the care of healthy women experiencing a
physiological labour and birth.
Guidelines are usually less specific than protocols and may be described as
suggestions for criteria or levels of performance that are provided to implement
agreed standards. Both guidelines and standards should be based on contemporary,
reliable research findings and include specific outcomes which act as performance
indicators, upon which progress can be measured as evidence of achievement within
an agreed timescale. The National Institute for Health and Care Excellence (NICE) sets
guidelines for clinical practice in all areas of health care, including maternity and
neonatal care to provide good practice guidance for midwives and obstetricians.
S upervisors of midwives play an important role in facilitating midwives to implement
these guidelines within their own scope of practice. The interpretation and application
of a guideline remains the responsibility of individual practitioners, as they should be
aware of local circumstances and the needs and wishes of informed women.
Guidelines are therefore tools to assist the midwife in making the most appropriate
clinical decision in partnership with the woman, based on best available evidence.
I t is acknowledged that there is a plethora of clinical guidelines not only produced
by N I CE but also organizations such as the S co ish I ntercollegiate Guidelines
N etwork (S I GN ), RCO G and RCM. However, as variations in outcomes persist, it
essential that commissioners build into their contracts the requirements to deliver
services to national standards and to manage performance against these. I t is the
responsibility of the Care Q uality Commission in England, Healthcare I mprovement
S cotland, the Regulator and Q uality I mprovement Authority in N orthern I reland and
Healthcare I nspectorate Wales to monitor health services against national standards
in the respective UK countries.
Audit
Clinical audit is a process that is undertaken to review and evaluate the effectiveness
of practice by measuring standards of health/midwifery care against national
benchmarks. I t is important to ensure that the auditing process is comprehensive,
multidisciplinary and centred upon the women who receive the care and that the audit
loop is closed completely. This means that should the data collected reveal any
shortfall in meeting clinical standards, strategies to rectify such a deficit should always
be implemented. Furthermore, when a change in practice is implemented, there
should always be an evaluation to ensure the audit cycle develops into an audit spiral,
leading to improved health care.
I n midwifery, local surveys should take place regularly to monitor women's
satisfaction with their maternity care to ensure these achieve the expected standards
as well as identify areas for improvement. To address clinical governance, each
maternity unit/service is expected to publish its local statistics and monitor generic
indicators of the effectiveness and efficiency of health care. S uch outcomes include
healthcare-acquired infection (HCA I ), infant mortality, neonatal mortality and
stillbirths, women's experiences of childbirth and admission of full-term babies to
neonatal care (DH 2012), as shown in Box 2.10.
Box 2.10
N H S out com e s fra m e work re la t ing t o m a t e rnit y ca re
Source: NHS outcomes framework, 2013–2014 (DH 2012)
Health care-associated infections (HCA I s) have become the subject of considerable
public interest as a consequence in the rise in methicillin-resistant Staphylococcus
aureus (‘MRS A ’) andClostridium difficile (‘C. diff’). This is of particular concern to the
maternity services as the latest Confidential Enquiries into maternal deaths reported
that the leading cause of direct deaths during the triennium 2006–2008 was sepsis,
accounting for 26 deaths (Harper 2011). Consequently, the prevention of infection was
one of the top 10 recommendations from the report. However, with the introduction of
a national strategy to reduce the rates of MRS A and C. diff, there is evidence that the
rates of both types of infection have more than halved (N ational Patient S afety A gency
[NPSA] 2007a, 2007b; National Audit Office 2009).
Risk management
Risk management is the systematic identification, analysis and control of any potential
and actual risk and of any circumstances that put individuals at risk of harm. The
concept was introduced in the mid-1990s with the principal aim of reducing litigation
costs. O rganizations such as the UK N HS are expected to adhere to the legislation
pertaining to health and safety in the work place and other legal principles such as the
duty of care to both the public and employees as part of their risk management strategy
(CQ C 2010; N HS LA 2013 ). Managing risk is therefore a fundamental component of
clinical governance.
W hen a risk is evaluated it is not only important to consider the probability of
something adverse happening but also the consequences if it should happen. I n the
context of health care, risk is usually associated with health risks, injury and death.
More specifically within the context of maternity care, the risk of harm would include
injury to a woman and/or her baby during childbirth or to a health professional
engaged in providing maternity care. The risk of detriment is associated with some form
of economic/social loss, which may not only include a valuation of harm to individuals
but also damage on a much wider scale, such as adverse publicity for the local
maternity services. A ll health service managers are expected to be conversant in risk
management theory in order to identify and manage risk so that the probability of
harm or detriment is lessened and the consequences of risk are reduced.
The introduction of the M odified Early O bstetric Warning Scoring(MEO W S ) system
(N I CE 2007; D H 2009b; Centre for Maternal and Child Enquiries [CMA CE] 2011 ) has
contributed to the recognition of early warning signs in those women identified at risk
of developing serious complications and life-threatening conditions to prompt earlier
initiation of high-level care and more senior involvement in care planning and
management.
Poor communication among health professionals is often criticized as being the
commonest cause of preventable adverse outcomes in hospitals and a significant cause
of wri en complaints (Health and S ocial Care I nformation Centre [HS CI C] 2012 ). A n
inquiry into the safety of birth in England found that when there are increased risks to
the woman or baby, that render some births less safe, functioning teams are the key to
improving the outcome for the woman and baby (Kings Fund 2008).
The use of the Situation, Background, Assessment and Recommendation (S BA R) tool
(N HS I nstitute for I nnovation and I mprovement 2008 ) can assist in improving
communication among members of the multiprofessional team. I ts purpose is to
enable health professionals to frame concise and focused information about the
condition of a childbearing woman that requires immediate a ention and action.
Consequently, the S BA R tool assists in clarifying which information should be
communicated between health professionals, enabling the development of efficient
teamwork and the fostering of a culture of safety (RCOG 2009).
Clinical Negligence Scheme for Trusts (CNST)
The Clinical N egligence S cheme for Trusts (CN S T) is a voluntary risk-pooling schem
for negligence claims arising out of incidents occurring after 1 A pril 1995. I t is
administered by the N HS LA , and all N HS Trusts, Foundation Trusts and Clinic
Commissioning Groups (formerly PCTS ) in England subscribe to CN S T by paying a
insurance premium based on their individual compliance to certain general standards.
There are equivalent schemes in S cotland (Clinical N egligence and O ther Risks
I ndemnity S cheme [CN O RI S ]), in Wales (the Welsh Risk Pool) and N orthern I relan
T he N HS LA (2013)have produced a special standard for maternity services with a set
of additional criteria and minimum requirements for specific situations. The basis of
the standard relate to the following:
• organization
• clinical care
• high-risk conditions
• communication
• postnatal and neonatal care.
Consequently, risk management is an essential mission with significant funding
implications for all healthcare providers striving for excellence.
I t has been reported by the N HS LA (2012)that within the decade 2000–2010 over
£3.1 billion was paid out in damages in a total of 5087 maternity claims to babies and
mothers who were injured as a result of harm incurred during childbirth. I n this
period there were 5.5 million births, thus less than 1 in every 1000 births (0.1%) had
become the subject of a claim, indicating that the vast majority of births do not result
in a clinical negligence claim. N evertheless, although obstetric and gynaecology claims
accounted for 20% of the total number of claims the N HS LA received, it is significant
to note that this area of practice was in fact responsible for 49% of the total value as
compensation often involves 24-hour care for the claimant for the rest of their lives.
Clinical governance, risk management and statutory
supervision of midwives
The statutory supervision of midwives is a vital element of leadership and clinical
governance within the maternity services that also supports risk management by
monitoring the development of maternity services and standards of midwifery practice
such that women receive care that is both safe and of a high quality. A n illustration of
how the statutory supervision of midwives sits within clinical governance.
The nature of statutory supervision of midwives can limit the volume of serious
adverse incidents within an organization by its supportive educative function to each
individual midwife. I n addition, the LS A Midwifery O fficers regularly monitor
standards of practice against documented evidence such as the Confidential Enquiries
into Maternal D eaths, stillbirths and infant deaths reports as well as national
standards and guidelines, through their supervisory audit visits to each maternity
unit. W here there are unacceptable variations in clinical midwifery practice or care is
inappropriate for women's needs, the LS A Midwifery O fficer as an outside assessor is
in a position to recommend remedial action (N MC 2012a). I n addition, the LS A can
contribute to the dissemination of national standards, such as safeguarding practices,
to ensure the implementation of the most effective care at a local level.
Local S upervising Authorities (LS A s) must publish guidelines for investigating
incidents including near misses, complaints or concerns relating to midwifery practice
or allegations of impaired fitness to practice against a midwife (N MC 2012b: Rule 10).
The guidelines should include a time frame for the investigation and a communication
strategy between the supervisor of midwives, the LS A and the employer (if the
midwife is employed), a support mechanism for the midwife undergoing investigation
and a procedure for obtaining an account of the woman and her family's experience.
There should also be details of the action to be taken upon completion of the
investigation, including disseminating the report and reporting to the midwife's
employer or other healthcare regulators should the investigation find issues with
systems or governance or other professions that may have contributed to unsafe
practice. O n occasion supervisory investigations are conducted by supervisors outside
of the area where the practice concern arose. The benefits of externally led
investigations as determined by Paeglis (2012: 25) include:
• no confusion for the midwives or employers that this is a LSA and not a
management process;
• complete objectivity;
• a fresh eyes approach to practice issues that might previously have been accepted as
custom and practice;
• sharing of good midwifery and supervisory practice and of lessons learned.
S hould there be an appeal against a decision, the LS A Midwifery O fficer is
responsible for convening a local panel to review the handling of the investigation and
the outcome in order to decide upon any further action.
Following an investigation, the LS A may recommendno action, local action under the
supervision of a named supervisor of midwives or a LSA practice programme/referral to the
NMC. Box 2.11 identifies the outcomes arising from a LS A investigation and the
subsequent actions taken.
Box 2.11
O ut com e s a rising from a L oca l S upe rvisory A ut horit y
inve st iga t ion a nd subse que nt a ct ions t a ke n
Source: Midwives Rules and Standards (NMC 2012b)
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Further reading
Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th edn. Oxford
University Press: Oxford; 2012.
This popular best-selling text provides a highly original, practical and insightful guide
to morality in the health professions. Drawing from contemporary research and
integrating detailed case studies and vivid real-life examples and scenarios, the
authors demonstrate how ethical principles can be expanded to apply to various
conflicts and dilemmas in clinical practice..
LSA Midwifery Officers Forum UK. Modern supervision in action – a practical guide
for midwives. NMC: London; 2009.
This useful book helps midwives to get the most out of supervision. It is very user-
friendly and explains the supervision of midwives very succinctly from the perspective
of the midwife rather than the supervisor of midwives..
Useful websites
Care Quality Commission (CQC) (England). www.cqc.org.uk.
Government departments (including Health). www.gov.uk.
HealthCare Improvement (Scotland). www.healthcareimprovementscotland.org.
Healthcare Inspectorate (Wales). www.hiw.org.uk.
International Confederation of Midwives (ICM).
www.internationalmidwives.org.
Medicines and Healthcare Products Regulatory Agency (MHPRA).
www.mhra.gov.uk.
National Health Service Improving Quality (formerly NHS Institute for
Innovation and Improvement). www.hsiq.nhs.uk.
National Health Service Litigation Authority (NHSLA). www.nhsla.com.
NHS England. www.england.nhs.uk.
Nursing and Midwifery Council (NMC). www.nmc-uk.org.
Professional Standards Authority (PSA). www.professionalstandards.org.uk.
Regulation and Quality Improvement Authority (Northern Ireland).
www.rqia.org.uk.
Royal College of Anaesthetists. www.rcoa.ac.uk.
Royal College of Midwives. www.rcm.org.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
Royal College of Paediatrics and Child Health. www.rcpch.ac.uk.
Scottish Intercollegiate Guidelines Network. www.sign.ac.uk.
The Scottish Government. www.scotland.gov.uk.
S E CT I ON 2
Human anatomy and reproduction
OU T LIN E
Chapter 3 The female pelvis and the reproductive organs
Chapter 4 The female urinary tract
Chapter 5 Hormonal cycles
Chapter 6 The placenta
Chapter 7 The fetus
C H AP T E R 3
The female pelvis and the reproductive
organs
Ranee Thakar, Abdul H Sultan
CHAPTER CONTENTS
Female external genital organs 55
The perineum 56
The urogenital triangle 56
The anal triangle 57
The ischioanal fossa 61
The perineal body 61
The pelvic floor 61
The pudendal nerve 62
The pelvis 62
The pelvic girdle 62
Pelvic joints 64
Pelvic ligaments 64
The pelvis in relation to pregnancy and childbirth 65
The true pelvis 65
The false pelvis 66
Pelvic diameters 66
Orientation of the pelvis 67
Four types of pelvis 68
Other pelvic variations 69
The female reproductive system 70
The vagina 70
The uterus 72
Uterine malformations 74
The fallopian tubes 75
The ovaries 76
The male reproductive system 77
The scrotum 78
The testes 78
The spermatic cord 78
The seminal vesicles 79
The ejaculatory ducts 79
The prostate gland 79
The bulbourethral glands 79
The penis 79
The male hormones 80
Formation of the spermatozoa 80
Further reading 80
It is important that midwives are well versed in the applied anatomy of the
female pelvis and understand the processes of reproduction.
The chapter aims to:
• cover the basic anatomy of the female and male reproductive system
• identify the main functions of the internal and external female and male genital organs.
Female external genital organs
The female external genitalia (the vulva) include the mons pubis, labia majora, labia
minora, clitoris, vestibule, the greater vestibular glands (Bartholin's glands) and bulbs
of the vestibule (Fig. 3.1).
• The mons pubis is a rounded pad of fat lying anterior to the symphysis pubis. It is
covered with pubic hair from the time of puberty.
• The labia majora (‘greater lips’) are two folds of fat and areolar tissue which are
covered with skin and pubic hair on the outer surface and have a pink, smooth inner
surface.
• The labia minora (‘lesser lips’) are two small subcutaneous folds, devoid of fat, that
lie between the labia majora. Anteriorly, each labium minus divides into two parts:
the upper layer passes above the clitoris to form along with its fellow a fold, the
prepuce, which overhangs the clitoris. The prepuce is a retractable piece of skin
which surrounds and protects the clitoris. The lower layer passes below the clitoris to
form with its fellow the frenulum of the clitoris.
• The clitoris is a small rudimentary sexual organ corresponding to the male penis. The
visible knob-like portion is located near the anterior junction of the labia minora,
above the opening of the urethra and vagina. Unlike the penis, the clitoris does not
contain the distal portion of the urethra and functions solely to induce the orgasm
during sexual intercourse.
• The vestibule is the area enclosed by the labia minora in which the openings of the
urethra and the vagina are situated.
• The urethral orifice lies 2.5 cm posterior to the clitoris and immediately in front of
the vaginal orifice. On either side lie the openings of the Skene's ducts, two small
blind-ended tubules 0.5 cm long running within the urethral wall.
• The vaginal orifice, also known as the introitus of the vagina, occupies the posterior
two-thirds of the vestibule. The orifice is partially closed by the hymen, a thin
membrane that tears during sexual intercourse. The remaining tags of hymen are
known as the ‘carunculae myrtiformes’ because they are thought to resemble myrtle
berries.
• The greater vestibular glands (Bartholin's glands) are two small glands that open on
either side of the vaginal orifice and lie in the posterior part of the labia majora. They
secrete mucus, which lubricates the vaginal opening. The duct may occasionally
become blocked, which can cause the secretions from the gland to accommodate
within it and form a cyst.
• The bulbs of the vestibule are two elongated erectile masses flanking the vaginal
orifice.
FIG. 3.1 Female external genital organs (vulva).
Blood supply
The blood supply comes from the internal and the external pudendal arteries. The
blood drains through corresponding veins.
Lymphatic drainage
Lymphatic drainage is mainly via the inguinal glands.
Innervation
The nerve supply is derived from branches of the pudendal nerve.
The perineum
The perineum corresponds to the outlet of the pelvis and is somewhat lozenge-shaped.
A nteriorly, it is bound by the pubic arch, posteriorly by the coccyx, and laterally by the
ischiopubic rami, ischial tuberosities and sacrotuberous ligaments. The perineum can
be divided into two triangular parts by drawing an arbitrary line transversely between
the ischial tuberosities. The anterior triangle, which contains the external urogenital
organs, is known as the urogenital triangle and the posterior triangle, which contains
the termination of the anal canal, is known as the anal triangle.
The urogenital triangle
The urogenital triangle (Fig. 3.2a) is bound anteriorly and laterally by the pubic
symphysis and the ischiopubic rami. The urogenital triangle has been divided into two
compartments: the superficial and deep perineal spaces, separated by the perineal
membrane which spans the space between the ischiopubic rami. The levator ani
muscles are a ached to the cranial surface of the perineal membrane. The vestibular
bulb and clitoral crus lie on the caudal surface of the membrane and are fused with it.
These erectile tissues are covered by the bulbospongiosus and the ischiocavernosus
muscles.
FIG. 3.2A Diagram of the perineum demonstrating the superficial muscles of the perineum. The
superficial transverse perineal muscle, the bulbospongiosus and the ischiocavernosus form a
triangle on either side of the perineum with a floor formed by the perineal membrane.
Superficial muscles of the perineum
Superficial transverse perineal muscle
The superficial transverse muscle is a narrow slip of a muscle that arises from the
inner and forepart of the ischial tuberosity and is inserted into the central tendinous
part of the perineal body (Fig. 3.2a). The muscle from the opposite side, the external
anal sphincter (EA S ) from behind, and the bulbospongiosus in the front, all a ach to
the central tendon of the perineal body.
Bulbospongiosus muscle
The bulbospongiosus (previously known as bulbocavernosus) muscle runs on either
side of the vaginal orifice, covering the lateral aspects of the vestibular bulb anteriorly
and the Bartholin's gland posteriorly (Fig. 3.2b). S ome fibres merge posteriorly with
the superficial transverse perineal muscle and the EA S in the central fibromuscular
perineal body. A nteriorly, its fibres pass forward on either side of the vagina and
insert into the corpora cavernosa clitoridis, a fasciculus crossing over the body of the
organ so as to compress the deep dorsal vein. This muscle diminishes the orifice of the
vagina and contributes to the erection of the clitoris.
FIG. 3.2B The left bulbospongiosus muscle has been removed to demonstrate the vestibular
bulb and the Bartholin's gland.
Ischiocavernosus muscle
The ischiocavernosus muscle is elongated, broader at the middle than at either end
and is situated on the side of the lateral boundary of the perineum (Fig. 3.2a). I t arises
by tendinous and fleshy fibres from the inner surface of the ischial tuberosity, behind
the crus clitoridis, from the surface of the crus and from the adjacent portions of the
ischial ramus.
Innervation
The nerve supply is derived from branches of the pudendal nerve.
The anal triangle
This area includes the anal canal, the anal sphincters and the ischioanal fossae.
Anal canal
The rectum terminates in the anal canal (Fig. 3.3). The anal canal is a ached
posteriorly to the coccyx by the anococcygeal ligament, a midline fibromuscular
structure that runs between the posterior aspect of the EA S and the coccyx. The anus
is surrounded laterally and posteriorly by loose adipose tissue within the ischioanal
fossae, which is a potential pathway for spread of perianal sepsis from one side to the
other. The pudendal nerves pass over the ischial spines at this point and can be
accessed for injection of local anaesthetic into the pudenal nerve at this site.
Anteriorly, the perineal body separates the anal canal from the vagina.
FIG. 3.3 (a) Coronal section of the anorectum. (b) Anal sphincter and levator ani.
The anal canal is surrounded by an inner epithelial lining, a vascular subepithelium,
the internal anal sphincter (I A S ), the EA S and fibromuscular supporting tissue. The
lining of the anal canal varies along its length due to its embryologic derivation. The
proximal anal canal is lined with rectal mucosa (columnar epithelium) and is arranged
in vertical mucosal folds called the columns of Morgagni (Fig. 3.3). Each column
contains a terminal radical of the superior rectal artery and vein. The vessels are
largest in the left-lateral, right-posterior and right-anterior quadrants of the wall of the
anal canal where the subepithelial tissues expand into three anal cushions. These
cushions seal the anal canal and help maintain continence of flatus and liquid stools.
The columns are joined together at their inferior margin by crescentic folds called anal
valves. A bout 2 cm from the anal verge, the anal valves create a demarcation called the
dentate line. A noderm covers the last 1–1.5 cm of the distal canal below the dentate
line and consists of modified squamous epithelium that lack skin adnexal tissues such
as hair follicles and glands, but contains numerous somatic nerve endings. S ince the
epithelium in the lower canal is well supplied with sensory nerve endings, acute
distension or invasive treatment of haemorrhoids in this area causes profuse
discomfort, whereas treatment can be carried out with relatively few symptoms in the
upper canal lined by insensate columnar epithelium. A s a result of tonic
circumferential contraction of the sphincter, the skin is arranged in radiating folds
around the anus and is called the anal margin. These folds appear to be flat or ironed
out when there is underlying sphincter damage. The junction between the columnar
and squamous epithelia is referred to as the anal transitional zone, which is variable in
height and position and often contains islands of squamous epithelium extending into
columnar epithelium. This zone probably has a role to play in continence by providing
a highly specialized sampling mechanism.
Anal sphincter complex
The anal sphincter complex consists of the EA S and I A S separated by the conjoin
longitudinal coat (Fig. 3.3). A lthough they form a single unit, they are distinct in
structure and function.
External anal sphincter
The EA S comprises of striated muscle and appears red in colour (similar to raw red
meat) (Fig. 3.4). A s the EA S is normally under tonic contraction, it tends to retract
when completely torn. A defect of the EAS can lead to urge faecal incontinence.
FIG. 3.4 An intact external anal sphincter (E) which is red in colour and appears like raw red
meat.
Internal anal sphincter
The I A S is a thickened continuation of the circular smooth muscle of the bowel and
ends with a well-defined rounded edge 6–8 mm above the anal margin at the junction
of the superficial and subcutaneous part of the EA S . I n contrast to the EA S , the I A S
has a pale appearance to the naked eye (Fig. 3.5). D efect of the I A S can lead to passive
soiling of stools and flatus incontinence.
FIG. 3.5 The internal anal sphincter (I) is pale in colour and appears like raw white meat: E =
external anal sphincter, M = mucosa.
The longitudinal layer and the conjoint longitudinal coat
The longitudinal layer is situated between the EA S and I A S and consists of a
fibromuscular layer, the conjoint longitudinal coat and the intersphincteric space with
its connective tissue components (see Fig. 3.3).
Innervation of the anal sphincter complex
The nerve supply is derived from branches of the pudendal nerve.
Vascular supply
The anorectum receives its major blood supply from the superior haemorrhoidal
(terminal branch of the inferior mesenteric artery) and inferior haemorrhoidal (branch
of the pudendal artery) arteries, and to a lesser degree, from the middle
haemorrhoidal artery (branch of the internal iliac), forming a wide intramural network
of collaterals. The venous drainage of the upper anal canal mucosa, I A S and conjoint
longitudinal coat passes via the terminal branches of the superior rectal vein into the
inferior mesenteric vein. The lower anal canal and the EA S drain via the inferior rectal
branch of the pudendal vein into the internal iliac vein.
Lymphatic drainage
The anorectum has a rich network of lymphatic plexuses. The dentate line represents
the interface between the two different systems of lymphatic drainage. A bove the
dentate line (the upper anal canal), the I A S and the conjoint longitudinal coat drain
into the inferior mesenteric and internal iliac nodes. Lymphatic drainage below the
dentate line, which consists of the lower anal canal epithelium and the EA S , proceeds
to the external inguinal lymph nodes.
The ischioanal fossa
The ischioanal fossa (previously known as the ‘ischiorectal fossa’) extends around the
anal canal and is bound anteriorly by the perineal membrane, superiorly by the fascia
of the levator ani muscle and medially by the EA S complex at the level of the anal
canal. The ischioanal fossa contains fat and neurovascular structures, including the
pudendal nerve and the internal pudendal vessels.
The perineal body
The perineal body is the central point between the urogenital and the anal triangles of
the perineum (see Fig. 3.2a). Within the perineal body there are interlacing muscle
fibres from the bulbospongiosus, superficial transverse perineal and EA S muscles.
A bove this level there is a contribution from the conjoint longitudinal coat and the
medial fibres of the puborectalis muscle. Therefore, the support of the pelvic
structures, and to some extent the hiatus urogenitalis between the levator ani muscles,
depends upon the integrity of the perineal body.
The pelvic floor
The pelvic floor is a musculotendinous sheet that spans the pelvic outlet and consists
mainly of the symmetrically paired levator ani muscle (LA M) (Fig. 3.6), which is a
broad muscular sheet of variable thickness a ached to the internal surface of the true
pelvis. A lthough there is controversy regarding the subdivisions of the muscle, it is
broadly accepted that it is subdivided into parts according to their a achments,
namely the pubovisceral (also known as pubococcygeus), puborectal and
iliococcygeus. The pubovisceral part is further subdivided according to its relationship
to the viscera, i.e. puboperinealis, pubovaginalis and puboanalis. The puborectalis
muscle is located lateral to the pubovisceral muscle, cephalad to the deep component
of the EAS, from which it is inseparable posteriorly.
FIG. 3.6 The levator muscle (reproduced courtesy of Professor John DeLancey). Schematic
view of the levator ani muscles from below after the vulvar structures and perineal membrane
have been removed showing the arcus tendineus levator ani (ATLA); external anal sphincter
(EAS); puboanal muscle (PAM); perineal body (PB) uniting the two ends of the puboperineal
muscle (PPM); iliococcygeal muscle (ICM); puborectal muscle (PRM). Note that the urethra and
vagina have been transected just above the hymenal ring.
The muscles of the levator ani differ from most other skeletal muscles in that they:
• maintain constant tone, except during voiding, defaecation and the Valsalva
manoeuvre;
• have the ability to contract quickly at the time of acute stress (such as a cough or
sneeze) to maintain continence;
• distend considerably during parturition to allow the passage of the term infant and
then contract after birth to resume normal functioning.
Until recently, the concept of pelvic floor trauma was a ributed largely to perineal,
vaginal and anal sphincter injuries. However, in recent years, with advances in
magnetic resonance imaging and three-dimensional ultrasound, it has become evident
that LA M injuries form an important component of pelvic floor trauma. LA M injuries
occur in 13–36% of women who have a vaginal birth. I njury to the LA M is a ributed to
vaginal birth resulting in reduced pelvic floor muscle strength, enlargement of the
vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an
association between LA M injuries and stress urinary incontinence and there seems to
be a trend towards the development of faecal incontinence.
Innervation of the levator ani
The levator ani is supplied on its superior surface by the sacral nerve roots (S 2–S 4) and
on its inferior surface by the perineal branch of the pudendal nerve.
Vascular supply
The levator ani is supplied by branches of the inferior gluteal artery, the inferior
vesical artery and the pudendal artery.
The pudendal nerve
The pudendal nerve is a mixed motor and sensory nerve and derives its fibres from the
ventral branches of the second, third and fourth sacral nerves and leaves the pelvis
through the lower part of the greater sciatic foramen. I t then crosses the ischial spine
and re-enters the pelvis through the lesser sciatic foramen. I t accompanies the internal
pudendal vessels upward and forward along the lateral wall of the ischioanal fossa,
contained in a sheath of the obturator fascia termed A lcock's canal (Fig. 3.7). I t is
presumed that during a prolonged second stage of labour, the pudendal nerve is
vulnerable to stretch injury due to its relative immobility at this site.
FIG. 3.7 Sagittal view of the pelvis demonstrating the pathway of the pudendal nerve and blood
supply.
The inferior haemorrhoidal (rectal) nerve then branches off posteriorly from the
pudendal nerve to innervate the EA S . The pudendal nerve then divides into two
terminal branches: the perineal nerve and the dorsal nerve of the clitoris. The perineal
nerve divides into posterior labial and muscular branches. The posterior labial
branches supply the labium majora. The muscular branches are distributed to the
superficial transverse perineal, bulbospongiosus, ischiocavernosus and constrictor
urethræ muscles. The dorsal nerve of the clitoris, which innervates the clitoris, is the
deepest division of the pudendal nerve (Fig. 3.8).
FIG. 3.8 Branches of the pudendal nerve.
The pelvis
Knowledge of anatomy of a normal female pelvis is key to midwifery and obstetrics
practice, as one of the ways to estimate a woman's progress in labour is by assessing
the relationship of the fetus to certain bony landmarks of the pelvis. Understanding
the normal pelvic anatomy helps to detect deviations from normal and facilitate
appropriate care.
The pelvic girdle
The pelvic girdle is a basin-shaped cavity and consists of two innominate bones (hip
bones), the sacrum and the coccyx. I t is virtually incapable of independent movement
except during childbirth as it provides the skeletal framework of the birth canal. I t
contains and protects the bladder, rectum and internal reproductive organs. I n
addition it provides an a achment for trunk and limb muscles. S ome women
experience pelvic girdle pain in pregnancy and need referral to a physiotherapist (see
Chapter 12).
Innominate bones
Each innominate bone or hip bone is made up of three bones that have fused together:
the ilium, the ischium and the pubis (Fig. 3.9). O n its lateral aspect is a large, cup
shaped acetabulum articulating with the femoral head, which is composed of the three
fused bones in the following proportions: two-fifths ilium, two-fifths ischium and one-
fifth pubis (Fig. 3.9). A nteroinferior to this is the large oval or triangular obturator
foramen. The bone is articulated with its fellow to form the pelvic girdle.
FIG. 3.9 Lateral view of the innominate bone showing important landmarks.
T he ilium has an upper and lower part. The smaller lower part forms part of the
acetabulum and the upper part is the large flared-out part. W hen the hand is placed
on the hip, it rests on the iliac crest, which is the upper border. A bony prominence
felt in front of the iliac crest is known as the anterior superior iliac spine. A short
distance below it is the anterior inferior iliac spine. There are two similar points at the
other end of the iliac crest, namely the posterior superior and the posterior inferior
iliac spines. The internal concave anterior surface of the ilium is known as the iliac
fossa.
T he ischium is the inferoposterior part of the innominate bone and consists of a
body and a ramus. A bove it forms part of the acetabulum. Below its ramus ascends
anteromedially at an acute angle to meet the descending pubic ramus and complete
the obturator foramen. I t has a large prominence known as the ischial tuberosity, on
which the body rests when si ing. Behind and a li le above the tuberosity is an
inward projection, the ischial spine. This is an important landmark in midwifery and
obstetric practice, as in labour, the station of the fetal head is estimated in relation to
the ischial spines allowing assessment of progress of labour.
T he pubis forms the anterior part. I t has a body and two oar-like projections, the
superior ramus and the inferior ramus. The two pubic bones meet at the symphysis
pubis and the two inferior rami form the pubic arch, merging into a similar ramus on
the ischium. The space enclosed by the body of the pubic bone, the rami and the
ischium is called the obturator foramen.
The sacrum
The sacrum is a wedge-shaped bone consisting of five fused vertebrae, and forms the
posterior wall of the pelvic cavity as it is wedged between the innominate bones. The
caudal apex articulates with the coccyx and the upper border of the first sacral vertebra
(sacral promontory) articulates with the first lumbar vertebra. The anterior surface of
the sacrum is concave and is referred to as the hollow of the sacrum. Laterally the
sacrum extends into a wing or ala. Four pairs of holes or foramina pierce the sacrum
and, through these, nerves from the cauda equina emerge to innervate the pelvic
organs. The posterior surface is roughened to receive attachments of muscles.
The coccyx
The coccyx is a vestigial tail. I t consists of four fused vertebrae, forming a small
triangular bone, which articulates with the fifth sacral segment.
Pelvic joints
There are four pelvic joints: one symphysis pubis, two sacroiliac joints and one
sacrococcygeal joint.
T he symphysis pubis is the midline cartilaginous joint uniting the rami of the left
and right pubic bones.
T he sacroiliac joints are strong, weight-bearing synovial joints with irregular
elevations and depressions that produce interlocking of the bones. They join the
sacrum to the ilium and as a result connect the spine to the pelvis. The joints allow a
limited backward and forward movement of the tip and promontory of the sacrum,
sometimes known as ‘nodding’ of the sacrum.
The sacrococcygeal joint is formed where the base of the coccyx articulates with the
tip of the sacrum. I t permits the coccyx to be deflected backwards during the birth of
the fetal head.
Pelvic ligaments
The pelvic joints are held together by very strong ligaments that are designed not to
allow movement. However, during pregnancy the hormone relaxin gradually loosens
all the pelvic ligaments allowing slight pelvic movement providing more room for the
fetal head as it passes through the pelvis. A widening of 2–3 mm at the symphysis
pubis during pregnancy above the normal gap of 4–5 mm is normal but if it widens
significantly, the degree of movement permitted may give rise to pain on walking.
The ligaments connecting the bones of the pelvis with each other can be divided
into four groups:
• those connecting the sacrum and ilium – the sacroiliac ligaments;
• those passing between the sacrum and ischium – the sacrotuberous ligaments and
the sacrospinous ligaments (Fig. 3.10);
FIG. 3.10 Posterior view of the pelvis showing the ligaments.
• those uniting the sacrum and coccyx – the sacrococcygeal ligaments;
• those between the two pubic bones – the inter-pubic ligaments.
The pelvis in relation to pregnancy and childbirth
The term pelvis is applied to the skeletal ring formed by the innominate bones and the
sacrum, the cavity within and even the entire region where the trunk and the lower
limbs meet. The pelvis is divided by an oblique plane which passes through the
prominence of the sacrum, the arcuate line (the smooth rounded border on the
internal surface of the ilium), the pectineal line (a ridge on the superior ramus of the
pubic bone) and the upper margin of the symphysis pubis, into the true and the false
pelves.
The true pelvis
The true pelvis is the bony canal through which the fetus must pass during birth. I t is
divided into a brim, a cavity and an outlet.
The pelvic brim
The superior circumference forms the brim of the true pelvis, the included space being
called the inlet. The brim is round except where the sacral promontory projects into it.
Midwives need to be familiar with the fixed points on the pelvic brim that are known
as its landmarks. Commencing posteriorly, these are (Fig. 3.11):
• sacral promontory (1)
• sacral ala or wing (2)
• sacroiliac joint (3)
• iliopectineal line, which is the edge formed at the inward aspect of the ilium (4)
• iliopectineal eminence, which is a roughened area formed where the superior ramus
of the pubic bone meets the ilium (5)
• superior ramus of the pubic bone (6)
• upper inner border of the body of the pubic bone (7)
• upper inner border of the symphysis pubis (8).
FIG. 3.11 Brim of female pelvis (for detail, see text).
The pelvic cavity
The cavity of the true pelvis extends from the brim superiorly to the outlet inferiorly.
The anterior wall is formed by the pubic bones and symphysis pubis and its depth is
4 cm. The posterior wall is formed by the curve of the sacrum, which is 12 cm in
length. Because there is such a difference in these measurements, the cavity forms a
curved canal. With the woman upright, the upper portion of the pelvic canal is
directed downward and backward, and its lower course curves and becomes directed
downward and forward. I ts lateral walls are the sides of the pelvis, which are mainly
covered by the obturator internus muscle.
The cavity contains the pelvic colon, rectum, bladder and some of the reproductive
organs. The rectum is placed posteriorly, in the curve of the sacrum and coccyx; the
bladder is anterior behind the symphysis pubis.
The pelvic outlet
The lower circumference of the true pelvis is very irregular; the space enclosed by it is
called the outlet. Two outlets are described: the anatomical and the obstetrical. The
anatomical outlet is formed by the lower borders of each of the bones together with
the sacrotuberous ligament. The obstetrical outlet is of greater practical significance
because it includes the narrow pelvic strait through which the fetus must pass. The
narrow pelvic strait lies between the sacrococcygeal joint, the two ischial spines and
the lower border of the symphysis pubis. The obstetrical outlet is the space between
the narrow pelvic strait and the anatomical outlet. This outlet is diamond-shaped.
The false pelvis
I t is bounded posteriorly by the lumbar vertebrae and laterally by the iliac fossae, and
in front by the lower portion of the anterior abdominal wall. The false pelvis varies
considerably in size according to the flare of the iliac bones. However, the false pelvis
has no significance in midwifery.
Pelvic diameters
Knowledge of the diameters of the normal female pelvis is essential in the practice of
midwifery because contraction of any of them can result in malposition or
malpresentation of the presenting part of the fetus.
Diameters of the pelvic inlet
The brim has four principal diameters: the anteroposterior diameter, the transverse
diameter and the two oblique diameters (Figs 3.12, 3.13).
FIG. 3.12 View of pelvic brim showing diameters.
FIG. 3.13 Measurements of the pelvic canal in centimetres.
The anteroposterior or conjugate diameter extends from the midpoint of the sacral
promontory to the upper border of the symphysis pubis. Three conjugate diameters
can be measured: the anatomical (true) conjugate, the obstetrical conjugate and the
internal or diagonal conjugate (Fig. 3.14).
FIG. 3.14 Median section of the pelvis showing anteroposterior diameters.
The anatomical conjugate, which averages 12 cm, is measured from the sacral
promontory to the uppermost point of the symphysis pubis. The obstetrical conjugate,
which averages 11 cm, is measured from the sacral promontory to the posterior border
of the upper surface of the symphysis pubis. This represents the shortest
anteroposterior diameter through which the fetus must pass and is hence of clinical
significance to midwives (Fig. 3.15). The obstetrical conjugate cannot be measured
with the examining fingers or any other technique.
FIG. 3.15 Fetal head negotiating the narrow obstetrical conjugate.
The diagonal conjugate is measured anteroposteriorly from the lower border of the
symphysis to the sacral promontory.
The transverse diameter is constructed at right-angles to the obstetric conjugate and
extends across the greatest width of the brim; its average measurement is about 13 cm.
Each oblique diameter extends from the iliopectineal eminence of one side to the
sacroiliac articulation of the opposite side; its average measurement is about 12 cm.
Each takes its name from the sacroiliac joint from which it arises, so the left oblique
diameter arises from the left sacroiliac joint and the right oblique from the right
sacroiliac joint.
A nother dimension, the sacrocotyloid (see Fig. 3.11), passes from the sacral
promontory to the iliopectineal eminence on each side and measures 9–9.5 cm. I ts
importance is concerned with posterior positions of the occiput when the parietal
eminences of the fetal head may become caught (see Chapter 20).
Diameters of the cavity
The cavity is circular in shape and although it is not possible to measure its diameters
exactly, they are all considered to be 12 cm (see Fig. 3.13).
Diameters of the outlet
The outlet, which is diamond-shaped, has three diameters: the anteroposterior
diameter, the oblique diameter and the transverse diameter (see Fig. 3.13).
The anteroposterior diameter extends from the lower border of the symphysis pubis
to the sacrococcygeal joint. I t measures 13 cm; as the coccyx may be deflected
backwards during labour, this diameter indicates the space available during birth.
The oblique diameter, although there are no fixed points, is said to be between the
obturator foramen and the sacrospinous ligament. The measurement is taken as being
12 cm.
The transverse diameter extends between the two ischial spines and measures 10–
11 cm. I t is the narrowest diameter in the pelvis. The plane of least pelvic dimensions
is said to be at the level of the ischial spines.
Orientation of the pelvis
I n the standing position, the pelvis is placed such that the anterior superior iliac spine
and the front edge of the symphysis pubis are in the same vertical plane,
perpendicular to the floor. I f the line joining the sacral promontory and the top of the
symphysis pubis were to be extended, it would form an angle of 60° with the
horizontal floor. S imilarly, if a line joining the centre of the sacrum and the centre of
the symphysis pubis were to be extended, the resultant angle with the floor would be
30°. The angle of inclination of the outlet is 15° (Fig. 3.16). W hen in the recumbent
position, the same angles are made as in the vertical position; this fact should be kept
in mind when carrying out an abdominal examination.
FIG. 3.16 Median section of the pelvis showing the inclination of the planes and the axis of the
pelvic canal.
Pelvic planes
Pelvic planes are imaginary flat surfaces at the brim, cavity and outlet of the pelvic
canal at the levels of the lines described above (Fig. 3.17).
FIG. 3.17 Fetal head entering plane of pelvic brim and leaving plane of pelvic outlet.
Axis of the pelvic canal
A line drawn exactly half-way between the anterior wall and the posterior wall of the
pelvic canal would trace a curve known as the curve of Carus. The midwife needs to
become familiar with this concept in order to make accurate observations on vaginal
examination and to facilitate the birth of the baby.
The four types of pelvis
The size of the pelvis varies not only in the two sexes, but also in different members of
the same sex. The height of the individual does not appear to influence the size of the
pelvis in any way, as women of short stature, in general, have a broad pelvis.
N evertheless, the pelvis is occasionally equally contracted in all its dimensions, so
much so that all its diameters can measure 1.25 cm less than the average. This type of
pelvis, known as a justo minor pelvis, can result in normal labour and birth if the fetal
size is consistent with the size of the maternal pelvis. However, if the fetus is large, a
degree of cephalopelvic disproportion will result. The same is true when a
malpresentation or malposition of the fetus exists.
The principal divergences, however, are found at the brim (Fig. 3.18) and affect the
relation of the anteroposterior to the transverse diameter. I f one of the measurements
is reduced by 1 cm or more from the normal, the pelvis is said to be contracted and
may give rise to difficulty in labour or necessitate caesarean section.
FIG. 3.18 Characteristic brim of the four types of pelvis.
Classically, pelves have been described as falling into four categories: the gynaecoid
pelvis, the android pelvis, the anthropoid pelvis and the platypelloid pelvis (Table 3.1).
Table 3.1
Features of the four types of pelvis
The gynaecoid pelvis (Fig. 3.19)
This is the best type for childbearing as it has a rounded brim, generous forepelvis,
straight side walls, a shallow cavity with a well-curved sacrum and a sub-pubic arch of
90°.
FIG. 3.19 Normal female pelvis (gynaecoid).
The android pelvis
The android pelvis is so called because it resembles the male pelvis. I ts brim is heart-
shaped, it has a narrow forepelvis and its transverse diameter is situated towards the
back. The side walls converge, making it funnel-shaped, and it has a deep cavity and a
straight sacrum. The ischial spines are prominent and the sciatic notch is narrow. The
sub-pubic angle is less than 90°. I t is found in short and heavily built women, who
have a tendency to be hirsute.
Because of the narrow forepelvis and the fact that the greater space lies in the
hindpelvis the heart-shaped brim favours an occipitoposterior position. Furthermore,
funnelling in the cavity may hinder progress in labour. At the pelvic outlet, the
prominent ischial spines sometimes prevent complete internal rotation of the head
and the anteroposterior diameter becomes caught on them, causing a deep transverse
arrest. The narrowed sub-pubic angle cannot easily accommodate the biparietal
diameter (Fig. 3.20) and this displaces the head backwards. Because of these factors,
this type of pelvis is the least suited to childbearing.
FIG. 3.20 (A) Outlet of android pelvis. The fetal head, which does not fit into the acute pubic
arch, is forced backwards onto the perineum. (B) Outlet of the gynaecoid pelvis. The head fits
snugly into the pubic arch.
The anthropoid pelvis
The anthropoid pelvis has a long, oval brim in which the anteroposterior diameter is
longer than the transverse diameter. The side walls diverge and the sacrum is long and
deeply concave. The ischial spines are not prominent and the sciatic notch and the
sub-pubic angle are very wide. W omen with this type of pelvis tend to be tall, with
narrow shoulders. Labour does not usually present any difficulties, but a direct
occipitoanterior or direct occipitoposterior position is often a feature and the position
adopted for engagement may persist to birth.
The platypelloid pelvis
The platypelloid (flat) pelvis has a kidney-shaped brim in which the anteroposterior
diameter is reduced and the transverse diameter increased. The sacrum is flat and the
cavity shallow. The ischial spines are blunt, and the sciatic notch and the sub-pubic
angle are both wide. The head must engage with the sagi al suture in the transverse
diameter, but usually descends through the cavity without difficulty. Engagement may
necessitate lateral tilting of the head, known as asynclitism, in order to allow the
biparietal diameter to pass the narrowest anteroposterior diameter of the brim (Box
3.1).
Box 3.1
N e got ia t ing t he pe lvic brim in a synclit ism
Anterior asynclitism
The anterior parietal bone moves down behind the symphysis pubis until
the parietal eminence enters the brim. The movement is then reversed and
the head tilts in the opposite direction until the posterior parietal bone
negotiates the sacral promontory and the head is engaged.
Posterior asynclitism
The movements of anterior asynclitism are reversed. The posterior parietal
bone negotiates the sacral promontory prior to the anterior parietal bone
moving down behind the symphysis pubis.
O nce the pelvic brim has been negotiated, descent progresses, normally
accompanied by flexion and internal rotation.
Other pelvic variations
H igh assimilation pelvis occurs when the 5th lumbar vertebra is fused to the sacrum
and the angle of inclination of the pelvic brim is increased. Engagement of the head is
difficult but, once achieved, labour progresses normally.
D eformed pelvis may result from a developmental anomaly, dietary deficiency,
injury or disease (Box 3.2).
Box 3.2
D e form e d pe lve s
Developmental anomalies
The N aegele's and Robert's pelves are rare malformations caused by a
failure in development. I n the N aegele's pelvis, one sacral ala is missing
and the sacrum is fused to the ilium causing a grossly asymmetric brim.
The Robert's pelvis has similar malformations which are bilateral. I n both
instances, the abnormal brim prevents engagement of the fetal head.
Dietary deficiency
D eficiency of vitamins and minerals necessary for the formation of healthy
bones is less frequently seen today than in the past but might still
complicate pregnancy and labour to some extent.
A rachitic pelvis is a pelvis deformed by rickets in early childhood, as a
consequence of malnutrition. The weight of the upper body presses
downwards on to the softened pelvic bones, the sacral promontory is
pushed downwards and forwards and the ilium and ischium are drawn
outwards resulting in a flat pelvic brim similar to that of the platypelloid
pelvis (Fig. 3.21). The sacrum tends to be straight, with the coccyx bending
acutely forward. Because the tuberosities are wide apart, the pubic arch is
wide. The clinical signs of rickets are bow legs and spinal deformity.
FIG. 3.21 Rachitic flat pelvis. (A) Note wide pubic arch and kidney-shaped brim.
(B) The lateral view shows the diminished anteroposterior diameter of the brim and
the increased anteroposterior diameter of the outlet.
I f severe contraction is present, caesarean section is required to deliver
the baby. The fetal head will attempt to enter the pelvis by asynclitism.
Osteomalacic pelvis. The disease osteomalacia is rarely encountered in the
United Kingdom. I t is due to an acquired deficiency of calcium and occurs
in adults. A ll bones of the skeleton soften because of gross calcium
deficiency. The pelvic canal is squashed together until the brim becomes a
Y-shaped slit. Labour is impossible. I n early pregnancy, incarceration of the
gravid uterus may occur because of the gross deformity.
Injury and disease
Trauma. A pelvis that has been fractured will develop callus formation or
may fail to unite correctly. This may lead to reduced measurements and
therefore to some degree of contraction. Conditions sustained in childhood
such as fractures of the pelvis or lower limbs, congenital dislocation of the
hip and poliomyelitis may lead to unequal weight-bearing, which will also
cause deformity.
Spinal deformity. I f kyphosis (forward angulation) or scoliosis (lateral
curvature) is evident, or is suggested by a limp or deformity, the midwife
must refer the woman to a doctor. Pelvic contraction is likely in these cases.
The female reproductive system
The female reproductive system consists of the external genitalia, known collectively
as the vulva, and the internal reproductive organs: the vagina, the uterus, two uterine
tubes and two ovaries. I n the non-pregnant state, the internal reproductive organs are
situated within the true pelvis.
The vagina
The vagina is a hollow, distensible fibromuscular tube that extends from the vestibule
to the cervix. I t is approximately 10 cm in length and 2.5 cm in diameter (although
there is wide anatomical variation). D uring sexual intercourse and when a woman
gives birth, the vagina temporarily widens and lengthens.
The vaginal canal passes upwards and backwards into the pelvis with the anterior
and posterior walls in close contact along a line approximately parallel to the plane of
the pelvic brim. W hen the woman stands upright, the vaginal canal points in an
upward-backward direction and forms an angle of slightly more than 45° with the
uterus.
Function
The vagina allows the escape of the menstrual fluids, receives the penis and the
ejected sperm during sexual intercourse, and provides an exit for the fetus during
birth.
Relations
Knowledge of the relations of the vagina to other pelvic organs is essential for the
accurate examination of the pregnant woman and the safe birth of the baby (Figs 3.22,
3.23).
• Anterior to the vagina lie the bladder and the urethra, which are closely connected to
the anterior vaginal wall.
• Posterior to the vagina lie the pouch of Douglas, the rectum and the perineal body,
which separates the vagina from the anal canal.
• Laterally on the upper two-thirds are the pelvic fascia and the ureters, which pass
beside the cervix; on either side of the lower third are the muscles of the pelvic floor.
• Superior to the vagina lies the uterus.
• Inferior to the vagina lies the external genitalia.
FIG. 3.22 Coronal section through the pelvis.
FIG. 3.23 Sagittal section of the female pelvis.
Structure
The posterior wall of the vagina is 10 cm long whereas the anterior wall is only 7.5 cm
in length; this is because the cervix projects into its upper part at a right-angle.
The upper end of the vagina is known as the vault. W here the cervix projects into it,
the vault forms a circular recess that is described as four arches or fornices. The
posterior fornix is the largest of these because the vagina is a ached to the uterus at a
higher level behind than in front. The anterior fornix lies in front of the cervix and the
lateral fornices lie on either side.
Layers
The vaginal wall is composed of three layers: mucosa, muscle and fascia. The mucosa
is the most superficial layer and consists of stratified, squamous non-keratinized
epithelium, thrown in transverse folds called rugae. These allow the vaginal walls to
stretch during intercourse and childbirth. Beneath the epithelium lies a layer of
vascular connective tissue. The muscle layer is divided into a weak inner coat of
circular fibres and a stronger outer coat of longitudinal fibres. Pelvic fascia surrounds
the vagina and adjacent pelvic organs and allows for their independent expansion and
contraction.
There are no glands in the vagina; however, it is moistened by mucus from the cervix
and a transudate that seeps out from the blood vessels of the vaginal wall.
I n spite of the alkaline mucus, the vaginal fluid is strongly acid (pH 4.5) owing to the
presence of lactic acid formed by the action of D oderlein's bacilli on glycogen found in
the squamous epithelium of the lining. These lactobacilli are normal inhabitants of the
vagina. The acid deters the growth of pathogenic bacteria.
Blood supply
The blood supply comes from branches of the internal iliac artery and includes the
vaginal artery and a descending branch of the uterine artery. The blood drains through
corresponding veins.
Lymphatic drainage
Lymphatic drainage is via the inguinal, the internal iliac and the sacral glands.
Nerve supply
The nerve supply is derived from the pelvic plexus. The vaginal nerves follow the
vaginal arteries to supply the vaginal walls and the erectile tissue of the vulva.
The uterus
The uterus is a hollow, pear-shaped muscular organ located in the true pelvis between
the bladder and the rectum. The position of the uterus within the true pelvis is one of
anteversion and anteflexion. A nteversion means that the uterus leans forward and
anteflexion means that it bends forwards upon itself. W hen the woman is standing,
the uterus is in an almost horizontal position with the fundus resting on the bladder if
the uterus is anteverted (see Fig. 3.23).
Function
The main function of the uterus is to nourish the developing fetus prior to birth. I t
prepares for pregnancy each month and following pregnancy expels the products of
conception.
Relations
Knowledge of the relations of the uterus to other pelvic organs (Figs 3.24, 3.25) is
desirable, particularly when giving women advice about bladder and bowel care
during pregnancy and childbirth.
• Anterior to the uterus lie the uterovesical pouch and the bladder.
• Posterior to the uterus are the recto-uterine pouch of Douglas and the rectum.
• Lateral to the uterus are the broad ligaments, the uterine tubes and the ovaries.
• Superior to the uterus lie the intestines.
• Inferior to the uterus is the vagina.
FIG. 3.24 Supports of the uterus, at the level of the cervix.
FIG. 3.25 Measurements of the uterus.
Supports
The uterus is supported by the pelvic floor and maintained in position by several
ligaments, of which those at the level of the cervix (Fig. 3.24) are the most important.
• The transverse cervical ligaments fan out from the sides of the cervix to the side walls
of the pelvis. They are sometimes known as the ‘cardinal ligaments’ or ‘Mackenrodt’s
ligaments’.
• The uterosacral ligaments pass backwards from the cervix to the sacrum.
• The pubocervical ligaments pass forwards from the cervix, under the bladder, to the
pubic bones.
• The broad ligaments are formed from the folds of peritoneum, which are draped
over the uterine tubes. They hang down like a curtain and spread from the sides of
the uterus to the side walls of the pelvis.
• The round ligaments have little value as a support but tend to maintain the
anteverted position of the uterus; they arise from the cornua of the uterus, in front of
and below the insertion of each uterine tube, and pass between the folds of the broad
ligament, through the inguinal canal, to be inserted into each labium majus.
• The ovarian ligaments also begin at the cornua of the uterus but behind the uterine
tubes and pass down between the folds of the broad ligament to the ovaries.
I t is helpful to note that the round ligament, the uterine tube and the ovarian
ligament are very similar in appearance and arise from the same area of the uterus.
This makes careful identification important when tubal surgery is undertaken.
Structure
The non-pregnant uterus is 7.5 cm long, 5 cm wide and 2.5 cm in depth, each wall
being 1.25 cm thick (see Fig. 3.25). The cervix forms the lower third of the uterus and
measures 2.5 cm in each direction. The uterus consists of the following parts:
• The cornua are the upper outer angles of the uterus where the uterine tubes join.
• The fundus is the domed upper wall between the insertions of the uterine tubes.
• The body or corpus makes up the upper two-thirds of the uterus and is the greater
part.
• The cavity is a potential space between the anterior and posterior walls. It is
triangular in shape, the base of the triangle being uppermost.
• The isthmus is a narrow area between the cavity and the cervix, which is 7 mm long.
It enlarges during pregnancy to form the lower uterine segment.
• The cervix or neck protrudes into the vagina. The upper half, being above the vagina,
is known as the supravaginal portion while the lower half is the infravaginal portion.
• The internal os (mouth) is the narrow opening between the isthmus and the cervix.
• The external os is a small round opening at the lower end of the cervix. After
childbirth, it becomes a transverse slit.
• The cervical canal lies between these two ostia and is a continuation of the uterine
cavity. This canal is shaped like a spindle, narrow at each end and wider in the
middle.
Layers
The uterus has three layers: the endometrium, the myometrium and the perimetrium,
of which the myometrium, the middle muscle layer, is by far the thickest.
The endometrium forms a lining of ciliated epithelium (mucous membrane) on a
base of connective tissue or stroma. I n the uterine cavity, this endometrium is
constantly changing in thickness throughout the menstrual cycle (see Chapter 5). The
basal layer does not alter, but provides the foundation from which the upper layers
regenerate. The epithelial cells are cubical in shape and dip down to form glands that
secrete an alkaline mucus.
The cervical endometrium does not respond to the hormonal stimuli of the
menstrual cycle to the same extent. Here the epithelial cells are tall and columnar in
shape and the mucus-secreting glands are branching racemose glands. The cervical
endometrium is thinner than that of the body and is folded into a pa ern known as
the ‘arbor vitae’ (tree of life). This is thought to assist the passage of the sperm. The
portion of the cervix that protrudes into the vagina is covered with squamous
epithelium similar to that lining the vagina. The point where the epithelium changes,
at the external os, is termed the squamo-columnar junction.
The myometrium is thick in the upper part of the uterus and is sparser in the
isthmus and cervix. I ts fibres run in all directions and interlace to surround the blood
vessels and lymphatics that pass to and from the endometrium. The outer layer is
formed of longitudinal fibres that are continuous with those of the uterine tube, the
uterine ligaments and the vagina.
I n the cervix, the muscle fibres are embedded in collagen fibres, which enable it to
stretch in labour.
The perimetrium is a double serous membrane, an extension of the peritoneum,
which is draped over the fundus and the anterior surface of the uterus to the level of
the internal os. I t is then reflected onto the bladder forming a small pouch between
the uterus and the bladder called the uterovesical pouch. The posterior surface is
covered to where the cervix protrudes into the vagina and is then reflected onto the
rectum forming the recto-uterine pouch. Laterally the perimetrium extends over the
uterine tubes forming a double fold, the broad ligament, leaving the lateral borders of
the body uncovered.
Blood supply
The uterine artery arrives at the level of the cervix and is a branch of the internal iliac
artery. It sends a small branch to the upper vagina, and then runs upwards in a twisted
fashion to meet the ovarian artery and form an anastomosis with it near the cornu. The
ovarian artery is a branch of the abdominal aorta, leaving near the renal artery. I t
supplies the ovary and uterine tube before joining the uterine artery. The blood drains
through corresponding veins (Fig. 3.26).
FIG. 3.26 Blood supply of the uterus, uterine tubes and ovaries.
Lymphatic drainage
Lymph is drained from the uterine body to the internal iliac glands and from the
cervical area to many other pelvic lymph glands. This provides an effective defence
against uterine infection.
Nerve supply
The nerve supply is mainly from the autonomic nervous system, sympathetic and
parasympathetic, via the inferior hypogastric or pelvic plexus.
Uterine malformations
The prevalence of uterine malformation is estimated to be 6.7% in the general
population. The female genital tract is formed in early embryonic life when a pair of
ducts develops. These paramesonephric or Müllerian ducts come together in the
midline and fuse into a Y-shaped canal. The open upper ends of this structure lead
into the peritoneal cavity and the unfused portions become the uterine tubes. The
fused lower portion forms the uterovaginal area, which further develops into the
uterus and vagina. A bnormal development of the Müllerian duct(s) during
embryogenesis can lead to uterine abnormalities (Box 3.3) (Fig. 3.27).
Box 3.3
U t e rine m a lform a t ions
Types of uterine malformation
Various types of structural abnormality can result from failure of fusion of
the Müllerian ducts. Three of these abnormalities can be seen in Fig. 3.27. A
double uterus with an associated double vagina will develop where there
has been complete failure of fusion. Partial fusion results in various
degrees of duplication. A single vagina with a double uterus is the result of
fusion at the lower end of the ducts only. A bicornuate uterus (one with two
horns) is the result of incomplete fusion at the upper portion of the
uterovaginal area. I n rare cases, one Müllerian duct regresses and the result
is a uterus with one horn – termed a unicornuate uterus.
FIG. 3.27 Uterine malformations. (A) Double uterus with duplication of body of
uterus, cervix and vagina. (B) Duplication of uterus and cervix with single vagina.
(C) Duplication of uterus with single cervix and vagina.
S tructural abnormality of the uterus can lead to various problems during pregnancy
and childbirth. The outcome depends on the ability of the uterus to accommodate the
growing fetus. A problem exists only if the tissue is insufficient to allow the uterus to
enlarge for a full-term fetus lying longitudinally. I f there is insufficient hypertrophy,
the possible difficulties are miscarriage, premature labour and abnormal lie of the
fetus. I n labour, poor uterine function may be experienced. Minor defects of structure
cause li le problem and might pass unnoticed, with the woman having a normal
outcome to her pregnancy. O ccasionally problems arise when a fetus is accommodated
in one horn of a double uterus and the empty horn has filled the pelvic cavity. I n this
situation, the empty horn has grown owing to the hormonal influences of the
pregnancy, and its size and position will cause obstruction during labour. Caesarean
section would be the method of delivery.
The fallopian tubes
The uterine tubes, also known as fallopian tubes, oviducts and salpinges, are two very
fine tubes leading from the ovaries into the uterus.
Function
The uterine tube propels the ovum towards the uterus, receives the spermatozoa as
they travel upwards and provides a site for fertilization. I t supplies the fertilized ovum
with nutrition during its continued journey to the uterus.
Position
The uterine tubes extend laterally from the cornua of the uterus towards the side walls
of the pelvis. They arch over the ovaries, the fringed ends hovering near the ovaries in
order to receive the ovum.
Relations
• Anterior, posterior and superior to the uterine tubes are the peritoneal cavity and the
intestines.
• Lateral to the uterine tubes are the side walls of the pelvis.
• Inferior to the uterine tubes lie the broad ligaments and the ovaries.
• Medial to the two uterine tubes lies the uterus.
Supports
The uterine tubes are held in place by their a achment to the uterus. The peritoneum
folds over them, draping down below as the broad ligaments and extending at the
sides to form the infundibulopelvic ligaments.
Structure
Each tube is 10 cm long. The lumen of the tube provides an open pathway from the
outside to the peritoneal cavity. The uterine tube has four portions (Fig. 3.28):
• The interstitial portion is 1.25 cm long and lies within the wall of the uterus. Its
lumen is 1 mm wide.
• The isthmus is another narrow part that extends for 2.5 cm from the uterus.
• The ampulla is the wider portion, where fertilization usually occurs. It is 5 cm long.
• The infundibulum is the funnel-shaped fringed end that is composed of many
processes known as fimbriae. One fimbria is elongated to form the ovarian fimbria,
which is attached to the ovary.
FIG. 3.28 The uterine tubes in section. Note the ovum entering the fimbriated end of one tube.
Layers (Fig. 3.29)
T he lining of the uterine tubes is a mucous membrane of ciliated cubical epithelium
that is thrown into complicated folds known as plicae. These folds slow the ovum
down on its way to the uterus. I n this lining are goblet cells that produce a secretion
containing glycogen to nourish the oocyte.
FIG. 3.29 Cross-section of a uterine tube and ovary.
Beneath the lining is a layer of vascular connective tissue.
T he muscle coat consists of two layers: an inner circular layer and an outer
longitudinal layer, both of smooth muscle. The peristaltic movement of the uterine
tube is due to the action of these muscles.
T he tube is covered with peritoneum but the infundibulum passes through it to
open into the peritoneal cavity.
Blood supply
The blood supply is via the uterine and ovarian arteries, returning by the
corresponding veins.
Lymphatic drainage
Lymph is drained to the lumbar glands.
Nerve supply
The nerve supply is from the ovarian plexus.
The ovaries
The ovaries are components of the female reproductive system and the endocrine
system.
Function
The ovaries produce oocytes and the hormones, oestrogen and progesterone.
Position
The ovaries are a ached to the back of the broad ligaments within the peritoneal
cavity.
Relations
• Anterior to the ovaries are the broad ligaments.
• Posterior to the ovaries are the intestines.
• Lateral to the ovaries are the infundibulopelvic ligaments and the side walls of the
pelvis.
• Superior to the ovaries lie the uterine tubes.
• Medial to the ovaries lie the ovarian ligaments and the uterus.
Supports
The ovary is a ached to the broad ligament but is supported from above by the
ovarian ligament medially and the infundibulopelvic ligament laterally.
Structure
The ovary is composed of a medulla and cortex, covered with germinal epithelium.
T he medulla is the supporting framework, which is made of fibrous tissue; the
ovarian blood vessels, lymphatics and nerves travel through it. The hilum where these
vessels enter lies just where the ovary is a ached to the broad ligament and this area
is called the mesovarium (see Fig. 3.29).
T he cortex is the functioning part of the ovary. I t contains the ovarian follicles in
different stages of development, surrounded by stroma. The outer layer is formed of
fibrous tissue known as the tunica albuginea. O ver this lies the germinal epithelium,
which is a modification of the peritoneum.
The cycle of the ovary is described in Chapter 5.
Blood supply
Blood is supplied to the ovaries from the ovarian arteries and drains via the ovarian
veins. The right ovarian vein joins the inferior vena cava, but the left returns its blood
to the left renal vein.
Lymphatic drainage
Lymphatic drainage is to the lumbar glands.
Nerve supply
The nerve supply is from the ovarian plexus.
The male reproductive system
The male reproductive system (Fig. 3.30) consists of a set of organs that are partly
visible and partly hidden within the body. The visible parts are the scrotum and the
penis. I nside the body are the prostate gland and tubes that link the system together.
The male organs produce and transfer sperm to the female for fertilization. The organs
are the scrotum, testis, rete and epididymis, ductus deferens, seminal vesicles prostate
gland, bulbourethral glands and penis with the urethra.
FIG. 3.30 Male reproductive system.
The scrotum
The scrotum is part of the external genitalia. A lso called the scrotal sac, the scrotum is
a thin-walled, soft, muscular pouch located below the symphysis pubis, between the
upper parts of the thighs behind the penis.
Function
The scrotum forms a pouch in which the testes are suspended outside the body,
keeping them at a temperature slightly lower than that of the rest of the body. A
temperature around 34.4 °C enables the production of viable sperm, whereas a
temperature of or above 36.7 °C can be damaging to sperm count.
Structure
The scrotum is formed of pigmented skin and has two compartments, one for each
testis.
The testes
Like the ovaries, to which they are homologous, the testes (also known as testicles) are
components of both the reproductive system and the endocrine system. Each testis
weighs about 25 g.
Function
The testes produce and store spermatozoa, and are the body's main source of the male
hormone testosterone. Testosterone is responsible for the development of secondary
sex characteristics.
Position
I n the embryo, the testes develop high up in the lumbar region of the abdominal
cavity. I n the last few months of fetal life they descend through the abdomen, over the
pelvic brim and down the inguinal canal into the scrotum outside the body. The testes
are contained within the scrotum.
Structure
Each testis is an oval structure about 5 cm long and 3 cm in diameter.
Layers
There are three layers to the testis:
The tunica vasculosa is an inner layer of connective tissue containing a fine network
of capillaries.
T he tunica albuginea is a fibrous covering, ingrowths of which divide the testis into
200–300 lobules.
T he tunica vaginalis is the outer layer, which is made of peritoneum brought down
with the descending testis when it migrated from the lumbar region in fetal life.
The duct system within the testes is highly intricate:
T he seminiferous (‘seed-carrying’) tubules are where spermatogenesis, or
production of sperm, takes place. There are up to three of them in each lobule.
Between the tubules are interstitial cells that secrete testosterone. The tubules join to
form a system of channels that lead to the epididymis.
The epididymis is a comma-shaped, coiled tube that lies on the superior surface and
travels down the posterior aspect to the lower pole of the testis, where it leads into the
deferent duct or vas deferens.
The spermatic cord
The spermatic cord is the name given to the cord-like structure consisting of the vas
deferens and its accompanying arteries, veins, nerves and lymphatic vessels.
Function
The function of the deferent duct is to carry the sperm to the ejaculatory duct.
Position
The cord passes upwards through the inguinal canal, where the different structures
diverge. The deferent duct then continues upwards over the symphysis pubis and
arches backwards beside the bladder. Behind the bladder, it merges with the duct
from the seminal vesicle and passes through the prostate gland as the ejaculatory duct
to join the urethra.
Blood supply
The testicular artery, a branch of the abdominal aorta, supplies the testes, scrotum and
attachments. The testicular veins drain in the same manner as the ovarian veins.
Lymphatic drainage
Lymphatic drainage is to the lymph nodes round the aorta.
Nerve supply
The nerve supply to the spermatic cord is from the 10th and 11th thoracic nerves.
The seminal vesicles
The seminal vesicles are a pair of simple tubular glands.
Function
The function of the seminal vesicles is production of a viscous secretion to keep the
sperm alive and motile. This secretion ultimately becomes semen.
Position
The seminal vesicles are situated posterior to the bladder and superior to the prostate
gland.
Structure
The seminal vesicles are 5 cm long and pyramid-shaped. They are composed of
columnar epithelium, muscle tissue and fibrous tissue.
The ejaculatory ducts
These small muscular ducts carry the spermatozoa and the seminal fluid to the
urethra.
The prostate gland
The prostate is an exocrine gland of the male reproductive system.
Function
The prostate gland produces a thin lubricating fluid that enters the urethra through
ducts.
Position
The prostate gland surrounds the urethra at the base of the bladder, lying between the
rectum and the symphysis pubis.
Structure
The prostate gland measures 4 × 3 × 2 cm. I t is composed of columnar epithelium, a
muscle layer and an outer fibrous layer.
The bulbourethral glands
The bulbourethral glands are two very small glands, which produce yet another
lubricating fluid that passes into the urethra just below the prostate gland.
The penis
The penis is the male reproductive organ and additionally serves as the external male
organ of urination.
Functions
The penis carries the urethra, which is a passage for both urine and semen. D uring
sexual excitement it stiffens (an erection) in order to be able to penetrate the vagina
and deposit the semen near the woman's cervix.
Position
The root of the penis lies in the perineum, from where it passes forward below the
symphysis pubis. The lower two-thirds are outside the body in front of the scrotum.
Structure
The penis has three columns of erectile tissue:
T he corpora cavernosa are two lateral columns that lie one on either side in front of
the urethra.
The corpus spongiosum is the posterior column that contains the urethra. The tip is
expanded to form the glans penis.
The lower two-thirds of the penis are covered in skin. At the end, the skin is folded
back on itself above the glans penis to form the prepuce or foreskin, which is a
movable double fold. The penis is extremely vascular and during an erection the blood
spaces fill and become distended.
The male hormones
The control of the male gonads is similar to that in the female, but it is not cyclical.
The hypothalamus produces gonadotrophin-releasing factors. These stimulate the
anterior pituitary gland to produce follicle stimulating hormone (FS H) and luteinizing
hormone (LH). FS H acts on the seminiferous tubules to bring about the production of
sperm, whereas LH acts on the interstitial cells that produce testosterone.
Testosterone is responsible for the secondary sex characteristics: deepening of the
voice, growth of the genitalia and growth of hair on the chest, pubis, axilla and face.
Formation of the spermatozoa
Production of sperm begins at puberty and continues throughout adult life.
S permatogenesis takes place in the seminiferous tubules under the influence of FS H
and testosterone. The process of maturation is a lengthy one and takes some weeks.
The mature sperm are stored in the epididymis and the deferent duct until ejaculation.
I f this does not happen, they degenerate and are reabsorbed. At each ejaculation, 2–
4 ml of semen is deposited in the vagina. The seminal fluid contains about 100 million
sperm/ml, of which 20–25% are likely to be abnormal. The remainder move at a speed
of 2–3 mm/min. The individual spermatozoon has a head, a body and a long, mobile
tail that lashes to propel the sperm along (Fig. 3.31). The tip of the head is covered by
an acrosome; this contains enzymes to dissolve the covering of the oocyte in order to
penetrate it.
FIG. 3.31 Spermatozoon.
Further reading
Kearney R, Sawhney R, DeLancey JO. Levator ani muscle anatomy evaluated by
origin-insertion pairs. Obstetrics and Gynecology. 2004;104:168–173.
A comprehensive and up-to-date description of levator ani muscle anatomy..
Schwertner-Tiepelmann N, Thakar R, Sultan AH, et al. Obstetric levator ani
muscle injuries – current status. Ultrasound in Obstetrics and Gynecology.
2012;39:372–383.
This review article critically appraises the diagnosis of obstetric LAM injuries, to
establish the relationship between LAM injuries and pelvic floor dysfunction and to
identify risk factors and preventive strategies to minimize such injuries..
Stables D, Rankin J. Physiology in childbearing: with anatomy and related biosciences.
3rd edn. Baillière Tindall: Edinburgh; 2010.
This textbook presents a comprehensive and clear account of anatomy and physiology
and related biosciences at all stages of pregnancy and childbirth..
Standring S. Gray's anatomy: the anatomical basis of clinical practice. 40th edn.
Elsevier Churchill Livingston: London; 2008.
This large volume, with detailed information about the anatomy of every part of the
human body, provides the reader with much more insight into the structure and
function of the reproductive organs. This edition includes specialist revision of topics
such as the anatomy of the pelvic floor..
Sultan AH, Thakar R, Fenner DE. Perineal and anal sphincter trauma: diagnosis and
clinical management. Springer-Verlag: London; 2007.
This is a comprehensive text that focuses on the maternal morbidity associated with
childbirth. It is essential reading for anyone involved in obstetric care such as
obstetricians, midwives and family practitioners but will also be of interest to
colorectal surgeons, gastroenterologists, physiotherapists, continence advisors and
lawyers..
C H AP T E R 4
The female urinary tract
Jean Rankin
CHAPTER CONTENTS
The kidneys 81
The nephron 82
Urine 84
The ureters 86
The bladder 87
The urethra 88
Micturition 89
Changes to the urinary tract in pregnancy 89
Conclusion 90
References 90
Further reading 90
The midwife must have a sound knowledge of the anatomy of the structures
of the urinary tract and the basics of normal renal physiology to then
understand the changes that take place during pregnancy and how they
may impact on the health and wellbeing of the childbearing woman.
The chapter aims to:
• provide an overview of the anatomy and functions of the various structures of the
urinary system
• describe the processes of excretion, elimination and homeostatic regulation of the
volume and solute concentration of blood plasma
• explain how urine is produced and eliminated through the process of micturition
• provide an overview of how the physiological effects of pregnancy and its hormonal
influences may impact on the functioning of the urinary tract.
The kidneys
The kidneys are excretory glands with both endocrine and exocrine functions. They
perform the excretory functions of the urinary system by removing metabolic waste
products from the circulation to produce urine. I n addition to removing waste
products the urinary system has a broad range of other essential homeostatic
functions (see Box 4.1).
Box 4.1
F unct ions of t he kidne y
• Regulation of water balance
• Regulation of blood pressure (renin–angiotensin system)
• Regulation of pH (acid–base balance) and inorganic ion balance
(potassium, sodium and calcium)
• Control of formation of red blood cells (via erythropoietin)
• Secretion of hormones – renin, erythropoietin, 1.25-dihydroxyvitamin D3
(1,25-dihydroxycholecatciferol (also called calcitriol) and prostaglandins
• Vitamin D activation and calcium balance
• Gluconeogenesis (formation of glucose from amino acids and other
precursors)
• Excretion of metabolic and nitrogenous waste products (urea from
protein, uric acid from nucleic acids, creatinine from muscle creatine and
haemoglobin breakdown products)
• Removal of toxic chemicals (drugs, pesticides and food additives)
A typical adult kidney is a bean-shaped reddish-brown organ. Each kidney is about
10 cm long, 6.5 cm wide, 3 cm thick and weighs about 100 g (Coad and D unstall 2011).
A lthough similar in shape, the left kidney is a longer and more slender organ than the
right kidney. Congenital absence of one or both kidneys, known as unilateral or
bilateral renal agenesis, can occur (J ones 2012). Bilateral renal agenesis is uncommon
but is a serious failure in the development of both kidneys in the fetus. I t is one
causative agent of the Po er sequence (also known as Po er's syndrome). This absence
of fetal kidneys causes oligohydramnios, a deficiency of amniotic fluid in a pregnant
woman which can place extra pressure on the developing fetus and can cause further
malformations. N on-pregnant adults with unilateral renal agenesis have a
considerably higher risk of developing hypertension, which will become even more
pronounced during pregnancy.
Position and relations
The kidneys are situated in the posterior part of the abdominal cavity, one on either
side of the vertebral column between the eleventh thoracic vertebra (T11) and the
third lumbar vertebra (L3) (Jones 2012). The right kidney is slightly lower than the left
kidney owing to its relationship to the liver (Coad and Dunstall 2011). The anterior and
posterior surfaces of the kidneys are related to numerous structures, some of which
come into direct contact with the kidneys whereas others are separated by a layer of
peritoneum:
Posteriorly, the kidneys are related to rib 12 and the diaphragm, psoas major,
quadratus lumborum and transversus abdominis muscles.
Anteriorly, the right kidney is related to the liver, duodenum, ascending colon and
small intestine. The left kidney is related to the spleen, stomach, pancreas,
descending colon and small intestine.
The triangular-shaped adrenal (suprarenal) glands are situated in the upper pole of
the kidneys (Coad and Dunstall 2011).
Supports
The kidneys are maintained in position within the abdominal cavity by the overlying
peritoneum, contact with adjacent visceral organs, such as the gastrointestinal tract,
and by supporting connective tissue (Martini et al 2011).
Structure
Each kidney has a smooth surface covered by a tough fibrous capsule. There is a
concave side facing medially. On this medial aspect is an opening called the hilum. The
hilum is the point of entry for the renal artery and renal nerves, and the point of exit
for the renal vein and the ureter (Fig. 4.1). I nternally the hilum is continuous with the
renal sinus.
FIG. 4.1 Longitudinal section of the kidney.
Each kidney is enclosed by a thick fibrous capsule and has two distinct layers: the
reddish-brown renal cortex, which has a rich blood supply, and the inner renal medulla
where the structural and functional units of the kidney are located (Coad and D unstall
2011). The renal medulla lies below the renal cortex and consists of between 8 and 18
distinct cone-shaped structures called medullary or renal pyramids. Each renal pyramid
(which is striped in appearance) together with the associated overlying renal cortex
forms a renal lobe. The base of each pyramid is broad and faces the cortex, while the
pointed apex (papilla) projects into a minor calyx. S everal minor calyces open into each
of two or three major calyces, which then open into the renal pelvis. The renal pelvis is
a flat funnel-shaped tube that is continuous with the ureter. Urine produced by the
kidney flows continuously from the renal pelvis into the ureter and then into the
bladder for storage (Stables and Rankin 2010).
The nephron
Each kidney has over 1 million nephrons, which are the functional units of the kidney.
The nephron is approximately 3 cm long and is a tubule that is closed at one end and
opens into the collecting duct at the other (Coad and D unstall 2011). The nephron has
five distinct regions, each of which is adapted to a specific function:
• Bowman's capsule containing the glomerulus (renal corpuscle)
• the proximal convoluted tubule
• the loop of Henle
• the distal convoluted tubule and
• the collecting duct (Jones 2012).
There are two types of nephrons: cortical nephrons and juxtomedullary nephrons. The
majority are cortical nephrons (85–90%) and these have short loops of Henle. Their
main function is to control plasma volume during normal conditions. The
juxtamedullary nephrons have longer loops of Henle extending into the medulla.
These nephrons facilitate increased water retention when there is restricted water
available (Coad and Dunstall 2011).
Each nephron begins at the renal corpuscle, which comprises the Bowman's capsule,
which is a blind-ended cup-shaped chamber, and the glomerulus, a coiled arranged
capillary network incorporated within the capsule (Fig. 4.2).
FIG. 4.2 A glomerular body. Reproduced from Coad J, Dunstall M 2011 Anatomy and physiology for
midwives, 3rd edn. Edinburgh, Churchill Livingstone Elsevier, figure 2.2, p 30, after Brooker 1998.
Blood enters the renal corpuscle by way of the afferent arteriole which delivers
blood to the glomerulus, with blood leaving by way of the efferent arteriole. This is the
only place in the body where an artery collects blood from capillaries. The pressure
within the glomerulus is increased because the afferent arteriole has a wider bore than
the efferent arteriole and this factor forces the filtrate out of the capillaries into the
capsule. At this stage any substance with a small molecular size will be filtered out.
The cup of the capsule is a ached to the tubule of the nephron (Fig. 4.3). The
proximal convoluted tubule initially winds and twists through the cortex, then forms a
straight loop of Henle that dips into the medulla (descending arm), rising up into the
cortex again (ascending arm) to wind and turn as the distal convoluted tubule before
joining the straight collecting tubule. The straight collecting tubule runs from the
cortex to a medullary pyramid where it forms a medullary ray and receives urine from
many nephrons along its length (Martini et al 2011).
FIG. 4.3 A nephron.
The distal convoluted tubule returns to pass alongside granular cells (also known as
juxtaglomerular cells) of the afferent arteriole and this part of the tubule is called the
macula densa (see Fig. 4.2). The granular cells and macula densa are known as the
juxtaglomerular apparatus. The granular cells secrete renin whereas the macula densa
cells monitor the sodium chloride concentration of fluid passing through.
Blood supply
The kidneys receive about 20–25% of the total cardiac output (J ones 2012). I n healthy
individuals, about 1200 ml of blood flows through the kidneys each minute. This is a
phenomenal amount of blood for organs that have a combined weight of less than
300 g to experience (Martini et al 2011).
Each kidney receives blood through the renal artery, which originates from the
lateral surface of the descending abdominal aorta near the level of the superior
mesenteric artery. The artery enters at the renal hilum, transmi ing numerous
branches into the cortex to form the glomerulus for each nephron. Blood is collected
up and returned via the renal vein.
Lymphatic drainage
A rich supply of lymph vessels lies under the cortex and around the urine-bearing
tubules. Lymph drains into large lymphatic ducts that emerge from the hilum and
lead to the aortic lymph glands.
Nerve supply
The kidneys are innervated by renal nerves. A renal nerve enters each kidney at the
hilum and follows tributaries of renal arteries to reach individual nephrons. The
sympathetic innervation adjusts rates of urine formation by changing blood flow and
blood pressure at the nephron and mobilizes the release of renin, which ultimately
restricts losses of water and salt in urine by stimulating re-absorption at the nephron
(Martini et al 2011).
Endocrine activity
The kidney secretes two hormones: renin and erythropoietin. Renin is produced in the
afferent arteriole and is secreted when the blood supply to the kidneys is reduced and
in response to lowered sodium levels. It acts on angiotensinogen, which is present in the
blood, to form angiotensin, which raises blood pressure and encourages sodium
reabsorption. The kidneys produce the hormone erythropoietin, in response to low
oxygen levels that stimulate an increase in the production of red blood cells from the
bone marrow (Coad and Dunstall 2011).
Urine
Urine is usually acid and contains no glucose or ketones, nor should it carry blood
cells or bacteria. The amber colour is due to the bile pigment urobilin and the colour
varies depending on the concentration (see Table 4.1). I n the newborn baby, it is
almost clear. The volume and final concentration of urea and solutes depend on fluid
intake. A n adult can void between 1000 ml and 2000 ml of urine daily. Urine has a
characteristic smell, which is not unpleasant when fresh. S trong odour or cloudiness
generally indicates a bacterial infection.
Table 4.1
Characteristics of urine
Characteristics Normal range
pH 4.5–8.0 (average 6.0)
Specific gravity 1.010–1.030
Osmotic concentration (osmolarity) 855–1335 mOsmol/l
Water content 93–97%
Volume Varies depending on intake but usually 1000–1500 ml/day
Colour Clear pale straw (dilute)
Dark brown (very concentrated)
Clear (in babies)
Odour Varies with composition
Bacterial content None (sterile)
W omen are susceptible to urinary tract infection, usually due to ascending infection
acquired via the urethra. A colony bacterial count of more than 100 000/ml is
considered to be pathologically significant and is often referred to as bacteraemia
(Coad and Dunstall 2011).
The production of urine
The production of urine takes place in three stages: filtration, selective reabsorption and
secretion.
Filtration
Filtration is a largely passive, non-selective process that occurs through the
semipermeable walls of the glomerulus and glomerular capsule. Fluids and solutes are
forced through the membrane by hydrostatic pressure. The passage of water and
solutes across the filtration membrane of the glomerulus is similar to that in other
capillary beds: moving down a pressure gradient. However, the glomerular filtration
membrane is thousands of times more permeable to water and solutes, and
glomerular pressure is much higher than normal capillary blood pressure (S tables and
Rankin 2010). Water and small molecules such as glucose, amino acids and vitamins
escape through the filter as the filtrate and enter the nephron, whereas blood cells,
plasma proteins and other large molecules are usually retained in the blood (Fig. 4.4).
The content of the Bowman's capsule is referred to as the glomerular filtrate (GF) and
the rate at which this is formed is referred to as the glomerular filtration rate (GFR). The
kidneys form about 180 l of dilute filtrate each day (125 ml/min). Most of this is
selectively reabsorbed so that the final volume of urine produced daily is about 1000–
1500 ml/day (Coad and Dunstall 2011).
FIG. 4.4 Filtration: larger molecules stay in the sieve (glomerulus) and smaller molecules filter
out (into the glomerular capsule).
Selective reabsorption
S ubstances from the glomerular filtrate are reabsorbed from the rest of the nephron
into the surrounding capillaries. S ome substances, such as amino acids and glucose,
are completely reabsorbed and are not normally present in urine. The reabsorption of
other substances is under the regulation of several hormones. Water balance is mainly
regulated by the antidiuretic hormone (A D H) produced by the posterior pituitary gland.
This is regulated through a negative feedback loop (Fig. 4.5).
FIG. 4.5 The action of ADH. Reproduced from Coad J, Dunstall M 2011 Anatomy and physiology for
midwives, 3rd edn. Edinburgh, Churchill Livingstone Elsevier, figure 2.5, p 33.
The secretion of A D H is initiated by an increase in plasma osmolality, by a decrease
in circulating blood volume and by lowered blood pressure (e.g. through reduced fluid
intake or sweating). The action of A D H is to increase permeability of the renal tubular
cells. More water is reabsorbed, resulting in reduced volume of more concentrated
urine. W hen the body has sufficient fluid intake and physiological paramenters are
within normal range then the production of A D H is inhibited and urineincreases in
volume and is more dilute. O ne exception to note relates to the consumption of
alcohol, which inhibits the effect of A D H on the kidneys, thereby inducing diuresis
that is out of proportion to the volume of fluid ingested (Weise et al 2000). N ewborn
babies have poor ability to concentrate and dilute their urine and this is even more so
for preterm infants. For this reason they are unable to tolerate wide variations in their
fluid intake.
Minerals are selected according to the body's needs. Calcitonin increases calcium
excretion and parathyroid hormone enhances reabsorption of calcium from the renal
tubules (Coad and D unstall 2011). The reabsorption of sodium is controlled by
aldosterone, which is produced in the cortex of the suprarenal gland. The interaction
of aldosterone and A D H maintains water and sodium balance. I t is vital that the pH of
the blood is controlled in the body and if it is tending towards acidity then acids will
be excreted in urine. However, if the opposite situation arises then alkaline urine will
be produced. O ften this is the result of an intake of an alkaline substance. A diet high
in meat and cranberry juice will keep the urine acidic whilst a diet rich in citrus fruit,
most vegetables and legumes will keep the urine alkaline. Bacteria causing a urinary
tract infection or bacterial contamination will also produce alkaline urine.
Secretion
Tubular secretion is an important mechanism in clearing the blood of unwanted
substances. S ecreted substances into the urine include hydrogen ions, ammonia,
creatinine, drugs and toxins.
The ureters
The ureters are hollow muscular tubes. The upper end is funnel-shaped and merges
into the renal pelvis, where urine is received from the renal tubules.
Function
The ureters transport urine from the kidneys to the bladder by waves of peristalsis.
A bout every 30 seconds a peristaltic contraction begins at the renal pelvis and sweeps
along the ureter, forcing urine towards the urinary bladder (Martini et al 2011).
Structure
Each ureter is about 0.3 cm in diameter and 25–30 cm long, running from the renal
hilum to the posterior wall of the bladder (Fig. 4.6).
FIG. 4.6 The ureters. Reproduced from Coad J, Dunstall M 2011 Anatomy and physiology for midwives, 3rd
edn. Edinburgh, Churchill Livingstone Elsevier, figure 2.1, p 30, after Brooker 1998.
The ureters extend inferiorly and medially, passing over the anterior surfaces of the
psoas major muscle and are firmly a ached to the posterior abdominal wall. At the
pelvic brim the ureters descend along the side walls of the pelvis to the level of the
ischial spines and then turn forwards to pass beside the uterine cervix and enter the
bladder from behind (Fig. 4.7). The ureters penetrate the posterior wall of the urinary
bladder without entering the peritoneal cavity. They pass through the bladder wall at
an oblique angle, and the ureteral openings are slit-like rather than rounded. This
shape helps prevent the backflow of urine toward the ureter and kidneys when the
urinary bladder contracts (Martini et al 2011).
FIG. 4.7 Diagram to show the entry of the ureter into the posterior wall of the bladder.
Layers
The ureters are composed of three layers: an inner lining, a middle muscular layer and
an outer coat (Martini et al 2011). The inner lining comprises of transitional epithelium
arranged in longitudinal folds. This type of epithelium consists of several layers of
pear-shaped cells and makes an elastic and waterproof inner coat.
T he middle muscular layer is made up of longitudinal and circular bands of smooth
muscle.
T he outer coat comprises of fibrous connective tissue that is continuous with the
fibrous capsule of the kidney.
Blood supply
The blood supply to the upper part of the ureter is similar to that of the kidney. I n its
pelvic portion, it derives blood from the common iliac and internal iliac arteries and
from the uterine and vesical arteries, according to its proximity to the different organs.
Venous return is along corresponding veins.
Lymphatic drainage
Lymph drains into the internal, external and common iliac nodes.
Nerve supply
The nerve supply is from the renal, aortic, superior and inferior hypogastric plexuses.
The bladder
The bladder is a distensible, hollow, muscular, pelvic organ that functions as a
temporary reservoir for the storage of urine until it is convenient for it to be voided.
Pregnancy and childbirth can affect bladder control and thus midwives need to be
familiar with the anatomy and physiology of the bladder.
Position, shape and size
The empty bladder lies in the pelvic cavity and is described as being pyramidal with its
triangular base resting on the upper half of the vagina and its apex directed towards
the symphysis pubis. However, as it fills with urine it rises up out of the pelvic cavity
becoming an abdominal organ and more globular in shape as its walls are distended.
I t can be palpated above the symphysis pubis when full. D uring labour the bladder is
an abdominal organ, as it is displaced by the fetus as it descends into the pelvic cavity.
The empty bladder is of similar size to the uterus, but when full of urine it becomes
much larger. The normal capacity of the bladder is approximately 600 ml although the
capacity in individuals does vary between 500 ml (S tables and Rankin 2010) and
1000 ml (Martini et al 2011).
Relations (see Fig. 4.8)
• Anterior to the bladder is the symphysis pubis, which is separated from it by a space
filled with fatty tissue called the Cave of Retzius.
• Posterior to the bladder is the cervix and ureters.
• Laterally are the lateral ligaments of the bladder and the side walls of the pelvis.
• Superiorly lie the intestines and peritoneal cavity. In the non-pregnant female the
anteverted, ante-flexed uterus lies partially over the bladder.
• Inferior to the bladder is the urethra and the muscular diaphragm of the pelvic floor,
which forms its main support, and on which its function partly depends.
FIG. 4.8 Sagittal section of the pelvis showing the relations of the bladder.
Supports
There are five ligaments a ached to the bladder (S tables and Rankin 2010). A fibrous
band called the urachus extends from the apex of the bladder to the umbilicus. Two
lateral ligaments extend from the bladder to the side walls of the pelvis. Two
pubovesical ligaments a ach from the bladder neck anteriorly to the symphysis pubis
and they also form part of the pubocervical ligaments of the uterus.
Structure
The base of the bladder is termed the trigone. I t is situated at the back of the bladder,
resting against the vagina. I ts three angles are the exit of the urethra below and the
two slit-like openings of the ureters above. The apex of the trigone is thus at its lowest
point, which is also termed the neck (Fig. 4.9).
FIG. 4.9 Section through the bladder.
The anterior part of the bladder lies close to the symphysis pubis and is termed the
apex of the bladder. From the apex of the bladder, the urachus runs up the anterior
abdominal wall to the umbilicus. I n fetal life, the urachus is the remains of the yolk
sac but in the adult is simply a fibrous band.
Layers
The lining of the bladder, like that of the ureter, is formed of transitional epithelium,
which helps to allow the distension of the bladder without losing its water-holding
effect. The lining, except over the trigone, is thrown into rugae, which fla en out as the
bladder expands and fills. The mucous membrane lining lies on a submucous layer of
areolar tissue that carries blood vessels, lymph vessels and nerves.
The epithelium over the trigone is smooth and firmly a ached to the underlying
muscle. The musculature of the bladder consists chiefly of the large detrusor muscle
whose function is to expel urine. This muscle has three coats of smooth muscle: an
inner longitudinal, a middle circular and an outer longitudinal layer. A round the neck of
the bladder, the circular muscle is thickened to form the internal urethral sphincter
(S tables and Rankin 2010). The general elasticity of the numerous muscle fibres
around the bladder neck tends to keep the urethra closed (S tandring 2009). I n the
trigone, the muscles are somewhat differently arranged. A band of muscle between
the ureteric openings forms the interureteric bar. The urethral dilator muscle lies in the
ventral part of the bladder neck and the walls of the urethra and it is thought to be of
significance in overcoming urethral resistance to micturition (Standring 2009).
The outer layer of the bladder is formed of visceral pelvic fascia, except on its
superior surface, which is covered with peritoneum (see Fig. 4.8).
Blood supply
Blood supply is from the superior and inferior vesical arteries and drainage is by the
corresponding veins.
Lymphatic drainage
Lymph drains into the internal iliac and the obturator nodes.
Nerve supply
The nerve supply is parasympathetic and sympathetic and comes via the Lee–
Frankenhauser pelvic plexus in the pouch of D ouglas. The stimulation of sympathetic
nerves causes the internal urethral sphincter to contract and the detrusor muscle to
relax, whereas the parasympathetic nerve fibres cause the sphincter to relax and the
bladder to empty.
The urethra
I n the female the urethra is a narrow tube, about 4 cm long, that is embedded in the
lower half of the anterior vaginal wall. I t passes from the internal meatus of the
bladder to the vestibule of the vulva, where it opens externally as the urethral meatus.
The internal sphincter surrounds the urethra as it leaves the bladder. A s the urethra
passes between the levator ani muscles it is enclosed by bands of striated muscle
known as the membranous sphincter of the urethra, which is under voluntary control
(S tables and Rankin 2010). D uring labour, the urethra becomes elongated as the
bladder is drawn up into the abdomen, extending several centimetres.
Structure
The urethra forms the junction between the urinary tract and the external genitalia.
The epithelium of its lining reflects this. The upper half is lined with transitional
epithelium whereas the lower half is lined with squamous epithelium. The lumen is
normally closed unless urine is passing down it or a catheter is in situ. W hen closed, it
has small longitudinal folds. S mall blind ducts called urethral crypts (of which the two
largest are the paraurethral glands or Skene's ducts) open into the urethra near the
urethral meatus (Martini et al 2011).
The submucous coat of the urethra is composed of epithelium, which lies on a bed
of vascular connective tissue.
The musculature of the urethra is arranged as an inner longitudinal layer,
continuous with the inner muscle fibres of the bladder, and an external circular layer.
The inner muscle fibres help to open the internal urethral sphincter during micturition.
The outer layer of the urethra is continuous with the outer layer of the vagina and is
formed of connective tissue.
At the lower end of the urethra, voluntary, striated muscle fibres form the so-called
membranous sphincter of the urethra. This is not a true sphincter but it gives some
voluntary control to the woman when she desires to resist the urge to void urine. The
powerful levator ani muscles, which pass on either side of the uterus, also assist in
controlling continence of urine.
Blood supply
The blood to the urethra is circulated by the inferior vesical and pudendal arteries and
veins.
Lymphatic drainage
Lymph drains through the internal iliac glands.
Nerve supply
The internal urethral sphincter is supplied by sympathetic and parasympathetic
nerves but the membranous sphincter is supplied by the pudendal nerve and is under
voluntary control.
Micturition
The process of micturition (urination) is a coordinated response that is due to the
contraction of the muscular wall of the bladder, reflex relaxation of the internal
sphincter of the urethra and voluntary relaxation of the external sphincter (Coad and
D unstall 2011). A s the bladder fills with urine, stretch receptors in the wall of the
urinary bladder are stimulated which then relay parasympathetic sensory nerve
impulses to the brain generating awareness of fluid pressure in the bladder. This
usually occurs when the bladder contains approximately 200–300 ml of urine (with
increasing discomfort as the volume increases). The urge to micturate can be
voluntarily resisted and postponed until a suitable time. This is due to the conscious
descending inhibition of the reflex bladder contraction and relaxation of the external
sphincter. I f the urge to micturate is not voluntarily resisted then the bladder will
empty of urine by the muscle wall contracting, the internal sphincter opening by the
action of Bell's muscles (see Fig. 4.9) and voluntary relaxation of the external sphincter.
This is assisted by the increased pressure in the pelvic cavity as the diaphragm is
lowered and the abdominal muscles contract. The tone of the external sphincter is also
affected by psychological stimuli (such as waking or leaving home) and external
stimuli (such as the sound of running water). A ny factor that raises the intra-
abdominal and intra-vesicular pressures (such as laughter or coughing) in excess of
the urethral closing pressure can result in incontinence (Coad and Dunstall 2011).
I nfants lack voluntary control over micturition because the necessary corticospinal
connections have yet to be established (Martini et al 2011). Cortical control of
micturition occurs from learned behaviour and is usually achieved by about 2 years of
age.
Changes to the urinary tract in pregnancy and childbirth
The urinary system can be markedly stressed by pregnancy, mostly because of its close
proximity to the reproductive organs and the major changes in fluid balance resulting
in fluid retention during pregnancy (Coad and D unstall 2011). I n pregnancy the
enlarging uterus affects all the parts of the urinary tract (see Chapter 9) at various
times. I n early pregnancy, bladder capacity is compromised by the growing uterus
within the pelvic cavity which is relieved once the uterus becomes an abdominal
organ. O nce the presenting part engages through the pelvic brim in late pregnancy
this again restricts space available for bladder capacity. The hormones of pregnancy
also have an influence on the urinary tract. Under the influence of progesterone,
bladder capacity increases to about 1000 ml by late pregnancy and the walls of the
ureters relax, which allows them to dilate, bend or ‘kink’ ( Fig. 4.10). I f this occurs in
the ureters, then it tends to result in a slowing down or stasis of urinary flow, causing
women to be more at risk from infection.
FIG. 4.10 Dilated, kinked ureters in pregnancy.
D uring pregnancy large amounts of urine are produced due to an increase in
glomerular filtration as this helps to eliminate the additional wastes created by
maternal and fetal metabolism. I n labour, the urethra becomes elongated as the
bladder is drawn up into the abdomen.
D uring the postnatal period there is a rapid and sustained loss of sodium and a
major diuresis occurs, especially on the 2nd to 5th postnatal day. A normal urine
output for a woman during this time may be up to 3000 ml/day with voiding of 500–
1000 ml at any one micturition (Stables and Rankin 2010).
Conclusion
The kidneys are excretory glands with both endocrine and exocrine functions. Urine
produced by the kidney flows continuously from the renal pelvis into the ureter and
then into the bladder for storage. The three major functions are: excretion, elimination
and homeostatic regulation of the volume and solute concentration of blood plasma.
Water balance is mainly regulated by the antidiuretic hormone (A D H) through a
negative feedback loop.
D uring pregnancy the urinary system can be markedly stressed, mostly because of
its close proximity to the reproductive organs, the major changes in fluid balance and
the hormones of pregnancy. It is therefore important that the midwife recognizes what
effects these can have on childbearing women to offer them appropriate advice and
support in relieving any discomfort.
References
Coad J, Dunstall M. Anatomy and physiology for midwives. 3rd edn. Churchill
Livingstone Elsevier: Edinburgh; 2011.
Jones TL. Crash course: renal and urinary system. 4th edn. Mosby Elsevier: London;
2012.
Martini FH, Nath JL, Bartholomew EF. Fundamentals of anatomy and physiology.
9th edn. Pearson International: London; 2011.
Stables D, Rankin J. Physiology in childbearing with anatomy and related biosciences.
3rd edn. Elsevier: Edinburgh; 2010.
Standring S. Gray's anatomy: the anatomical basis of clinical practice. 40th edn.
Churchill Livingstone: New York; 2009.
Weise JG, Shlipak MG, Browner WS. The alcohol hangover. Annals of Internal
Medicine. 2000;132(11):897–902.
Further reading
Coad J, Dunstall M. Anatomy and physiology for midwives. 3rd edn. Churchill
Livingstone: Elsevier, Edinburgh; 2011.
Chapter 2 of this book includes several stylized diagrams related to urine production.
The diagrams are detailed and well explained and may help the individual who
learns best from visual representation..
Stables D, Rankin J. Physiology in childbearing with anatomy and related biosciences.
3rd edn. Elsevier: Edinburgh; 2010.
Chapter 19 offers a fuller and more in-depth account of the physiology related to the
renal and urinary system, including changes in pregnancy and a short account of the
postnatal period..
C H AP T E R 5
Hormonal cycles
Fertilization and early development
Jenny Bailey
CHAPTER CONTENTS
The ovarian cycle 92
The follicular phase 93
Ovulation 94
The luteal phase 94
The menstrual or endometrial cycle 94
The menstrual phase 94
The proliferative phase 94
The secretory phase 95
Fertilization 95
Development of the zygote 96
The pre-embryonic period 96
References 99
Further reading 100
Monthly physiological changes take place in the ovaries and the uterus,
regulated by hormones produced by the hypothalamus, anterior pituitary
gland and ovaries. These monthly cycles commence at puberty and occur
simultaneously and together are known as the female reproductive cycle.
The chapter aims to:
• explore in detail the events that occur during the ovarian and menstrual cycles
• describe in detail the process of fertilization followed by the subsequent development
of the conceptus into the pre-embryonic period.
Introduction
The functions of the female reproductive cycle are to prepare the egg, often referred to
as the gamete or oocyte, for fertilization by the spermatozoon (sperm), and to prepare the
uterus to receive and nourish the fertilized oocyte. I f fertilization has not taken place
the inner lining of the uterus or endometrium and the oocyte are shed and bleeding
occurs per vagina, and the cyclic events begin again.
Before the onset of puberty, luteinizing hormone (LH) and follicle stimulating
hormone (FS H) levels are low. Pulsatile increases in gonadotrophin releasing hormone
(GnRH), particularly at night, cause increase in LH secretion. This increasing surge of
LH is established prior to menarche (Wennink et al 1990). I t is also thought that the
interaction of leptin with GnRH may have a role in the initiation of puberty. The first-
ever occurrence of cyclic events is termed menarche, meaning the first menstrual
bleeding. The average age of menarche is 12 years, although between the ages 8 and 16
is considered normal. The onset of menstrual bleeding (‘periods’ or menses) is a major
stage in a girl's life, representing the maturation of the reproductive system and
physical transition into womanhood. For many women this monthly phenomenon
signals and embodies the quintessence of being a ‘woman’. S imilarly, for other women
it is regarded as an inconvenience, causing pain, shame and embarrassment (Chrisler
2011). Cultural and religious traditions affect how women and their communities feel
about menstruation. The advent of hormonal contraception (Chapter 27) affords
women, especially those in Western society, an element of control over their periods.
Factors such as heredity, diet, obesity and overall health can accelerate or delay
menarche. I nterference with the hormonal–organ relationship prior to and during the
reproductive years is likely to cause menstrual cycle dysfunction which may result in
failure to ovulate. The cessation of cyclic events is referred to as the menopause, and
signifies the end of reproductive life. Each woman has an individual reproductive cycle
that varies in length, although the average cycle is normally 28 days long, and recurs
regularly from puberty to the menopause except when pregnancy intervenes (Fig. 5.1).
FIG. 5.1 The female reproductive cycle.
The ovarian cycle
The ovarian cycle (Fig. 5.2) is the name given to the physiological changes that occur in
the ovaries essential for the preparation and release of an oocyte. The ovarian cycle
consists of three phases, all of which are under the control of hormones.
FIG. 5.2 The cycle of a Graafian follicle in the ovary.
The follicular phase
The formation of oogonia in the germinal epithelium of the ovaries is known as
oogenesis. Primordial germ cells differentiate into oogonia in the ovaries during fetal
life. These diploid stem cells divide mitotically and proliferate into millions of germ
cells. Most of the germ cells degenerate (by atresia), however some develop further
into primary oocytes, and enter the prophase of meiosis I cell division. Meiotic arrest
occurs and the process does not continue until after puberty (further meiotic division
takes place at ovulation of the secondary oocyte and the process is only completed if
fertilization occurs).W hilst in this arrested prophase stage of meiosis I the primary
oocyte is surrounded by follicular cells and is hence known as the primordial follicle.
There are up to 2 million primary oocytes in each ovary at birth and due to atresia the
number is reduced to approximately 40 000 at puberty; 400 of these will mature and
ovulate during the woman's lifetime (Tortora and D errickson 2011). Following puberty
FSH and LH further stimulate the development of primordial follicles into primary and
secondary follicles and subsequently into large preovulatory or Graafian follicles (Fig. 5.3)
by a process known as folliculogenesis.
FIG. 5.3 A ripe Graafian follicle.
Low levels of oestrogen and progesterone stimulate the hypothalamus to produce
GnRH. This releasing hormone causes the production of FS H and LH by the anterio
pituitary gland. FS H controls the growth and maturity of the Graafian follicles. The
Graafian follicles begin to secrete oestrogen, which comprises oestradiol, oestrone and
oestriol. Rising levels of oestradiol cause a surge in LH. W hen oestradiol reaches a
certain peak, the secretion of FS H is inhibited. The reduced FS H secretion causes a
slowing in follicle growth and eventually leads to follicle death, known as atresia. The
largest and dominant follicle secretes inhibin, which further suppresses FS H. This
dominant follicle prevails and forms a bulge near the surface of the ovary, and soon
becomes competent to ovulate. The time from the growth and maturity of the Graafian
follicles to ovulation is normally around 1 week. O ccasionally the follicular phase may
take longer if the dominant follicle does not ovulate, and the phase will begin again.
The differing lengths of menstrual cycle reported between individual women are as a
result in the varying timespans in this pre-ovulatory phase. I t can last 6–13 days in a
28-day cycle (Tortora and Derrickson 2011).
Ovulation
High oestrogen levels cause a sudden surge in LH around day 12–13 of a 28 day cycle,
which lasts for approximately 48 hours. This matures the oocyte and weakens the wall
of the follicle and causes ovulation to occur on day 14.
Ovulation is the process whereby the dominant Graafian follicle ruptures and
discharges the secondary oocyte into the pelvic cavity. Fimbrae guide it into the
uterine tube where it awaits fertilization. D uring the time of ovulation, meiotic cell
division resumes and the diploid oocyte becomes haploid (with a first polar body).
D uring ovulation some women experience varying degrees of abdominal pain known
a s mittelschmerz, which can last several hours. There may be some light bleeding
caused by the hormonal changes taking place. S tringy clear mucus appears in the
cervix, ready to accept the sperm from intercourse. Following ovulation the fertilized
or unfertilized oocyte travels to the uterus.
The luteal phase
T h e luteal phase is the process whereby the cells of the residual ruptured follicle
proliferate and form a yellow irregular structure known as the corpus luteum. The
corpus luteum produces oestrogen, relaxin, inhibin and progesterone for
approximately 2 weeks, to develop the endometrium of the uterus, which awaits the
fertilized oocyte. S mall amounts of relaxin cause uterine quiescence, which is an ideal
environment for the fertilized oocyte to implant. The corpus luteum continues its role
until the placenta is adequately developed to take over. D uring the luteal phase the
cervical mucus becomes sticky and thick. I n the absence of fertilization the corpus
luteum degenerates and becomes the corpus albicans (white body), and progesterone,
oestrogen, relaxin and inhibin levels decrease. I n response to low levels of oestrogen
and progesterone the hypothalamus produces GnRH. The rising levels of GnRH
stimulate the anterior pituitary gland to produce FS H and the ovarian cycle
commences again (S tables and Rankin 2010). The luteal phase is the most constant
part of the ovarian cycle, lasting 14 days out of a 28 day cycle (Tortora and D errickson
2011).
The menstrual or endometrial cycle
T he menstrual cycle is the name given to the physiological changes that occur in the
endometrial layer of the uterus, and which are essential to receive the fertilized oocyte.
The menstrual cycle consists of three phases.
The menstrual phase
This phase is often referred to as menstruation, bleeding, menses, or a period.
Physiologically this is the terminal phase of the reproductive cycle of events and is
simultaneous with the beginning of the follicular phase of the ovarian cycle. Reducing
levels of oestrogen and progesterone stimulate prostaglandin release that causes the
spiral arteries of the endometrium to go into spasm, withdrawing the blood supply to
it, and the endometrium dies, referred to as necrosis. The endometrium is shed down
to the basal layer along with blood from the capillaries, the unfertilized oocyte tissue
fluid, mucus and epithelial cells. Failure to menstruate (amenorrhoea) is an indication
that a woman may have become pregnant. The term eumenorrhoea denotes normal,
regular menstruation that lasts for typically 3–5 days, although 2–7 days is considered
normal. The average blood loss during menstruation is 50–150 ml. The blood is
inhibited from clo ing due to the enzyme plasmin contained in the endometrium. The
menstrual flow passes from the uterus through the cervix and the vagina to the
exterior. The term menorrhagia denotes heavy bleeding. S ome women experience
uterine cramps caused by muscular contractions to expel the tissue. S evere uterine
cramps are known as dysmenorrhoea.
The proliferative phase
This phase follows menstruation, is simultaneous with the follicular phase of the ovary
and lasts until ovulation. There is the formation of a new layer of endometrium in the
uterus, referred to as the proliferative endometrium. This phase is under the control of
oestradiol and other oestrogens secreted by the Graafian follicle and consist of the re-
growth and thickening of the endometrium in the uterus. D uring the first few days of
this phase the endometrium is re-forming, described as the regenerative phase. At the
completion of this phase the endometrium consists of three layers. The basal layer lies
immediately above the myometrium and is approximately 1 mm thick. I t contains all
the necessary rudimentary structures for building new endometrium. The functional
layer, which contains tubular glands, is approximately 2.5 mm thick, and lies on top of
the basal layer. I t changes constantly according to the hormonal influences of the
ovary. The layer of cuboidal ciliated epithelium covers the functional layer. I t dips down
to line the tubular glands of the functional layer. I f fertilization occurs, the fertilized
oocyte implants itself within the endometrium.
The secretory phase
This phase follows the proliferative phase and is simultaneous with ovulation. I t is
under the influence of progesterone and oestrogen secreted by the corpus luteum. The
functional layer of the endometrium thickens to approximately 3.5 mm and becomes
spongy in appearance because the glands are more tortuous. The blood supply to the
area is increased and the glands produce nutritive secretions such as glycogen. These
conditions last for approximately 7 days, awaiting the fertilized oocyte.
Fertilization
Human fertilization, known as conception, is the fusion of genetic material from the
haploid sperm cell and the secondary oocyte (now haploid), to form the zygote (Fig.
5.4). The process takes approximately 12–24 hours and normally occurs in the ampulla
of the uterine tube. Following ovulation, the oocyte, which is about 0.15 mm in
diameter, passes into the uterine tube. The oocyte, having no power of locomotion, is
wafted along by the cilia and by the peristaltic muscular contraction of the uterine
tube. At the same time the cervix, which is under the influence of oestrogen, secretes a
flow of alkaline mucus that a racts the spermatozoa. I n the fertile male at intercourse
approximately 300 million sperm are deposited in the posterior fornix of the vagina.
A pproximately 2 million reach the loose cervical mucus, survive and propel
themselves towards the uterine tubes while the rest are destroyed by the acid medium
of the vagina. A pproximately 200 sperm will ultimately reach the oocyte (Tortora and
D errickson 2011). S perm swim from the vagina and through the cervical canal using
their whip-like tails (flagella). Prostaglandins from semen and uterine contractions as
a result of intercourse facilitate the passage of the sperm into the uterus and beyond.
O nce inside the uterine tubes (within minutes of intercourse), the sperm undergo a
process known as capacitation. This process takes up to 7 hours. I nfluenced by
secretions from the uterine tube the sperm undergo changes to the plasma membrane,
resulting in the removal of the glycoprotein coat and increased flagellation. The zona
pellucida of the oocyte produces chemicals that a ract capacitated sperm only. The
acrosomal layer of the capacitated sperm becomes reactive and releases the enzyme
hyaluronidase known as the acrosome reaction, which disperses the corona radiata (the
outermost layer of the oocyte) allowing access to the zona pellucida (see Fig. 5.4C).
Many sperm are involved in this process. O ther enzymes, such as acrosin, produce an
opening in the zona pellucida. The first sperm that reaches the zona pellucida
penetrates it (see Fig. 5.4D).
FIG. 5.4 Fertilization. Diagrammatic representation of the fusion of the oocyte and the
spermatozoon. (Note that B, C and D are more greatly magnified than A.)
Upon penetration the oocyte releases corticol granules; this is known as the cortical
reaction. The cortical reaction and depolarization of the the oocyte cell membrane
makes it impermeable to other sperm. This is important as there are many sperm
surrounding the oocyte at this time. The plasma membranes of the sperm and oocyte
fuse. The oocyte at this stage completes its second meiotic division, and becomes
mature. The pronucleus now has 23 chromosomes, referred to as haploid. The tail and
mitochondria of the sperm degenerate as the sperm penetrates the oocyte, and there is
the formation of the male pronucleus. The male and female pronuclei fuse to form a
new nucleus that is a combination of the genetic material from both the sperm and
oocyte, referred to as a diploid cell. The male and the female gametes each contribute
half the complement of chromosomes to make a total of 46 (Box 5.1). This new cell is
called a zygote.
Box 5.1
C hrom osom e s
Each human cell has a complement of 46 chromosomes arranged in 23
pairs, of which one pair are sex chromosomes. The remaining pairs are
known as autosomes. D uring the process of maturation, both gametes shed
half their chromosomes, one of each pair, during a reduction division called
meiosis. Genetic material is exchanged between the chromosomes before
they split up. I n the male, meiosis starts at puberty and both halves
redivide to form four sperm in all. I n the female, meiosis commences
during fetal life but the first division is not completed until many years
later at ovulation. The division is unequal; the larger part will eventually go
on to form the oocyte while the remainder forms the first polar body. At
fertilization the second division takes place and results in one large cell,
which is now mature, and a much smaller one, the second polar body. At
the same time, division of the first polar body creates a third polar body.
W hen the gametes combine at fertilization to form the zygote, the full
complement of chromosomes is restored. S ubsequent division occurs by
mitosis where the chromosomes divide to give each new cell a full set.
Sex determination
Females carry two similar sex chromosomes, XX; males carry two dissimilar
sex chromosomes, XY. Each sperm will carry either an X or a Y
chromosome, whereas the oocyte always carries an X chromosome. I f the
oocyte is fertilized by an X-carrying sperm a female is conceived, if by a Y-
carrying one, a male.
D izygotic twins (fraternal twins) are produced from two oocytes released
independently but in the same time frame fusing with two different sperm; they are
genetically different from each other. Monozygotic twins develop from a single zygote
for a variety of reasons, where cells separate into two embryos, usually before 8 days
following fertilization. These twins are genetically identical.
Development of the zygote
The development of the zygote can be divided into three periods. The first 2 weeks
after fertilization, referred to as the pre-embryonic period, includes the implantation of
the zygote into the endometrium; weeks 2–8 are known as the embryonic period; and
weeks 8 to birth are known as the fetal period.
The pre-embryonic period
D uring the first week the zygote travels along the uterine tube towards the uterus. At
this stage a strong membrane of glycoproteins called the zona pellucida surrounds the
zygote. The zygote receives nourishment, mainly glycogen, from the goblet cells of the
uterine tubes and later the secretory cells of the uterus. D uring the travel the zygote
undergoes mitotic cellular replication and division referred to as cleavage, resulting in
the formation of smaller cells known as blastomeres. The zygote divides into two cells
at 1 day, then four at 2 days, eight by 2.5 days, 16 by 3 days, now known as the morula.
The cells bind tightly together in a process known as compactation. N ext cavitation
occurs whereby the outermost cells secrete fluid into the morula and a fluid-filled
cavity or blastocele appears in the morula. This results in the formation of the blastula
or blastocyst, comprising 58 cells. The process from the development of the morula to
the development of the blastocyst is referred to as blastulation and has occurred by
around day 4 (Fig. 5.5).
FIG. 5.5 Diagrammatic representation of the development of the zygote.
The zona pellucida remains during the process of cleavage, so that despite an
increase in number of cells the overall size remains that of the zygote and constant at
this stage. The zona pellucida prevents the developing blastocyst from increasing in
size and therefore ge ing stuck in the uterine tube; it also prevents embedding
occurring in the tube rather than the uterus, which could result in an ectopic
pregnancy. A round day 4 the blastocyst enters the uterus. Endometrial glands secrete
glycogen-rich fluid into the uterus which penetrates the zona pellucida. This and
nutrients in the cytoplasm of the blastomeres provides nourishment for the
developing cells. The blastocyst digests its way out of the zona pellucida once it enters
the uterine cavity. The blastocyst possesses an inner cell mass or embryoblast, and an
outer cell mass or trophoblast. The trophoblast becomes the placenta and chorion, while
the embryoblast becomes the embryo, amnion and umbilical cord (Carlson 2004;
Tortora and Derrickson 2011).
D uring week 2, the trophoblast proliferates and differentiates into two layers: the
outer syncytio-trophoblast or syncytium and the inner cytotrophoblast (cuboidal dividing
cells) (Fig. 5.6). I mplantation of the trophoblast layer into the endometrium, now
known as the decidua, begins. I mplantation is usually to the upper posterior wall. At
the implantation stage the zona pellucida will have totally disappeared. The
syncytiotrophoblast layer invades the decidua by forming finger-like projections called
villi that make their way into the decidua and spaces called lacunae that fill up with the
mother's blood. The villi begin to branch, and contain blood vessels of the developing
embryo, thus allowing gaseous exchange between the mother and embryo.
I mplantation is assisted by proteolytic enzymes secreted by the syncytiotrophoblast
cells that erode the decidua and assist with the nutrition of the embryo. The
syncytiotrophoblast cells also produce human chorionic gonadotrophin (hCG), a
hormone that prevents menstruation and maintains pregnancy by sustaining the
function of the corpus luteum.
FIG. 5.6 The development of the blastocyst.
S imultaneous to implantation, the embryo continues developing. The cells of the
embryoblast differentiate into two types of cells: the epiblast (closest to the
trophoblasts) and the hypo-blast (closest to the blastocyst cavity). These two layers of
cells form a flat disc known as the bilaminar embryonic disc. A process of gastrulation
turns the bilaminar disc into a tri-laminar embryonic disc (three layers). D uring
gastrulation, cells rearrange themselves and migrate due to predetermined genetic
coding. Three primary germ layers are the main embryonic tissues from which various
structures and organs will develop. The first appearance of these layers, collectively
known as the primitive streak, is around day 15.
• The ectoderm is the start of tissue that covers most surfaces of the body: the
epidermis layer of the skin, hair and nails. Additionally it forms the nervous system.
• The mesoderm forms the muscle, skeleton, dermis of skin, connective tissue, the
urogenital glands, blood vessels, and blood and lymph cells.
• The endoderm forms the epithelial lining of the digestive, respiratory and urinary
systems, and glandular cells of organs such as the liver and pancreas.
The epiblast separates from the trophoblast and forms the floor of a cavity, known
as the amniotic cavity. The amnion forms from the cells lining the cavity. The cavity is
filled with fluid, and gradually enlarges and folds around the bilaminar disc to enclose
it. This amniotic cavity fills with fluid (amniotic fluid) derived initially from maternal
filtrate; later the fetus contributes by excreting urine. Fetal cells can be found in the
amniotic fluid and can be used in diagnostic testing for genetic conditions via a
procedure known as amniocentesis (Chapter 11).
At about 16 days mesodermal cells form a hollow tube in the midline called the
notochordal process; this becomes a more solid structure, the notochord, about a week
later. S pecialized inducing cells and responding tissues cause development of the
vertebral bodies and intervertebral discs to occur. The neural tube is developed from
further cell migration, differentiation and folding of embryonic tissue. This occurs in
the middle of the embryo and develops towards each end. The whole process is known
a s neurulation. Teratogens, diabetes or folic acid deficiency may lead to neural tube
defects.
The hypoblast layer of the embryoblast gives rise to extra-embryonic structures only,
such as the yolk sac. Hypoblast cells migrate along the inner cytotrophoblast lining of
the blastocele-secreting extracellular tissue which becomes the yolk sac. The yolk sac is
lined with extraembryonic endoderm, which in turn is lined with extraembryonic
mesoderm. The yolk sac serves as a primary nutritive function, carrying nutrients and
oxygen to the embryo until the placenta fully takes over this role. The endoderm and
mesoderm cells contribute to the formation of some organs, such as the primitive gut
arising out of the endoderm cells. A n outpouching of endodermic tissue forms the
allantois, this extends to the connecting stalk around which the umbilical cord later
forms. Growth of blood vessels is induced, connecting separately to vessels of the
embryo and placenta (Kay et al 2011). Blood islands that later go on to develop blood
cells arise from the mesodermal layer; the remainder resembles a balloon floating in
front of the embryo until it atrophies by the end of the 6th week when blood-forming
activity transfers to embryonic sites. A fter birth, all that remains of the yolk sac is a
vestigial structure in the base of the umbilical cord, known as the vitelline duct.
The pre-embryonic period is crucial in terms of initiation and maintenance of the
pregnancy and early embryonic development. I nability to implant properly can results
in ectopic pregnancy or miscarriage. A dditionally chromosomal defects and
abnormalities in structure and organs can occur during this time (Moore and Persaud
2003).
D uring embryological development stem cells under predetermined genetic control
become specialized giving rise to further differentiation with a varying functionality
according to their predefined role (Box 5.2).
Box 5.2
S t e m ce lls
• Stem cells are unspecialized and give rise to specialized cells.
• The zygote can give rise to a whole organism, known as a totipotent stem
cell.
• Stem cells such as those in the inner cell mass can give rise to many
different types of cells and are consequently known as pluripotent.
• Further specialization of pluripotent stem cells gives rise to cells with
more specific functions, known as multipotent stem cells.
S tem cells in adult organs (also known as adult stem cells, somatic or
tissue-specific cells) have the potential to become any type of cell in a
specific organ – multipotent. These cells facilitate repair of a damaged or
diseased organ. A dult stem cells may have some ‘plasticity’ and may have
the potential to be used in other organs of the body.
I n the United Kingdom, cell cleavage up to 14 days after fertilization can
be used for research. This tends to be undertaken at 5–6 days. A s research
occurs on the cells at this stage the embryo does not exist as a 3-D entity
and its properties are changed – in essence it is no longer an ‘embryo’.
Stem cell harvesting
S tem cells from an embryo, if transferred into another individual where
there is no genetic match, will cause rejection issues similar to tissue
transplantation.
S tem cells found in the umbilical cord, which can be collected, have
originated in the fetal liver; most stem cells found in cord are progenitor
cells and have differentiated further – usually into haematopoetic stem
cells.
These cells may cause transplant issues if used in other people unless
there is a very close genetic match, such as a sibling. The cells could then be
used to treat acute lymphoblastic leukaemia.
I n the United Kingdom, theHuman Tissue Authority (HTA 2010) , the
Royal College of Obstetricians and Gynaecologists (RCOG)/Royal College of
Midwives (RCM) (2011) and Tro er (2008) have produced useful guidance
papers to help inform midwifery practice around the issue of stem cell
harvesting and routine commercial umbilical cord blood collection.
References
Carlson BM. Human embryology and developmental biology. 3rd edn. Mosby:
Philadelphia; 2004.
Chrisler JC. Leaks, lumps, and lines: stigma and women's bodies. Psychology of
Women Quarterly. 2011;35(2):202–214.
Human Tissue Authority (HTA). guidance for licensed establishments involved in
cord blood collection. [Accessed online at] www.hta.gov.uk; 2010 [(11 April
2013)] .
Kay HH, Nelson DM, Wang Y. The placenta. From development to disease. Wiley–
Blackwell: Oxford; 2011.
Moore KL, Persaud T V N. Before we are born: essentials of embryology and birth
defects. 8th edn. Saunders: London; 2003.
Royal College of Obstetricians and Gynaecologists (RCOG)/Royal College of
Midwives (RCM). Statement on umbilical cord blood collection and banking.
[Available at] www.rcog.org.uk; 2011 [(accessed 11 April 2013)] .
Stables D, Rankin J. Physiology in childbearing: with anatomy and related biosciences.
3rd edn. Baillière Tindall: Edinburgh; 2010.
Tortora GJ, Derrickson B. Principles of anatomy and physiology. Maintenance and
continuity of the human body. 13th edn. John Wiley & Sons: Hoboken, NJ; 2011.
Trotter S. Cord blood banking and its implications for midwifery practice: time
to review the evidence? MIDIRS Midwifery Digest. 2008;18(2):159–164.
Wennink J M B, Delemarre-van de Waal HA, Schoemaker R, et al. Luteinizing
hormone and follicle stimulating hormone secretion patterns in girls
throughout puberty measured using highly sensitive immunoradiometric
assays. Clinical Endocrinology. 1990;33(3):333–344.
Further reading
Coad J, with Dunstall M. Anatomy and physiology for midwives. 3rd edn. Churchill
Livingstone: Edinburgh; 2011.
A very full and clear explanation of endocrine activity is given in Chapter 3. Chapter 4
addresses the reproductive cycles in similar detail with clear diagrams to assist the
reader..
Johnson MH, Everitt BJ. Essential reproduction. 5th edn. Blackwell Science: Oxford;
2000.
This authoritative volume provides the interested reader with a much greater depth of
information than is possible in the present book and is recommended for those who
wish to study the hormonal patterns of reproduction in detail..
Schoenwolf GC, Bleyl SB, Brauer PR, Francis-West PH. Larsen's human
embryology. 9th edn. Churchill Livingstone: Philadelphia; 2009.
Detailed embryology for those students wanting greater depth..
C H AP T E R 6
The placenta
Jenny Bailey
CHAPTER CONTENTS
Early development 101
Implantation 102
The chorionic villous tree 103
The placenta at term 103
Functions 104
Placental circulation 106
The membranes 106
Amniotic fluid 107
The umbilical cord (funis) 107
Anatomical variations of the placenta and cord 108
Conclusion 109
References 109
Further reading 110
This chapter discusses the development of the placenta – a complex organ,
deriving from two separate individuals, the mother and the fetus (Tortora
and Derrickson 2011). It is formed from the merging of the chorion and the
allantois (see Chapter 5) in early pregnancy (Rampersad et al 2011). The
process of forming a placenta (known as placentation) involves prevention
of immune rejection, transfer of nutrients and waste products and the
secretion of hormones to maintain the pregnancy. In addition, the chapter
includes details of anatomical variations of the placenta and umbilical cord,
highlighting their significance to midwifery practice.
The chapter aims to:
• outline the development of the placenta
• explore variations of the placenta and umbilical cord and highlight their significance to
midwifery practice.
Early development
Within a few days of fertilization, the trophoblasts (see Chapter 5) begin to produce
human chorionic gonadotrophin (hCG), ensuring that the endometrium will be
receptive to the implanting embryo. The endometrium increases in vascularity and
undergoes a series of structural changes in a process known as decidualization in
preparation for implantation; hence the endometrium is referred to as the decidua in
pregnancy. I nterconnecting arteriovenous shunts form between the maternal spiral
arteries and veins which persist into the immediate postpartum period. A reduction of
the number of shunts leading to narrower uterine arteries is involved with
complications of pregnancy such as pre-eclampsia (Burton et al 2009).
The decidua has regions named according to its relationship to the implantation
site:
• The decidua basalis lies between the developing embryo and the stratum basalis of
the uterus at the implantation site.
• The decidua capsularis covers the developing embryo separating it from the uterine
cavity.
• The decidua vera (otherwise known as the decidua parietalis) lines the remainder of the
uterine cavity.
Uterine glands secrete nutrients such as glycogen, to maintain the developing
conceptus until the intraplacental blood flow is fully developed, some 10–12 weeks
later (Burton et al 2002).
I n pregnancy a sophisticated immune adaptation occurs to prevent rejection of the
fetus. The decidua is invaded by macrophages, which become immunosuppressive.
A dapted T-regulator cells, known as Tregs, become less effective as part of the specific
hormonal response to antigens and the effect of natural killer (N K) cells is reduced
such that their cytotoxicity becomes impaired and they are less likely to destroy any
foreign cells.
Microchimerism is the term for the presence of a small number of cells in one
individual that originated in a different individual. S ome fetal cells actively move into
the mother's circulation, tissues and organs in the first trimester of pregnancy without
triggering an immune response. The role of these cells in maternal systems is unclear.
They could have an immunosuppressant effect to protect the fetus and they also can
facilitate growth and repair in maternal systems.
Implantation
Implantation involves two stages: prelacunar and lacunar.
Prelacunar stage
S even days post conception the blastocyst makes contact with the decidua (apposition)
and the process of placentation begins (Fig. 6.1). The process of implantation is
extremely aggressive: chemical mediators, prostaglandins and proteolytic enzymes are
released by both the decidua and the trophoblasts and maternal connective tissue is
invaded. N earby maternal blood vessels ensure there is optimum blood flow to the
placenta. At this stage the cytotrophoblasts form a double layer and further
differentiate into various types of syncytiotrophoblasts. The supply of
syncytiotrophoblasts is as a result of continued mitotic proliferation of the
cytotrophoblastic layer below.
FIG. 6.1 Early implantation of the blastocyst.
Lacunar stage
I ncreasing numbers of syncytiotrophoblasts surround the blastocyst and small lakes
form within these cells known as lacunae, which will become the intervillous spaces
between the villi (Fig. 6.2) and will be bathed in blood as maternal spiral arteries are
eroded some 10–12 weeks following conception. Prior to this the embryo is nourished
from uterine glands (see Chapter 5).
FIG. 6.2 Chorionic villi.
The trophoblasts have a potent invasive capacity, which if left unchecked would
spread throughout the uterus. This potential is moderated by the decidua, which
secretes cytokines and protease inhibitors that modulate trophoblastic invasion. The
layer of N itabusch is a collaginous layer between the endometrium and myometrium
which assists in preventing invasion further than the decidua. Trophoblastic invasion
into the myometrium can give rise to a morbidly adhered placenta, known as placenta
accreta (see Chapter 18).
The chorionic villous tree
Chorionic villi are finger-like projections of chorion surrounded by cytotrophoblastic
and syncytiotrophoblastic layers. I nitially new blood vessels develop from progenitor
cells within the chorionic villi of the placenta (known as vasculogenesis). A relatively
low level of oxygen promotes this. Further growth of these vessels (angiogenesis)
produces a vascular network that ultimately connects with those blood vessels
developed independently in the embryo via the umbilical arteries and vein through
the connecting stalk.
The villi proliferate and branch out approximately three weeks after fertilization.
O ver time the villi can differentiate and specialize, resulting in different functions.
Villi become most profuse in the area where the blood supply is richest, the decidua
basalis. This part of the trophoblastic layer, which is known as the chorion frondosum,
eventually develops into the placenta. The villi under the decidua capsularis gradually
degenerate due to lack of nutrition, forming the chorion laeve, which is the origin of the
chorionic membrane (Fig. 6.3). A s the fetus enlarges and grows, the decidua capsularis
is pushed towards the decidua vera on the opposite wall of the uterus until, at about
27 weeks of gestation, the decidua capsularis subsequently disappears.
FIG. 6.3 Implantation site at 3 weeks.
The syncytiotrophoblasts surrounding the villi erode the walls of maternal vessels as
they penetrate the lower myometrium, opening them up into a funnel shape, forming
a lake of maternal blood in which the villi float. This opening up reduces the velocity
at which maternal blood enters the central cavity of the cotyledon (lobule) and villous
tree (Burton et al 2009). The maternal blood circulates, enabling the villi to absorb
nutrients and oxygen and to excrete waste. These are known as the nutritive villi. A few
villi are more deeply attached to the decidua and are called anchoring villi.
Each chorionic villus is a branching structure like a tree arising from one stem. I ts
centre consists of mesoderm and fetal blood vessels, as well as branches of the
umbilical artery and vein. These are covered by a single layer of cytotrophoblast cells
and the external layer of the villus is the syncytiotrophoblast (see Fig. 6.2). This means
that four layers of tissue separate the maternal blood from the fetal blood making it
impossible for the two circulations to mix unless any villi are damaged.
The placenta at term
At term the placenta is discoid in shape, about 20 cm in diameter and 2.5 cm thick at
its centre and weighing approximately 470 g, which is directly proportional to the
weight of the fetus. Rampersad et al (2011) state that, by term, the ratio of fetal size to
that of the placenta is about 7 to 1. Placental pathology and maternal disease can affect
this ratio: such sequelae being diabetes, pre-eclampsia, pregnancy-induced
hypertension or intrauterine growth restriction (I UGR) (seeChapter 13). The weight of
the placenta may be affected by physiological or active management of the third stage
of labour owing to the varying amounts of fetal blood retained in the vessels. The
placenta is no longer routinely weighed in clinical practice; however some maternity
units may do so as part of clinical trials and research activities.
The maternal surface of the placenta (i.e. the basal plate) is dark red in colour due to
maternal blood and partial separation of the basal decidua (Fig. 6.4A). The surface is
arranged in up to 40 cotyledons (lobes), which are separated by sulci (furrows), into
which the decidua dips down to form septa (walls). The cotyledons are made up of
lobules, each of which contains a single villus with its branches. S ometimes deposits
of lime salts may be present on the surface, making it slightly gri y. This has no
clinical significance.
FIG. 6.4 The placenta at term. (A) Maternal surface. (B) Fetal surface.
The fetal surface of the placenta (i.e. the chorionic plate) has a shiny appearance due to
the amnion covering it (Fig. 6.4B). Branches of the umbilical vein and arteries are
visible, spreading out from the insertion of the umbilical cord, which is normally in
the centre. The amnion can be peeled off the surface of the chorion as far back as the
umbilical cord, whereas the chorion, being derived from the same trophoblastic layer
as the placenta, cannot be separated from it.
Functions
The placenta performs a variety of functions for the developing fetus which can be
determined by the pneumonic SERPENT (Fig. 6.5).
FIG. 6.5 Summary of the functions of the placenta (SERPENT).
Storage
The placenta metabolizes glucose, stores it in the form of glycogen and reconverts it to
glucose as required. It can also store iron and the fat-soluble vitamins.
Endocrine
The many and varied endocrine functions of the placenta are complex, requiring
maternal and fetal input. Both types of trophoblasts produce steroidal hormones
(oestrogens and progesterone) in addition to many placental protein hormones
necessary for pregnancy (Kay et al 2011).
Steroid hormones
There are three important oestrogens: oestrone, oestradiol and oestriol. Both maternal and
fetal adrenal production provide precursors for oestrogen production by the placenta.
Pregnalone sulphate is converted to oestriol by the feto-placental unit from 6 to 12
weeks onwards, rising steadily until term. O estrogens influence uterine blood flow,
enhance ribonucleic acid (RN A) and protein synthesis and aid growth of uterine
muscle. They also increase the size and mobility of the maternal nipple and cause
alveolar and duct development of the breast tissue. S erial serum (mmol/l) oestriol
measurements can indicate the level of feto-placental wellbeing.
Progesterone production is maintained by the corpus luteum for approximately 8
weeks until the placenta takes over this function and is dependent on maternal
cholesterol stores. Progesterone is thought to play an important part in
immunosuppression to maintain the pregnancy (Kay et al 2011). Progesterone is
produced in the syncytial layer of the placenta in increasing quantities until
immediately before the onset of labour when its level falls. I t maintains the
myometrium in a quiescent state, during pregnancy. I t is involved in preparing breast
tissue during pregnancy and when levels reduce after birth of the placenta, prolactin
stimulates lactation.
Protein hormones
H uman chorionic gonadotrophin (hCG) is produced under the influence of placental
gonadotrophic releasing hormone (GnRH) by the trophoblasts. I nitially it is present in
very large quantities, with peak levels being achieved between the 7th and 10th week,
but these gradually reduce as the pregnancy advances. The function of hCG is to
stimulate the corpus luteum to produce mainly progesterone. I t also increases fetal
leydig cells to affect male sexual development prior to fetal luteinizing hormone (LH)
production (Kay et al 2011). Human chorionic gonadotrophin forms the basis of the
many pregnancy tests available, as it is excreted in the mother's urine.
H uman placental lactogen (hPL) is sometimes known as human chorionic
somatomammotropin hormone (hCS ) as it not only stimulates somatic growth but also
stimulates proliferation of breast tissue in preparation for lactation. I n early
pregnancy, HPL stimulates food intake and weight gain, mobilizing free fa y acids,
and functions with prolactin to increase circulating insulin levels (Barbour et al 2007;
Kay et al 2011). Human placental lactogen is no longer considered the primary agent of
insulin resistance as other growth hormones, such as human placental growth
hormone (hPGH), appear to be the main determinants for this. Levels of hPL have
been used as a screening tool in pregnancy to assess placental function.
H uman placental growth hormone (hPGH ) levels rise throughout pregnancy. This
hormone is involved with hPL as a determinant of insulin resistance in late pregnancy.
I t mobilizes maternal glucose for transfer to the fetus and contributes to lipolysis,
lactogenesis and fetal growth.
There are also many other factors, such as insulin growth factor (I GF) andvascular
endothelial growth factor (VEGF), playing a variety of roles in metabolism, growth,
vasculogenesis and regulation of utero-placental blood flow.
Respiration
Gaseous exchange to and from the fetus occurs as a result of diffusion. Transfer of
gases is assisted by a slight maternal respiratory alkalosis in pregnancy. The fetal
haemoglobin level is high in utero to facilitate transport of gases. The fetal
haemoglobin also has a high affinity for oxygen.
Protection
The placenta provides a limited barrier to infection. Few bacteria can penetrate with
the exception of the treponema of syphilis and the tubercle bacillus. However, many
types of virus can penetrate the placental barrier, such as human immunodeficiency
virus (HI V), hepatitis strains, Parvo virus B19, human cytomegalovirus (CMV) and
rubella. I n addition to this, some parasitic and protozoal diseases, such as malaria and
toxoplasmosis, will cross the placenta.
The placenta filters substances of a high molecular weight therefore some drugs and
medicines may transfer to the fetus. A lthough such drugs will cross the placental
barrier to the fetus, many will be harmless, and others, such as antibiotics
administered to a pregnant woman with syphilis, are positively beneficial (see Chapter
13). S ubstances including alcohol and some chemicals associated with smoking
cigare es and recreational drug use are not filtered out. These substances can cross
the placental barrier freely and may cause congenital malformations and subsequent
problems for the baby.
I mmunoglobulins will be passed from mother to fetus transplacentally in late
pregnancy, providing about 6–12 weeks' naturally acquired passive immunity to the
baby.
I n the case of Rhesus disease, if sensitization occurs and fetal blood cells enter the
maternal circulation, responding antibodies produced by the mother may cross the
placenta and destroy fetal surface antigens and consequently fetal cells, causing
haemolysis, hydrops fetalis and potential fetal demise.
Excretion
The main substance excreted from the fetus is carbon dioxide. Bilirubin will also be
excreted as red blood cells are replaced relatively frequently. There is very li le tissue
breakdown apart from this and the amounts of urea and uric acid excreted are very
small.
Nutrition
The fetus requires nutrients for its ongoing development, such as amino acids and
glucose which are required for growth and energy, calcium and phosphorus for bones
and teeth, and iron and other minerals for blood formation. These nutrients are
actively transferred from the maternal to the fetal blood through the walls of the villi.
The placenta is able to select those substances required by the fetus, even depleting
the mother's own supply in some instances. Water, vitamins and minerals also pass to
the fetus. Fats and fat-soluble vitamins (A , D and E) cross the placenta only with
difficulty and mainly in the later stages of pregnancy. S ome substances, including
amino acids, are found at higher levels in the fetal blood than in the maternal blood.
Transfer of substances
S ubstances transfer to and from the fetus by a variety of transport mechanisms, as
stated below:
• Simple diffusion of gases and lipid soluble substances.
• Water pores transfer water-soluble substances as a result of osmotic and potentially
hydrostatic forces.
• Facilitated diffusion of glucose using carrier proteins.
• Active transport against concentration gradients of ions, calcium (Ca) and
phosphorus (P).
• Endocytosis (pinocytosis) of macromolecules.
Placental circulation
I nvading trophoblasts modify maternal spiral arterioles to accommodate a 10-fold
increase in blood flow where there is open circulation around the chorionic villi.
Maternal blood is discharged in a pulsatile fashion into the intervillous space by 80–
100 spiral arteries in the decidua basalis after 10–12 weeks of gestation. The blood
flows slowly around the villi, eventually returning to the endometrial veins and the
maternal circulation. There are about 150 ml of maternal blood in the intervillous
spaces, which is exchanged three or four times per minute.
Fetal blood, which is low in oxygen, is pumped by the fetal heart towards the
placenta along the umbilical arteries and transported along their branches to the
capillaries of the chorionic villi where exchange of nutrients takes place between the
mother and fetus. Having yielded carbon dioxide and waste products and absorbed
oxygen and nutrients, the blood is returned to the fetus via the umbilical vein (Fig.
6.6).
FIG. 6.6 Blood flow around chorionic villi.
The membranes
The basal and chorionic plates come together and meet at the edges to form the
chorioamnion membrane where the amniotic fluid is contained. The chorioamnion
membrane is composed of two membranes: the amnion and the chorion.
The amnion is the inner membrane derived from the inner cell mass and consists of
a single layer of epithelium with a connective tissue base. I t is a tough, smooth and
translucent membrane, continuous with the outer surface of the umbilical cord which
moves over the chorion aided by mucous. The amnion contains amniotic fluid, which
it produces in small quantities as well as prostaglandin E2 (PGE2) which plays a role in
the initiation of labour. I n rare instances, the amnion can rupture, causing amniotic
bands that can affect the growth of fetal limbs.
T he chorion, which is the outer membrane that is continuous with the edge of the
placenta, is composed of mesenchyme, cytotrophoblasts and vessels from the
extended spiral arteries of the decidua basalis. I t is a rough, thick, fibrous, opaque
membrane which lines the decidua vera during pregnancy, although loosely a ached.
I t produces enzymes that can reduce progesterone levels and also produces
prostaglandins, oxytocin and platelet-activating factor which stimulate uterine activity.
This membrane is friable and can rupture easily, so it can be retained in the uterus
following birth.
Amniotic fluid
A mniotic fluid is a clear alkaline and slightly yellowish liquid contained within the
amniotic sac. I t is derived essentially from the maternal circulation across the
placental membranes and exuded from the fetal surface. The fetus contributes to the
amniotic fluid through metabolism in small quantities of urine and fluid from its
lungs. This fluid is returned to the fetus by intramembranous flow across the amnion
into the fetal vessels and through the mechanism of the fetus swallowing.
Functions of the amniotic fluid
A mniotic fluid distends the amniotic sac allowing for the growth and free movement
of the fetus and permi ing symmetrical musculoskeletal development. I t equalizes
pressure and protects the fetus from jarring and injury. The fluid maintains a constant
intrauterine temperature, protecting the fetus from heat loss and providing it with
small quantities of nutrients. I n labour, as long as the membranes remain intact the
amniotic fluid protects the placenta and umbilical cord from the pressure of uterine
contractions. I t also aids effacement of the cervix and dilatation of the uterine os,
particularly where the presenting part is poorly applied.
Constituents of the amniotic fluid
A mniotic fluid consists of 99% water with the remaining 1% being dissolved solid
ma er including food substances and waste products. I n addition, the fetus sheds
skin cells, vernix caseosa and lanugo into the fluid. A bnormal constituents of the liquor,
such as meconium in the case of fetal compromise, may give valuable diagnostic
information about the condition of the fetus. A spiration of amniotic fluid for
diagnostic examination is termed amniocentesis.
Research has found that amniotic fluid is a plentiful source of non-embryonic stem
cells (D e Coppi et al 2007). These cells have demonstrated the ability to differentiate
into a number of different cell-types, including brain, liver and bone.
Volume of amniotic fluid
D uring pregnancy, amniotic fluid increases in volume as the fetus grows: from 20 ml
at 10 weeks to approximately 500 ml at term.
The umbilical cord (funis)
The umbilical cord, which extends from the fetal surface of the placenta to the
umbilical area of the fetus, is formed by the 5th week of pregnancy. I t originates from
the duct that forms between the amniotic sac and the yolk sac, which transmits the
umbilical blood vessels (see Chapter 5).
Functions
The umbilical cord transports oxygen and nutrients to the developing fetus, and
removes waste products.
Structure
The umbilical cord contains two arteries and one vein (Fig. 6.7), which are continuous
with the blood vessels in the chorionic villi of the placenta. The blood vessels are
enclosed and protected by W harton's jelly, a gelatinous substance formed from
primary mesoderm. The whole cord is covered in a layer of amnion that is continuous
with that covering the placenta. There are no nerves in the umbilical cord, so cu ing it
following the birth of the baby is not painful.
FIG. 6.7 Cross-section through the umbilical cord.
The presence of only two vessels in the cord may indicate renal malformations in the
fetus; however, in some instances this has li le significance to the subsequent health
of the baby.
Measurements
The cord is approximately 1–2 cm in diameter and 50 cm in length. This length is
sufficient to allow for the birth of the baby without applying any traction to the
placenta.
A cord is considered short when it measures <40 cm. There is no specific agreed
length for describing a cord as too long, but the disadvantages of a very long cord are
that it may become wrapped round the neck or body of the fetus or become kno ed.
Either event could result in occlusion of the blood vessels, especially during labour.
Compromise of the fetal blood flow through the umbilical cord vessels can have
serious detrimental effects on the health of the fetus and baby. True knots should
always be noted on examination of the cord, but they must be distinguished from false
knots, which are lumps of W harton's jelly on the side of the cord and do not have any
physiological significance.
Anatomical variations of the placenta and cord
A succenturiate lobe of placenta is the most significant of the variations in conformation
of the placenta. A small extra lobe is present that is separate from the main placenta,
and joined to it by blood vessels that run through the membranes to connect it (Fig.
6.8). The danger is that this small lobe may be retained in utero after the placenta is
expelled, and if it is not removed, it may lead to haemorrhage and infection. Every
placenta must be examined for evidence of a retained succenturiate lobe, which can be
identified by a hole in the membranes with vessels running to it.
FIG. 6.8 Succenturiate lobe of placenta.
I n a circumvallate placenta, an opaque ring is seen on the fetal surface of the
placenta. I t is formed by a doubling back of the fetal membrane onto the fetal surface
of the placenta and may result in the membranes leaving the placenta nearer the
centre instead of at the edge as usual (Fig. 6.9). This placental variation is associated
with placental abruptio and intrauterine growth restriction (IUGR).
FIG. 6.9 Circumvallate placenta.
I n a bipartite placenta, there are two complete and separate lobes where the main
cord bifurcates to supply both parts (Fig. 6.10). A tripartite placenta is similar to a
bipartite placenta but it has three distinct parts.
FIG. 6.10 Bipartite placenta.
I n a battledore insertion of the cord, the cord is a ached at the very edge of the
placenta, and where the a achment is fragile it may cause significant problems with
active management of the third stage of labour (Fig. 6.11).
FIG. 6.11 Battledore insertion of the cord.
A velamentous insertion of the cord, occurs when the cord is inserted into the
membranes some distance from the edge of the placenta. The umbilical vessels run
through the membranes from the cord to the placenta (Fig. 6.12). I f the placenta is
normally situated, no harm will result to the fetus, but the cord is likely to become
detached upon applying traction during active management of the third stage of
labour. However, if the placenta is low-lying, the vessels may pass across the uterine os
(vasa praevia ). I n this case, there is great danger to the fetus when the membranes
rupture and even more so during artificial rupture of the membranes, as the vessels
may be torn, leading to rapid exsanguination of the fetus. I f the onset of haemorrhage
coincides with rupture of the membranes, fetal haemorrhage should be assumed and
the birth expedited. I t is possible to distinguish fetal blood from maternal blood by
S inger's alkali-denaturation test, although, in practice, time is so short that it may not
be possible to save the life of the baby. I f the baby survives, haemoglobin levels
should be estimated after birth and blood transfusion considered.
FIG. 6.12 Velamentous insertion of the cord.
Conclusion
D evelopment of the placenta requires complex processes involving enzymes,
hormones and growth factors which remodel maternal tissue in addition to
constructing new tissue specifically for the sustenance of the fetus. The placenta acts
as a life support system for the developing embryo and fetus until birth.
References
Barbour LA, McCurdy CE, Hernandez TL, et al. Cellular mechanisms for insulin
resistance in normal pregnancy and gestational diabetes. Diabetes Care.
2007;30(Suppl 2):112–119.
Burton GJ, Woods AW, Jauniaux E, et al. Rheological and physiological
consequences of conversion of maternal spiral arteries for unteroplacental
blood flow during human pregnancy. Placenta. 2009;30(6):473–482.
Burton GJ, Watson AL, Hempstock J, et al. Uterine glands provide histiotrophic
nutrition for the human fetus during the first trimester of pregnancy. Journal of
Clinical Endocrinology and Metabolism. 2002;87(6):2954–2959.
De Coppi P, Bartsch G Jr, Siddiqui MM, et al. Isolation of amniotic stem cell lines
with potential for therapy. Nature Biotechnology. 2007;25(1):100–105.
Kay HH, Nelson DM, Wang Y. The placenta: from development to disease. Blackwell:
Oxford; 2011.
Rampersad R, Cerva-Zivkovic M, Nelson DM. Development and anatomy of the
human placenta. Kay HH, Nelson DM, Wang Y. The placenta: from development
to disease. Blackwell: Oxford; 2011.
Tortora GJ, Derrickson B. Principles of anatomy and physiology: maintenance and
continuity of the human body. 13th edn. John Wiley & Sons: Hoboken, NJ; 2011.
Further reading
Coad J, with Dunstall M. Anatomy and physiology for midwives. 3rd edn. Churchill
Livingstone/Elsevier: London; 2011.
Chapter 8 of this comprehensive text provides a detailed account of the placenta..
Kay HH, Nelson DM, Wang Y. The placenta: from development to disease. Blackwell:
Oxford; 2011.
Chapters 3 and 4 provide details regarding placental development for students who
wish a more in-depth knowledge..
Oats JK, Abraham S. Llewellyn-Jones fundamentals of obstetrics and gynaecology. 9th
edn. Mosby/Elsevier: London; 2010.
This book has a section on the placenta (Chapter 3) that the reader may find useful..
Stables D, Rankin J. Physiology in childbearing with anatomy and related biosciences.
3rd edn. Elsevier: Edinburgh; 2010.
Section 2A in Chapter 12 considers the placenta, membranes and amniotic fluid.
C H AP T E R 7
The fetus
Jenny Bailey
CHAPTER CONTENTS
Time scale of development 111
Fetal growth and maturation 112
The cardiovascular system 112
The respiratory system 114
The urogenital system 115
The endocrine system 115
The digestive system 115
The nervous system 115
Integumentary, skeletal and muscular system 116
The fetal circulation 116
Adaptation to extrauterine life 117
The fetal skull 118
Divisions of the fetal skull 118
Diameters of the fetal skull 120
Moulding 122
Conclusion 122
References 123
Further reading 123
This chapter provides a system-by-system approach for the reader to
appreciate the complexities surrounding embryonic and fetal development
and the subsequent changes that occur in the baby at the time of birth. In
addition, discussion of the fetal skull and the significance of its diameters in
late pregnancy and during labour in influencing an optimum birth outcome is
provided.
An understanding of the detail is of value to the midwife when providing
parents with information about the effects of maternal lifestyle, such as diet,
smoking, alcohol intake, drug use and exercise, on fetal growth and
development (see Chapter 8) and when a baby is born before term (see
Chapter 30).
The chapter aims to:
• outline the early development of the embryo and subsequent development of the fetus
• discuss the fetal circulation and the changes that occur at birth
• discuss the significance of the fetal skull and the significance of its diameters in
determining a successful birth outcome.
Time scale of development
Embryological development is complex and occurs from the 2nd to the 8th week of
pregnancy and includes the development of the zygote in the first 2–3 weeks following
fertilization. Fetal development occurs from the 8th week until birth. The interval from
the beginning of the last menstrual period (LMP) until fertilization is not part of
pregnancy, however this period is important for the calculation of the expected date of
birth. Figure 7.1 illustrates the comparative lengths of these prenatal events.
FIG. 7.1 Timescales of prenatal events.
A summary of embryological and fetal development categorized into 4-week periods
is provided in Box 7.1. This should be used to complement the text below.
Box 7.1
S um m a ry of e m bryologica l a nd fe t a l de ve lopm e nt
Embryo
0–4 weeks
• Blastocyst implants
• Primitive streak appears
• Conversion of bilaminar disc into trilaminar disc
• Some body systems laid down in primitive form
• Primitive central nervous system forms (neurulation)
• Primitive heart develops and begins to beat
• Covered with a layer of skin
• Limb buds form
– Optic vessels develop
– Gender determined
4–8 weeks
• Very rapid cell division
• More body systems laid down in primitive form and continue to develop
• Spinal nerves begin to develop
• Blood is pumped around the vessels
• Lower respiratory system begins to develop
• Kidneys begin to develop
• Skeletal ossification begins developing
• Head and facial features develop
• Early movements
• Embryo visible on ultrasound from 6 weeks
Fetus
8–12 weeks
• Rapid weight gain
• Eyelids meet and fuse
• Urine passed
• Swallowing begins
• Distinguishing features of external genitalia appear
• Fingernails develop
• Some primitive reflexes present
12–16 weeks
• Rapid skeletal development – visible on X-ray
• Lanugo appears
• Meconium present in gut
• Nasal septum and palate fuse
• Eternal genitalia fully differentiate into male or female by week 12
• Fetus capable of sucking thumb
16–20 weeks
• Constant weight gain
• ‘Quickening’ – mother feels fetal movements
• Fetal heart heard on auscultation
• Vernix caseosa appears
• Skin cells begin to be renewed
• Brown adipose tissue (BAT) forms
20–24 weeks
• Most organs functioning well
• Eyes complete
• Periods of sleep and activity
• Ear apparatus developing
• Responds to sound
• Skin red and wrinkled
• Surfactant secreted in the lungs from week 20
24–28 weeks
• Legally viable and survival may be expected if born
• Eyelids open
• Respiratory movements
28–32 weeks
• Begins to store fat and iron
• Testes descend into scrotum
• Lanugo disappears from face
• Skin becomes paler and less wrinkled
32–36 weeks
• Weight gain 25 g/day
• Increased fat makes the body more rounded
• Lanugo disappears from body
• Hair on fetal head lengthens
• Nails reach tips of fingers and toes
• Ear cartilage soft
• Plantar creases visible.
36 weeks to birth
• Birth is expected
• Body round and plump
• Skull formed but soft and pliable
Fetal growth and maturation
From the 9th week of pregnancy, fetal growth is rapid. Tissues grow by cell
proliferation, cell enlargement and accretion of extracellular material. A n adequate
supply of nutrients and oxygen from the placenta to the fetus is crucial for growth. I n
developed countries the average birth weight is around 3400 g of which 50% is
acquired by 30 weeks' gestation. The fetus gains approximately 25 g/day between
weeks 32 and 40. A visual representation of growth in terms of height is provided in
Fig. 7.2.
FIG. 7.2 Sizes of embryos and fetus between 3 and 12 weeks' gestation.
A s fetal growth is an indicator of fetal health and wellbeing, monitoring of growth is
crucial. This is done by visual observation of the uterus for size, symphysis fundal
height measurements and ultrasonography.
The cardiovascular system
The early development of the cardiovascular system in the 3rd week of pregnancy
coincides with the lack of the yolk sac, and the urgent need to supply the growing
embryo with oxygen and nutrients from the maternal blood through the placenta.
The cardiovascular system is the first system to function in the embryo. The heart
and vascular system commences development in the 3rd week, and by the 4th week a
primitive heart is visible and is beginning to function, beating at around 22 days
(S choenwolf et al 2009). Vascular endothelial growth factor is a protein that causes
vasculogenesis and subsequent angiogenesis to occur. I nitially a vascular plexus is
formed in the embryo, which is continually remodeled into a system of arteries and
veins to accommodate the growing and developing embryo.
The first signs of the heart are the appearance of paired endothelial strands in the
cardiogenic mesoderm, which canalize to become heart tubes and then fuse to become
a tubular-shaped heart. The development continues to include remodeling and
septation while the heart continues to beat. Blood is pumped around the vessels from
the 4th week, by which time three major vascular systems have developed.
Arteries
Vitelline arteries link the aorta with the yolk sac which subsequently supplies the gut
and other arteries in the neck and thorax. Mid gestation they are remodelled to form
three main arteries which supply the gastrointestinal tract.
Two umbilical arteries deliver deoxygenated blood to the placenta.
Veins
The embryo has three major venous systems draining into the tubular-shaped heart:
vitelline, umbilical and cardinal (Schoenwolf et al 2009).
T he vitelline veins return poorly oxygenated blood from the gut and yolk sac. The
hepatic veins and the portal vein develop from the vitelline veins and their networks.
A temporary shunt, the ductus venosus, also develops from these veins.
Umbilical veins form in the body stalk. The right umbilical vein anastomoses with
the ductus venosus shunting oxygenated placental blood into the inferior vena cava
leaving the left umbilical vein to continue carrying oxygenated blood from the
placenta to the embryo. Between 5–7 weeks of pregnancy, the foramen ovale is formed.
From here on there is shunting of highly oxygenated blood from the right to left
atrium, bypassing the right ventricle and pulmonary system, allowing the higher
oxygenated blood to be pumped immediately to the brain and upper body.
The cardinal veins drain the head, neck and body wall into the heart.
D evelopment over time ensures that the three systems develop into the adult
pa ern whilst maintaining some temporary structures in the fetus which resolve at, or
soon after, birth.
There are three phases of red blood cell formation:
• the yolk sac period, between weeks 3 and 13;
• the hepatic/liver period, between weeks 5 and 36 (Stables and Rankin 2010); and
• the bone marrow period, from the 10th week throughout life (Schoenwolf et al 2009).
Red blood cells, known as erythrocytes, which are produced from ‘blood islands’ in
the extra embryonic mesoderm lining the yolk sac and liver, contain fetal
haemoglobin. Fetal haemoglobin (HbF) has a much greater affinity for oxygen and is
found in greater concentrations (18–20 g/dl at term) in the blood than adult
haemoglobin (HbA), thus enhancing the transfer of oxygen across the placental site.
Fetal erythrocytes have a life span of 90 days, shorter than adult erythrocytes, which is
around 120 days. The short life span of fetal erythrocytes contributes to neonatal
physiological jaundice (see Chapter 33). Genes passed from both parents determine
the fetal blood group and Rhesus factor.
The respiratory system
The development of the respiratory system begins in the 3rd week. The lower
respiratory tract and lungs develop simultaneously. The lungs originate from a ‘lung
bud’ growing out of the foregut, which repeatedly subdivides to form the branching
structure of the bronchial tree. By 36 weeks of pregnancy, respiratory bronchioles have
a capillary network and culminate in terminal sacs (alveoli). Lung development occurs
on several levels and continues after birth until about 8 years of age when the full
number of bronchioles and alveoli will have developed. The development of type I I
alveolar cells commences around 20 weeks of fetal life. These cells are necessary for
the production of surfactant, a lipoprotein that reduces the surface tension in the
alveoli and assists gaseous exchange. The amount of surfactant increases until the
alveoli mature between 36 weeks and birth.
There is some movement of the thorax from the 12th week of fetal life and more
definite diaphragmatic movements from the 24th week. This does not constitute
breathing as gaseous exchange is via the placenta.
At term, the lungs contain about 100 ml of lung fluid. A bout one-third of this is
expelled during birth and the rest is absorbed and transported by the lymphatics and
blood vessels as air takes its place.
Babies born before 24 weeks of pregnancy have a reduced chance of survival owing
to the immaturity of the capillary system in the lungs and the lack of surfactant (see
Chapter 33).
The urogenital system
The urogenital system is divided functionally into the urinary/renal system and the
genital/reproductive system. Both systems develop from the intermediate mesoderm.
The kidneys develop from the 4th week of fetal life and produce small amounts of
urine between the 6th and 10th week. They become more functional around the 15th
week when more urine is produced. The urine does not constitute a route for excretion
as elimination of waste products is via the placenta. The urine forms much of the
amniotic fluid and production increases with fetal maturity.
The superior vesical arteries arise from the first few centimetres of the hypogastric
arteries, which lead to the umbilical arteries. A single umbilical artery at birth is
suggestive of malformations of the renal tract (see Chapter 32).
The sex of the embryo is determined at fertilization: either two X chromosomes (in
the female) or one X and one Y chromosome (in the male) are inherited. The gonads
develop from the 5th week from the intermediate mesoderm. I n the two sexes, genital
development is similar and is referred to as the indifferent state of sexual development. A
single sex determining protein on the gene of the Y chromosome (S RY) controls the
subsequent male development pa ern (S choenwolf et al 2009). D ifferentiation occurs
from the 7th week, but female gonad development occurs slowly under the influence
of pro-ovarian genes and the ovaries may not be identifiable until the 10th week. The
external genitalia in both sexes develop in the 9th week, but males and females are not
distinguishable until about the 12th week.
The endocrine system
The adrenal glands develop from mesoderm and neural crest cells from the 6th week
of fetal life, and grow to 10–20 times larger than the adult adrenals. Their size
regresses during the first year of life. They produce the precursors for placental
formation of oestriols and influence maturation of the lungs, liver and epithelium of
the digestive tract. I t is also thought that the adrenal glands play a part in the
initiation of labour, but the exact mechanism is not fully understood (J ohnson and
Everitt 2000).
The pituitary gland develops and takes on its characteristic shape from between the
9th and 17th week of fetal life. The fetal pituitary produces gonadotrophins, i.e.
luteinizing hormone (LH) and follicle stimulating hormone (FS H) from weeks 13–14,
and human growth hormone (hGH) is present by weeks 19–20.
The digestive system
The primitive gut develops from the endodermal layer of the yolk sac in the 4th week
of fetal life. I t begins as a straight tube, and proceeds on several levels: foregut,
midgut and hindgut.
By the 5th week, the foregut (oesophagus, stomach and duodenum) is visible. The
liver, gallbladder and pancreas bud form the gut tube around the 4th to 5th week of
fetal life. The liver grows rapidly from the 5th week and by the 10th week occupies
much of the abdominal cavity, constituting about 10% of the fetal weight by the 9th
week. Towards the end of pregnancy, iron stores are laid down in the liver and the
liver cells produce bile from the 12th week.
T he midgut (small intestine, caecum and vermiform appendix, ascending colon and
transverse colon) undertakes much of its development in the 6th week, while the
hindgut (rectum and anal canal) completes its development in the 7th week of fetal life.
A round 12 weeks, the digestive tract is well formed and the lumen is patent. Most
digestive juices are present before birth and act on the swallowed substances to form
meconium. Bile enters the duodenum from the bile duct during the 13th week, giving
the intestinal contents a dark green colour. Meconium is normally retained in the gut
until after birth when it is passed as the first stool of the baby.
I nsulin is secreted from 10 weeks of fetal life and glucagon from 15 weeks, both of
which rise steadily with increasing fetal age.
The nervous system
The brain begins to develop from around day 19 and three structures are visible:
forebrain, midbrain and hindbrain. By the 5th week, there is differentiation between the
major regions, namely the thalamus and the hypothalamus.
The neural tube is derived from the ectoderm which folds inwards by a complicated
process to form the neural tube, which is then covered over by skin. Closure of the
neural tube is essential and takes place by 26 days. This process is occasionally
incomplete, leading to open neural tube defects (see Chapter 32).
The development of the sense organs, including the transmission of sensory input
to the brain and output from the brain, occurs under complex processes. The eyes and
ears are associated with the development of the head and neck, which begin early and
continue until the cessation of growth in the late teens. A lthough the eyes develop
from around 22 days, for normal vision to occur many complex structures within the
eye must properly relate to neighbouring structures. The eye is completely formed by
20 weeks but the eyelids are fused until around 24 weeks. The developing eyes are
sensitive to light.
The development of the inner ear, which contains the structures for hearing and
balance, commences early in embryological life but is not complete until around 25
weeks.
Motor output controlled by the basal ganglia in the form of movement, begins
around 8 weeks, however these movements are not usually felt by the mother until
around 16 weeks, and are referred to as quickening. A s the nervous system matures
fetal behaviour becomes more complex and more defined. The fetus develops
behavioural pa erns: sleep with no eye or body movements; sleep with periodic eye
and body movements, known as REM sleep; wakefulness with subtle eye and limb
movements; active phase with vigorous eye and limb movements.
Integumentary, skeletal and muscular systems
The epidermis develops from a single layer of ectoderm to which other layers are
added. By the end of 4 weeks, a thin outer layer of fla ened cells covers the embryo.
Further development continues until 24 weeks. Brown adipose tissue (BAT) develops
from 18 weeks' gestation; this plays an important part in thermoregulation after birth.
From 18 weeks, the fetus is covered with a white, creamy substance called vernix
caseosa, which protects the skin from the amniotic fluid and from any friction against
itself. Hair begins to develop between the 9th and 12th week. By 20 weeks the fetus is
covered with a fine downy hair called lanugo; at the same time the hair on the head
and eyebrows begin to form. Lanugo is shed from 36 weeks and by term, there is li le
left. Fingernails develop from about 10 weeks but the toenails do not form until about
18 weeks. By term the nails usually extend beyond the fingertips and so it is not
unusual to see scratches on the baby's face.
Most skeletal tissue arises from the mesodermal and neural crest cells but skeletal
tissue in different parts of the body are diverse in morphology and tissue architecture.
The skull develops during the 4th week from the mesenchyme surrounding the
developing brain. I t consists of two major parts: the neurocranium, which forms the
bones of the skull, and the viscerocranium, which forms the bones of the face (Tortora
and D errickson 2011). The neurocranium forms flat bones at the roof and sides of the
skull. O ssification here is intramembranous and the membranous separations
between the flat bones are known as sutures and fontanelles. The functions of these will
be discussed later in the chapter.
The fetal circulation
The placenta is the source of oxygenation, nutrition and elimination of waste for the
fetus. There are several temporary structures in addition to the placenta and the
umbilical cord that enable the fetal circulation to occur (Fig. 7.3). These include:
• The ductus venosus, which connects the umbilical vein to the inferior vena cava.
• The foramen ovale, which is an opening between the right and left atria.
• The ductus arteriosus, which leads from the bifurcation of the pulmonary artery to the
descending aorta.
• The hypogastric arteries, which branch off from the internal iliac arteries and become
the umbilical arteries when they enter the umbilical cord.
The fetal circulation takes the following course:
FIG. 7.3 A diagram of the fetal circulation. The arrows show the course taken by the blood. The
temporary structures are labelled in colour.
O xygenated blood from the placenta travels to the fetus in the umbilical vein. The
umbilical vein divides into two branches – one that supplies the portal vein in the
liver, the other anastomosing with the ductus venosus and joining the inferior vena
cava. Most of the oxygenated blood that enters the right atrium passes across the
foramen ovale to the left atrium, which mixes with a very small amount of blood
returning from the lungs from where it passes into the left ventricle via the bicuspid
valve, and then the aorta. The head and upper extremities receive approximately 50%
of this blood via the coronary and carotid arteries, and the subclavian arteries
respectively. The rest of the blood travels down the descending aorta, mixing with
deoxygenated blood from the right ventricle via the ductus arteriosus.
D eoxygenated blood collected from the head and upper parts of the body returns to
the right atrium via the superior vena cava. Blood that has entered the right atrium
from the superior vena cava enters at a different angle to the blood that enters from
the inferior vena cava and heads towards the foramen ovale. Hence there are two
distinct blood flows entering the right atrium. Most of the lesser oxygenated blood
entering the right atrium from the superior vena cava passes behind the flow of highly
oxygenated blood going to the left atrium and enters the right ventricle via the
tricuspid valve. There is a small amount of blood mixing where the two blood flows
meet in the atrium. From the right ventricle a li le blood travels to the lungs in the
pulmonary artery, for their development. Most blood, however, passes from the
pulmonary artery through the ductus arteriosus into the descending aorta. This blood,
although low in oxygen and nutrients, is sufficient to supply the lower body of the
fetus. I t is also by this means that deoxygenated blood travels back to the placenta via
the internal iliac arteries, which lead into the hypogastric arteries, and ultimately into
the umbilical arteries. This circulation means that the fetus has a well-oxygenated and
perfused head, brain and upper body compared to its lower extremities.
Adaptation to extrauterine life
At birth, there is a dramatic alteration to the fetal circulation and an almost immediate
change occurs. The cessation of umbilical blood flow causes a cessation of flow in the
ductus venosus and a fall in pressure in the right atrium. A s the baby takes its first
breath, blood is drawn along the pulmonary system via the pulmonary artery and as a
consequence, pressure increases in the left atrium due to the increased blood supply
returning to it via the pulmonary veins. The alteration of pressures between the two
atria causes a mechanical closure of the foramen ovale. I n addition, as the baby takes
its first breath, the lungs inflate, and there is a rapid fall in pulmonary vascular
resistance of approximately 80%, a slight reverse flow of oxygenated aortic blood along
the ductus arteriosus and a rise in the oxygen tension. This causes the smooth muscle
in the walls of the ductus arteriosus to contract and constrict, usually within 24 hours
following birth, though it can remain patent for a few days.
As these structural changes become permanent, the following fetal structures arise:
• The umbilical vein becomes the ligamentum teres.
• The ductus venosus becomes the ligamentum venosum.
• The ductus arteriosus becomes the ligamentum arteriosum.
• The foramen ovale becomes the fossa ovalis.
• The hypogastric arteries become the obliterated hypogastric arteries except for the first
few centimetres, which remain open and are known as the superior vesical arteries.
Adaptation to extrauterine life also involves:
• Maintenance of a nutritional state through the establishment of breastfeeding.
• Elimination of waste via the kidneys and gastrointestinal system.
• Establishment of the portal and liver circulation.
• Temperature control.
• Communication developed through parent–baby interactions (Stables and Rankin
2010).
The fetal skull
The fetal head is large in relation to the fetal body compared with the adult (Fig. 7.4).
A dditionally, it is large in comparison with the maternal pelvis and is the largest part
of the fetal body to be born.
FIG. 7.4 Comparison of a baby's proportions to those of an adult. The baby's head is wider than
the shoulders and one-quarter of the total length.
A daptation between the skull and the pelvis is necessary to allow the head to pass
through the pelvis during labour without complications. The bones of the vault are
thin and pliable, and if subjected to great pressure damage to the underlying delicate
brain may occur. I mportant intracranial membranes, venous sinuses and structures
can be seen in Figs 7.5, 7.6.
FIG. 7.5 Coronal section through the fetal head to show intracranial membranes and venous
sinuses.
FIG. 7.6 Diagram showing intracranial membranes and venous sinuses. Arrows show direction
of blood flow.
Divisions of the fetal skull
The skull is divided into the vault, the base and the face (Fig. 7.7).
FIG. 7.7 Divisions of the skull showing the large, compressible vault and the non-compressible
face and base.
The vault is the large, dome-shaped part above an imaginary line drawn between the
orbital ridges and the nape of the neck.
T he base comprises bones that are firmly united to protect the vital centres in the
medulla oblongata.
The face is composed of 14 small bones that are also firmly united and non-
compressible.
The bones of the vault
The bones of the vault (Fig. 7.8) are laid down in membrane. They harden from the
centre outwards in a process known as ossification. O ssification is incomplete at birth,
leaving small gaps between the bones, known as the sutures and fontanelles. The
ossification centre on each bone appears as a protuberance. O ssification of the skull is
not complete until early adulthood.
FIG. 7.8 View of fetal head from above (head partly flexed), showing bones, sutures and
fontanelles.
The bones of the vault consist of:
• The occipital bone, which lies at the back of the head. Part of it contributes to the base
of the skull as it contains the foramen magnum, which protects the spinal cord as it
leaves the skull. The ossification centre is the occipital protuberance.
• The two parietal bones, which lie on either side of the skull. The ossification centre of
each of these bones is called the parietal eminence.
• The two frontal bones, which form the forehead or sinciput. The ossification centre of
each bone is the frontal eminence. The frontal bones fuse into a single bone by eight
years of age.
• The upper part of the temporal bone on both sides of the head forms part of the vault.
Sutures and fontanelles
T he sutures are the cranial joints formed where two bones meet. W here two or more
sutures meet, a fontanelle is formed (see Fig. 7.8). The sutures and fontanelles
described below permit a degree of overlapping of the skull bones during labour,
which is known as moulding.
• The lambdoidal suture separates the occipital bone from the two parietal bones.
• The sagittal suture lies between the two parietal bones.
• The coronal suture separates the frontal bones from the parietal bones, passing from
one temple to the other.
• The frontal suture runs between the two halves of the frontal bone. Whereas the
frontal suture becomes obliterated in time, the other sutures eventually become fixed
joints.
• The posterior fontanelle or lambda (shaped like the Greek letter lambda λ) is situated
at the junction of the lambdoidal and sagittal sutures. It is small, triangular in shape
and can be recognized vaginally because a suture leaves from each of the three
angles. It normally closes by 6 weeks of age.
• The anterior fontanelle or bregma is found at the junction of the sagittal, coronal and
frontal sutures. It is broad, kite-shaped ◆ and recognizable vaginally because a
suture leaves from each of the four corners. It measures 3–4 cm long and 1.5–2 cm
wide and normally closes by 18 months of age. Pulsations of cerebral vessels can be
felt through this fontanelle.
Regions and landmarks of the fetal skull
The skull is further separated into regions, and within these there are important
landmarks as shown in Fig. 7.9. These landmarks are useful to the midwife when
undertaking a vaginal examination as they help ascertain the position of the fetal head.
• The occiput region lies between the foramen magnum and the posterior fontanelle.
The part below the occipital protuberance (landmark) is known as the sub-occipital
region.
• The vertex region is bounded by the posterior fontanelle, the two parietal eminences
and the anterior fontanelle.
• The forehead/sinciput region extends from the anterior fontanelle and the coronal
suture to the orbital ridges.
• The face extends from the orbital ridges and the root of the nose to the junction of
the chin or mentum (landmark) and the neck. The point between the eyebrows is
known as the glabella.
FIG. 7.9 Fetal skull showing regions and landmarks of clinical importance.
Diameters of the fetal skull
Knowledge of the diameters of the skull alongside the diameters of the pelvis allows
the midwife to determine the relationship between the fetal head and the mother's
pelvis.
There are six longitudinal diameters (Fig. 7.10).
FIG. 7.10 Diagram showing the longitudinal diameters of the fetal skull.
Diameter Length (cm)
SOB, sub-occipitobregmatic 9.5
SOF, sub-occipitofrontal 10.0
OF, occipitofrontal 11.5
MV, mentovertical 13.5
SMV, sub-mentovertical 11.5
SMB, sub-mentobregmatic 9.5
The longitudinal diameters are:
• The sub-occipitobregmatic (SOB) diameter (9.5 cm) measured from below the occipital
protuberance to the centre of the anterior fontanelle or bregma.
• The sub-occipitofrontal (SOF) diameter (10 cm) measured from below the occipital
protuberance to the centre of the frontal suture.
• The occipitofrontal (OF) diameter (11.5 cm) measured from the occipital protuberance
to the glabella.
• The mentovertical (MV) diameter (13.5 cm) measured from the point of the chin to the
highest point on the vertex.
• The sub-mentovertical (SMV) diameter (11.5 cm) measured from the point where the
chin joins the neck to the highest point on the vertex
• The sub-mentobregmatic (SMB) diameter (9.5 cm) measured from the point where the
chin joins the neck to the centre of the bregma (anterior fontanelle).
There are also two transverse diameters, as shown in Fig. 7.11.
• The biparietal diameter (9.5 cm) – the diameter between the two parietal eminences.
• The bitemporal diameter (8.2 cm) – the diameter between the two furthest points of
the coronal suture at the temples.
FIG. 7.11 Diagram showing the transverse diameters of the fetal skull.
Knowledge of the diameters of the trunk is also important for the birth of the
shoulders and breech (as detailed in Box 7.2).
Box 7.2
D ia m e t e rs of t he fe t a l t runk
Bisacromial diameter 12 cm
This is the distance between the acromion processes on the two shoulder
blades and is the dimension that needs to pass through the maternal pelvis
for the shoulders to be born. The articulation of the clavicles on the
sternum allows forward movement of the shoulders, which may reduce the
diameter slightly.
Bitrochanteric diameter 10 cm
This is measured between the greater trochanters of the femurs and is the
presenting diameter in breech presentation.
Presenting diameters
S ome presenting diameters are more favourable than others for easy passage through
the maternal pelvis and this will depend on the a itude of the fetal head. This term
attitude is used to describe the degree of flexion or extension of the fetal head on the
neck. The a itude of the head determines which diameters will present in labour and
therefore influences the outcome.
The presenting diameters of the head are those that are at right-angles to the curve of
Carus of the maternal pelvis. There are always two: a longitudinal diameter and a
transverse diameter. The presenting diameters determine the presentation of the fetal
head, for which there are three:
1. Vertex presentation. When the head is well flexed the sub-occipitobregmatic diameter
(9.5 cm) and the biparietal diameter (9.5 cm) present (Fig. 7.12). As these two
diameters are the same length the presenting area is circular, which is the most
favourable shape for dilating the cervix and birth of the head. The diameter that
distends the vaginal orifice is the sub-occipitofrontal diameter (10 cm). When the
head is deflexed, the presenting diameters are the occipitofrontal (11.5 cm) and the
biparietal (9.5 cm). This situation often arises when the occiput is in a posterior
position. If it remains so, the diameter distending the vaginal orifice will be the
occipitofrontal (11.5 cm).
FIG. 7.12 Diagram showing the dimensions presenting when the fetal head is well flexed in a
vertex presentation.
2. Face presentation. When the head is completely extended the presenting diameters
are the sub-mentobregmatic (9.5 cm) and the bitemporal (8.2 cm). The sub-
mentovertical diameter (11.5 cm) will distend the vaginal orifice.
3. Brow presentation. When the head is partially extended, the mentovertical diameter
(13.5 cm) and the bitemporal diameter (8.2 cm) present. If this presentation
persists, vaginal birth is unlikely.
Moulding
The term moulding is used to describe the change in shape of the fetal head that takes
place during its passage through the birth canal. A lteration in shape is possible
because the bones of the vault allow a slight degree of bending and the skull bones are
able to override at the sutures. This overriding allows a considerable reduction in the
size of the presenting diameters, while the diameter at right-angles to them is able to
lengthen owing to the give of the skull bones (Fig. 7.13). The shortening of the fetal
head diameters may be by as much as 1.25 cm. The do ed lines in Figs 7.14–7.19
illustrate moulding in the various presentations.
FIG. 7.13 Demonstration of the principle of moulding. The diameter compressed is diminished;
the diameter at right-angles to it is elongated.
FIG. 7.14 Moulding in a normal vertex presentation with the head well flexed. The sub-
occipitobregmatic diameter is reduced and the mentovertical elongated.
FIG. 7.15 Vertex presentation, head well flexed.
FIG. 7.16 Vertex presentation, head partially flexed.
FIG. 7.17 Vertex presentation, head deflexed.
FIG. 7.18 Face presentation.
FIG. 7.19 Brow presentation.
FIGS 7.15–7.19 Series of diagrams showing moulding when the head presents. Moulding is shown by the
dotted line.
A dditionally, moulding is a protective mechanism and prevents the fetal brain from
being compressed as long as it is not excessive, too rapid or in an unfavourable
direction. The skull of the pre-term infant is softer and has wider sutures than that of
the term baby, and hence may mould excessively should labour occur prior to term.
Venous sinuses are closely associated with the intracranial membranes, as shown in
Fig. 7.6, and if membranes are torn due to excessive moulding or precipitate labour
there is danger of bleeding. A tear of the tentorium cerebelli may result in bleeding
from the great cerebral vein.
Conclusion
Embryonic and fetal development occurs alongside placental development. There is
constant growth and remodelling of cells, tissues, organs and systems prior to birth.
S everal temporary structures in the fetus support systems in utero; these consequently
become redundant at birth and they either disappear or become ligaments. At birth all
organs are functioning but some may be immature and continue to develop as part of
extrauterine life.
References
Johnson MH, Everitt BJ. Essential reproduction. 5th edn. Blackwell: Oxford; 2000.
Schoenwolf G, Bleyl S, Brauer P, Francis-West P. Larsens human embryology. 4th
edn. Churchill Livingstone: Philadelphia; 2009.
Stables D, Rankin J. Physiology in childbearing with anatomy and related biosciences.
3rd edn. Elsevier: Edinburgh; 2010.
Tortora GJ, Derrickson B. Principles of anatomy and physiology: maintenance and
continuity of the human body. 13th edn. John Wiley & Sons: Hoboken, NJ; 2011.
Further reading
Coad J, Dunstall M. Anatomy and physiology for midwives. 3rd edn. Churchill
Livingstone/Elsevier: London; 2011.
A detailed discussion of embryonic and fetal development appears in Chapter 9. The
fetal circulation and transition to neonatal life are addressed in Chapter 15..
England MA. Life before birth. 2nd edn. Mosby–Wolfe: London; 1996.
This text serves to illustrate embryological and fetal development in photographic form.
For the student who requires a detailed understanding of prenatal events and in
particular the hormonal influences, this book is unsurpassed..
Schoenwolf GC, Bleyl SB, Brauer PR, et al. Larson's human embryology. 4th edn.
Churchill Livingstone: Philadelphia; 2009.
Originating in a series of Christmas lectures at the Royal Institution, this text explores
the unifying principles that may account for the way embryos develop. Written for the
non-specialist, it invites the reader to think broadly and aims to inspire as well as
instruct..
S E CT I ON 3
Pregnancy
OU T LIN E
Chapter 8 Antenatal education for birth and parenting
Chapter 9 Change and adaptation in pregnancy
Chapter 10 Antenatal care
Chapter 11 Antenatal screening of the mother and fetus
Chapter 12 Common problems associated with early and advanced pregnancy
Chapter 13 Medical conditions of significance to midwifery practice
Chapter 14 Multiple pregnancy
C H AP T E R 8
Antenatal education for birth and
parenting*
Mary Louise Nolan
CHAPTER CONTENTS
Parent education: the research and policy background 127
Antenatal education: the evidence 129
Leading antenatal sessions: aims and skills 129
Sharing information 129
Promoting discussion 131
Practical skills work 132
Content of antenatal education in groups 133
Getting to know our unborn baby 133
Changes for me and us 133
Giving birth and meeting our baby 134
Our health and wellbeing 134
Caring for our baby 136
Who is there for us? People and resources 136
Defining learning outcomes 136
Maximizing attendance at antenatal sessions 137
Including fathers 138
How many mothers and fathers in the group? 139
How many sessions and how long? 139
Conclusion 140
References 140
Further reading 142
This chapter discusses the special opportunities that antenatal sessions
provide for midwives to help mothers and fathers make a happy and
successful transition to parenthood. It explores new thinking about the
content of antenatal education provided to groups, and describes skills and
activities which midwives can use to enable parents to acquire information,
problem-solving skills and support relevant to their individual
circumstances.
The chapter aims to:
• justify the allocation of time and resources to providing antenatal education in groups
• place new thinking about antenatal education in the context of research and health
policy
• build midwives' confidence and skills to facilitate antenatal sessions that effectively
meet the needs of women and men making the transition to parenthood.
Parent education: the research and policy background
I n 2007, a survey of 3682 women (N olan 2008) from all parts of the United Kingdom
(UK) revealed that a large number had been offered no or very few antenatal classes
during their most recent pregnancy. Many of those who had a ended classes were
dissatisfied with their quality, criticizing in particular the unrealistic portrayal of
labour, birth and early parenting, lack of practical skills work to help them use their
own resources for coping with the pain of labour, and being given no opportunity to
discuss how to cope with being a mother.
These comments are in line with research carried out over the past 20 years. The
study by Spiby and coworkers (1999) found that women were dissatisfied with the time
given to practising self-help skills for labour during antenatal classes and cited this as
a reason for not being able to put such skills into practice when they were actually in
labour. The study by Ho and Holroyd (2002) of Hong Kong women's experience of
classes highlighted the lack of engagement of midwives with women's individual
worries. W omen felt that the sessions were not organized around their life situations
rather than according to subject ma er. Too much information was given in the short
time available and there was too li le emphasis on discussion to enable women to
hear each other's viewpoints and move towards deciding what was best for them in
their particular circumstances. The women especially highlighted that they had not
been able to make friends. The importance of antenatal classes as an opportunity for
developing a peer support network has featured repeatedly in the literature over many
years; for example, the study by S tamler (1998) found that the seven women
interviewed wanted ‘more socialization’ and considered classes unsatisfactory that did
not encourage this by facilitating discussion. More recently, N olan et al (2012)
explored the nature of friendships made at antenatal classes and identified their role
in securing women's mental health in the early months of new motherhood by
allowing them to share information about babycare, normalizing their experiences and
increasing their confidence to manage their own and their babies' welfare.
I n the year of publication of the survey carried out by N olan during 2007 which
highlighted the steady decrease in the availability of antenatal education (N olan 2008),
the Child Health Promotion Programme D ( epartment of Health [D H] 2008) described
the government's commitment to a new emphasis on parenting support, especially for
first-time mothers and fathers. This document spoke of the need for stable positive
relationships within families in order to provide the best possible home environment
for babies to develop robust physical and emotional health. I t advocated approaches
to educating and supporting parents that focused on their strengths rather than on
their deficits. Fathers were brought to the fore and services were reminded that men
must be included in all perinatal and childcare services, to ensure that they were
equally as well informed as mothers and able to make a strong, positive contribution
to the upbringing of their children.
This focus on supporting families with babies stemmed from the increasingly public
profile of new evidence from neuroscience showing that the development of the
unborn baby was affected not only by genetic heritage, the efficiency of the placenta,
the quality of the mother's diet, whether she smoked, her use of alcohol, prescribed
and street drugs, but also by her mental and emotional wellbeing. Wadhwa et al (1993:
858) concluded that ‘independent of biomedical risk, maternal prenatal stress factors
are significantly associated with infant birth weight and with gestational age at birth’.
At the beginning of the 21st century, Glover and O 'Connor (2002) produced evidence
from 7448 women participating in the Avon Longitudinal S tudy of Parents and
Children that the pregnant woman's mood could have a direct effect not just on
newborn babies' weight, but also on their brain development, with later consequences
for behavioural development throughout childhood. A meta-analysis (Talge et al 2007)
of studies looking at the relationship between maternal mental health, babies'
development in utero and their progress during the first years of life, concluded that
maternal stress in pregnancy makes it substantially more likely that children will have
emotional, cognitive and physical problems. N euroscience also explained how the
architecture of the brain is shaped by new babies' earliest experiences, that is, by their
relationship with their primary caregiver(s). W hile antenatal education had
traditionally focused on helping mothers (and sometimes fathers) acquire practical
babycare skills such as changing nappies, feeding and bathing babies, neuroscience
suggested that equal emphasis should be placed on helping parents understand how
their newborn babies are primed to enter into a relationship with them, and how they
invite interaction through a variety of cues.
A generation of childcare gurus had ba led for supremacy over the hearts and
minds of new parents, from those advocating ‘a achment parenting’ ( Liedloff 1986;
J ackson 2003) to those requiring that both parents and baby adhere to a strict routine
as soon as the baby is born (Ford 2006). Parents had also been persuaded that ‘early
education’ in the form of playing Mozart through headphones placed on the pregnant
woman's abdomen, or teaching infants to ‘sign’ would give them a head start. N ow the
evidence was supporting parents' basic instinct to respond to their children when they
cried, to enjoy playing with them and to ‘watch, wait and wonder’ ( Cohen et al 1999).
The importance of ‘mutual gaze’ (simply looking at the baby), talking and singing to
the baby (with nursery rhymes very much back in fashion) and baby massage to
promote the release of the ‘social hormone’, oxytocin, were all established on a solid
evidence base that was also in tune with most parents' instinctive understanding of
how to meet their babies' needs.
This evidence, coupled with uncomfortable reports stating that Britain's children
and young people were amongst the unhappiest in Europe (Children's S ociety 2012),
impelled government to reconsider the value of pregnancy as an educational
opportunity. Pregnancy is an ideal opportunity for helping women acquire
understanding, skills and support networks to make the transition to motherhood less
stressful and more fulfilling, both for them and for their infants. Midwives, health
visitors and childbirth educators had long known that pregnancy was ‘a teachable
moment’, a period of crisis that renders women and men unusually open to reflecting
on their self concept, lifestyle, values and ideas about parenthood. The D epartment of
Health (D H 2009) set up an Expert Reference Group to devise a programme of high-
quality antenatal education which would ‘help prepare parents for parenthood from
early pregnancy onwards’ (section 3.36).
Antenatal education: the evidence
The Expert Reference Group D ( H 2009) commissioned a systematic review of antenatal
education to inform its work. This review (McMillan et al 2009) found that the quality
of research into antenatal group-based education was generally poor. The Review's
conclusions were, therefore, tentatively presented. S ome evidence was found for a
positive effect on maternal psychological wellbeing when antenatal programmes
focused on:
• the emotional changes that men and women experience across the transition to
parenthood
• the couple relationship
• parenting skills and early childcare
• bonding and attachment
• problem-solving skills.
The review by McMillan et al (2009) also found evidence that programmes focusing
on strengthening the couple's relationship in preparation for parenting improved
parental confidence and satisfaction with the couple and parent–infant relationship in
the postnatal period. N o evidence was found of a link between a ending antenatal
classes and improved birth outcomes in terms of reduced caesarean section or
instrumental delivery rates.
Effective facilitation of antenatal programmes was found to be dependent on their
being sensitive to people's cultures, responsive to both parents, participative and
focused on building social support. This was in agreement with a powerful study of
‘maternal health literacy’ carried out by Renkert and Nutbeam (2001) which noted that
‘teaching methods (in antenatal classes) were heavily weighted towards the transfer of
factual information, as distinct from the development of decision making skills, and
practical skills for childbirth and parenting’. The study concluded that, ‘if the purpose
of antenatal classes is to improve maternal health literacy, then women need to leave a
class with the skills and confidence to take a range of actions that contribute to a
successful pregnancy, childbirth and early parenting’ ( Renkert and N utbeam 2001:
381). W omen need to know where they can find more information, how to access
support and what resources are available to them in the community.
Leading antenatal sessions: aims and skills
There is a popular myth, much detested by teachers, that ‘those who can, do, and
those who can’t, teach’. Leading a group of adults may not primarily be about
teaching, although in the case of antenatal sessions, there is likely to be an element of
instruction. However, ensuring that participants find the experience of a ending
classes as relevant and useful as possible, demands sophisticated skills on the part of
the group leader. I t is unfortunate that while the potential of antenatal and postnatal
groups has been recognized anew, there is an increasing tendency to use unqualified
maternity support workers and parent link workers to lead them rather than
midwives. The quality of health and social care services has regularly been linked to
the level of training of those who deliver them. Recently, nursery provision has come
under scrutiny and a clear link established between how well carers understand the
needs of very small children, and the optimal development of those children
(D epartment for Children, S chools and Families [D CS F] 2012 ). The same is true of
antenatal sessions. I f the aim is to run a peer support group where mothers and
fathers can get to know each other, then li le more is required than an accessible
venue, a pleasant room, comfortable seating, refreshments and someone to introduce
people to each other. However, the presence of an educated, confident, competent and
empathic group leader is essential if antenatal sessions are to help participants
identify and acquire information relevant to their life circumstances and practise new
skills. Trained facilitators can help parents challenge each other's beliefs and change
or renew them in the light of ideas they might not have considered before.
W hile ideally, antenatal group courses would be led by the same person throughout,
this is not always possible ‘in the real world’, just as it is not always possible for a
woman to have the same midwife throughout childbirth. I f several people are taking
responsibility for antenatal sessions, it is vital that they have spent time together,
talking about and agreeing what it is they want to achieve. These aims then underpin
every session, whoever is the group leader, and ensure that the mothers and fathers
a ending have an integrated learning experience. The aims for one Community
Healthcare Trust's antenatal programme are given in Box 8.1.
Box 8.1
A im s of a nt e na t a l e duca t ion
• To provide a high-quality pregnancy programme that reflects the most
recent evidence regarding what is effective in group-based antenatal
education.
• To help mothers and fathers recognize and build on their strengths as
parents-to-be.
• To enhance the physical and mental wellbeing of participants so that they
can provide a secure environment for their new baby.
• To equip participants with knowledge of a range of resources to enable
them to acquire the information and support they need during pregnancy
and new parenthood.
• To maximize the potential of group antenatal education to build positive
social capital on which mothers and fathers can draw after the birth of
their babies.
Sharing information
A ny antenatal group session is likely to involve information-sharing, discussion and
practical skills work. O f these, the first is probably the area in which many group
leaders who are health professionals feel most competent, and the one in which they
are often, in fact, least. There are two pitfalls: first, to believe that the more
information given, the be er; and the second, that giving information will change
people's behaviour.
The fact that many group leaders know from personal experience that most
information is forgo en as soon as individuals leave a lecture, does not deter them
from overloading mothers and fathers with information. I n order for people to retain
information:
• it must be the information that they want at that moment in their lives;
• it must be linked either to first-hand or to vicarious experiences;
• it must be presented succinctly in as many different forms as possible.
Many topics that might be covered in antenatal sessions are huge, for example,
‘Labour and Birth’. Yet mothers and fathers do not need to know the anatomy and
physiology or the clinical management of labour and birth in the depth that a midwife
needs to know these things. W hat group participants need to know is ‘what will it be
like for me?’
A fascinating experiment was conducted in an old-fashioned ‘N ightingale Ward’ in
the 1950s (J anis 1958) with patients undergoing prostate surgery. The patients on one
side of the ward were given detailed, technical information about the surgical
procedures they would undergo, including the names of the instruments and drugs
employed. The patients on the other side of the ward were given descriptions of the
sensations involved in having an anaesthetic, waking up after surgery and recovering
from an abdominal wound. The patients who had received this kind of information
made far speedier recoveries than those given ‘textbook’ information.
Mothers and fathers a ending antenatal sessions already know a great deal – they
will be the repositories of both correct and incorrect information. The task of the
group leader is to elicit what they know so that she can reinforce what is correct and
restructure what is not. A sking participants to share their own experiences of a
particular aspect of labour, for example having an induction, or what they have heard
about it from friends and other informants, enables her to judge the level of
knowledge in the group and to find out what parents want to know. By exploring the
details of the experience as described by members of the group, acknowledging
accurate information, asking group members themselves to correct misinformation
(which they are often able to do), answering questions raised by people on a need to
know basis, a rich learning experience is provided (as seen in Box 8.2). Embedding new
information in a web made up of what people already know and their shared ideas of
what an experience might be like, provides the most effective means of transmi ing
information that may influence their decision-making.
Box 8.2
S ha ring group knowle dge a nd e x pe rie nce
I t is often the case that group members know far more about a topic than
might be expected. Finding out what the group knows, and building on that
knowledge is an important skill for the group leader. The example below is
taken from a recent antenatal session.
W hen asked to talk about friends' experiences of having a caesarean
section, group members' pooled knowledge proved extensive:
• some friends had had planned caesareans and some emergency
• emergency caesareans were more traumatic for both mother and father
(and probably the baby)
• the surgery proceeded quickly until the birth of the baby; once the baby
was born, the mother remained in theatre for quite a long time
• some fathers found being present during surgery daunting
• often the father held the baby first because the mother had drips in both
arms
• there was an unexpected amount of pain afterwards and it could be
difficult for the mother to hold the baby for feeding
• some mothers recovered quickly and were back to normal in a few weeks;
some took months
• some mothers felt fine about their caesarean and some felt as if they had
‘failed’.
I n this session, the group leader had li le to do beyond answering a few
questions raised by the group and stressing the importance of asking for
help with the baby on the postnatal ward, keeping the wound clean,
recognizing signs of infection, and not expecting to do too much once
home.
A study by S tapleton et al (2002) of the effectiveness of the MI D wives I nformation
Resource S ervice (MI D I RS ) information leaflets came to the conclusion that women
did not value or use information that was presented to them ‘cold’, in this case, in
leaflet form. They did value having the opportunity to discuss the information in the
leaflets with a midwife or well-informed person who could answer their questions.
This research constitutes a warning to group leaders who believe that information-
giving is satisfactory without interaction with the recipient and discussion as to its
relevance to the woman's circumstances.
The more varied the means by which information is transmi ed, the more locations
in the brain will be used to store it. This increases the likelihood that information will
be retained. The repertoire of creative ideas for facilitating learning that is
demonstrated by any primary school teacher is just as relevant for the person leading
an antenatal group session with adults. The adult brain is assisted to retain
information in the same way as the child's. Pictures that present information visually
aid memory and enhance enjoyment of learning, which in itself makes learning more
effective. Today, there is a huge range of video material available which can be used to
present facts in an exciting way, or provide material to trigger discussion. A quick
foray into YouTube will produced a multitude of video clips ideal for antenatal
sessions.
Three-dimensional models that parents can handle to enable learning to take place
through the hands and eyes, such as plastic pelves, dolls, different kinds of nappies
and pieces of clinical equipment, help in the journey from simply knowing facts to
understanding them and ultimately to applying them. Role-play is also a form of three-
dimensional modelling that is enormously effective in enriching mothers' and fathers'
concept of ‘what it will be like’.
Promoting discussion
I t is often mistakenly assumed that an educational group in which the leader gives
information and the group members are free to ask questions is having a discussion.
However, a group whose interactions can be charted as in Fig. 8.1 is not having a
discussion but rather, a question and answer session.
FIG. 8.1 Leader–participant interaction without group discussion.
A group whose interactions can be charted as in Fig. 8.2 depicts a more engaging
discussion.
FIG. 8.2 Interactions among a group engaged in discussion.
I n order to have a discussion, group members need to know a li le about each other
and therefore to feel at ease. A group consisting of more than six will deter many
people from contributing and the group leader therefore has to break a big group into
smaller units so that making a contribution becomes less daunting. I ce-breakers are
important to help people start to learn each other's names and something of each
other's history, as well as because they make a statement that this group is going to be
as much about participants talking as about the group leader talking.
The first 10 minutes of a group session are an excellent learning opportunity. People
are usually excited about joining the group, perhaps slightly anxious. A s long as they
are not paralysed with nerves, a li le adrenalin in the system primes them for
learning. I ce-breakers can incorporate both a ‘ge ing to know you’ element and an
exchange of ideas on topics integral to the antenatal course. Having invited group
members to form small groups or three or four people, they might talk about:
• What they already know about their unborn babies. Aim: to develop the relationship
between parents and their babies.
• Where they are planning on giving birth and why they have chosen this location.
Aim: to establish parents as the individuals who make decisions for themselves and
their babies.
• What they see as the most enjoyable aspects of parenting, and what the most
challenging. Aim: to encourage reflection on parenting, and project beyond the birth
of the baby.
S haring thoughts and feelings, even if cautiously in the beginning, enables group
members to appreciate that there is much they have in common as ‘becoming
parents’, and to have their fears and worries ‘normalized’. Establishing the
commonalities that mark everyone's journey into parenthood provides a secure basis
from which group members can develop friendships and engage in future, perhaps
more profound discussions.
Research by N olan et al 2012 has shown that friendship formation may proceed at a
faster pace when happening in pregnancy, and bypass much of the ‘social chit-chat’
that generally characterizes the early stages of relationships. A n emerging
appreciation of the responsibilities that parenting entails and of the extent to which
current lifestyles will change following the birth of a baby motivates people, in the
interests of survival, to reach out to others for support and companionship. Perhaps
the overriding duty of antenatal group sessions is to facilitate the forming of
friendships and this is dependent on providing multiple opportunities for people to
get to know each other.
The use of open-ended questions such as ‘How do you feel about that?’, ‘Could you
say a li le more?’, and of reflecting questions raised by group members back to the
group ‘W ould anyone like to answer that from their point of view?’, are key tools in
promoting discussion. D iscussion may also be facilitated by prompts such as pictures
and video clips, by inviting new parents to visit the group to talk about their
experiences and by engaging the group in activities that require them to do more than
simply write down facts. Finding the right trigger for discussion can transform a group
that appears disinterested in the session into one where everyone is contributing and
learning (see Box 8.3).
Box 8.3
P rom ot ing va lua ble discussion
A fairly reserved group of young mothers quickly began to function as a
group in which quality learning was taking place when asked to discuss
how to manage with a new baby with only £67 a week. D uring the vigorous
exchanges that took place, the teenagers learned from each other which
shops offered the best prices for nappies and an array of household items;
how to prepare a variety of easy-to-make, inexpensive (and often nutritious)
meals; how to avoid bank charges; where to go to find out about benefit
entitlements; and what each thought about the amount of help boyfriends
and partners should give with the new baby.
Practical skills work
The survey by N olan (2008) of antenatal education noted that many women wanted
more time in their antenatal sessions to be devoted to practising self-help skills for
labour such as breathing and other relaxation techniques, different positions and
massage. W hile fathers may not ask to learn babycare skills, group leaders should
make it a priority to help men learn how to change nappies, bathe, soothe and se le
babies. I f men feel confident and competent to care for their babies, they are able to
offer practical support to the mother in the early postnatal period. High levels of
father involvement are strongly linked with both mothers' and fathers' satisfaction
with their relationship and with family life (Craig and Sawriker 2006).
Many antenatal group leaders are daunted at the prospect of leading practical
sessions. This discomfort may be a ributed to lack of ease with their own bodies, lack
of belief that teaching such skills makes a difference in labour, a perception that group
members might be reluctant to participate, and poor quality venues where there is
insufficient space for people to move around freely. Leaders whose only preparation
for antenatal group sessions was a couple of lectures during their pre-registration
training, and whose apprenticeship as group leaders has been spent observing other
group leaders equally diffident about introducing practical work, are understandably
nervous. Yet labour, birth and caring for babies are intensely physical activities (as is
midwifery) and people need practice to be well prepared for their role either as parent
(or as midwife).
The best way to gain in confidence to teach physical skills is to observe and speak to
as many skilled practitioners as possible. A ctive Birth teachers, Hypnobirthing
therapists, Birth D ance teachers, antenatal teachers trained by the N ational Childbirth
Trust (N CT) – all of these are able to demonstrate and analyse the facilitation of
practical skills work.
These are some of the ways of making practical work easier for both group leaders
and mothers and fathers:
• Ensure that you know why you are teaching these skills, and that group participants
have a strong rationale for why they should practise them.
• Ask everyone to try the same exercises at the same time.
• Demonstrate what you want people to do – with confidence.
• Support people constantly while they are practising, giving positive feedback and
making suggestions to each woman or couple individually.
• Have a laugh with the group.
• Relate the skills being practised to the stage of labour for which they are relevant.
• If practising babycare skills, separate the fathers from the mothers because women
tend to mock men's efforts while men will strongly support each other. So the men
can practise bathing and dressing a doll at one end of the room, and the women at
the other.
Group members may seem reluctant to participate in practical work, but provided
that the group leader is sufficiently confident, she will be able to help people
overcome their anxiety. The learning that is achieved through practical work can be
dramatic (see Box 8.4).
Box 8.4
P ra ct ica l skills: a significa nt im pa ct
A group that included a very young father who was clearly a ending
antenatal sessions under a certain amount of duress was taught some
simple baby massage skills. W hile everyone was practising, the group
leader put on a CD of nursery rhymes and talked about how massaging a
baby and singing or reciting nursery rhymes would make the baby feel
secure, help him or her develop language, and be a source of enjoyment for
both parent and child. At the end of the session, the young father asked the
leader where he could get a copy of the CD she had used and where he
could attend baby massage sessions with his baby.
Content of antenatal education in groups
The Expert Reference Group convened by the D epartment of Health in 2007 devised an
antenatal programme based on six themes which they felt best captured what the
literature said was important to people making the journey into parenthood. These six
themes – Ge ing to Know Your U nborn Baby; Changes for M e and U s; Giving Birth and
M eeting O ur Baby; O ur H ealth and Wellbeing; Caring for O ur Baby; and W ho is There for
U s? People and Resources – were not necessarily meant to be delivered in six sessions,
with one session for each theme. I nstead, the themes were intended to permeate every
session.
Getting to Know Our Unborn Baby
Given recent research indicating that the development of the baby's brain is affected
by maternal physical and emotional wellbeing, topics such as healthy diet and lifestyle
and coping with stress are very important. The difficulty is that the best time to
discuss these topics is prior to pregnancy. Even early pregnancy classes happen too
late since they are difficult to arrange before the end of the first trimester (and many
women are reluctant to acknowledge their pregnancy publicly before they are safely
past the first three months). By the second trimester, making changes in lifestyle will
have less impact, although by no means, none. A strong case should therefore be
made by the midwifery profession for midwives to be active in schools, leading the
curriculum on pregnancy, birth and parenting.
There is scope, however, for antenatal group sessions to increase participants'
understanding of how the unborn baby is affected by the mother's state of mind. This
is not so as to induce guilt in mothers who are experiencing stress over which they
have no control (living with domestic abuse; unable to speak English; isolated from
family and friends; burdened with financial worries etc.) but to emphasize that every
mother and baby are uniquely in harmony with each other, and respond to each
other's moods. The closeness of the relationship is designed to ensure the survival of
the baby. Topics that might, therefore, be covered under the heading of Ge ing to
Know O ur Unborn Baby (seeBox 8.5) are how the baby's brain develops during
pregnancy; what the baby can see, hear, taste, touch and smell and at what stage of
pregnancy; what part the baby plays in the initiation of labour, and how recreating the
experience of the uterus can comfort newborn babies (being held close, hearing their
mothers' heartbeat and voice, being kept warm through contact with their mothers'
skin, being fed on demand). Relaxation can be taught as a skill to reduce adrenalin
levels and optimize the uterine environment for the baby as well as conferring health
benefits on the mother.
Box 8.5
G e ing t o K now O ur U nborn B a by
Activity
A sk mothers and fathers to consider what life is like for their unborn baby
in the womb.
• What do they know about their baby; what are the baby's patterns or
waking and sleeping?
• Does the baby have particular likes or dislikes?
• Does the baby have his own idiosyncrasies?
• How will the baby feel when she leaves the womb and is born?
• How can that change from womb to world be made as easy as possible for
the baby?
Changes for Me and Us
The Expert Reference Group acknowledged the difficulties inherent in covering
lifestyle issues specifically in relation to pregnancy, and preferred to set these issues in
the broader context of family life. Making decisions about reducing smoking and
alcohol intake as well as improving diet may help parents provide a be er
environment for their new baby to grow up in as well as improving the quality of their
own lives. Pregnancy also provides a 9-month period of reflection for mothers and
fathers to consider how this baby will affect their network of relationships, personal
interests, social obligations and work commitments. Babies enter their parents'
complex world, and planning ahead may ensure that adding one more element does
not cause the whole world to fall apart (see Box 8.6).
Box 8.6
C ha nge s for M e a nd U s
Activity
I nvite participants to complete a 24-hour clock representing the activities of
their current life. Then ask them to complete another showing their life
after their baby is born with time allocated to feeding, changing,
comforting and playing with the baby.
The discussion that follows focuses on how their lives are going to
change, who is there to support them, what kind of support they want and
how they can access it. A lso how life will change for other family members,
such as grandparents, and the baby's siblings.
W hat kind of mother or father do they want to be? D o they have parental
role models? D o they know what they definitely want to do and not do as
parents?
Giving Birth and Meeting Our Baby
The theme of Giving Birth and Meeting O ur Baby focuses on normal labour and birth
drawing on group members' knowledge of how labour starts , how long it lasts, what
helps and what does not. S ince people often a ack their antenatal classes postnatally
on the grounds of lack of realism, it is important to use as many different teaching and
learning strategies as possible to convey what labour ‘is really like’. A picture of a
woman in labour can be a trigger for discussion of upright positions and birth
companions' role; pictures of the hospital environment are very helpful in
contextualizing information (How might being in this room affect your labour? W ho
are the staff you will meet and what is their role?). Labour and birth stories are
invaluable in telling it from the woman's (or man's) point of view and there are also
YouTube videos that recount parents' birth stories in their own words. I n addition,
mental rehearsal is a useful technique for helping mothers and fathers create an
experience in their own minds and imagine their own roles (see Box 8.7).
Box 8.7
G iving B irt h a nd M e e t ing O ur B a by
Activity
W hile playing some relaxing background music, ask group members to
make themselves comfortable and to try to imagine what might be
happening to them at different points in labour:
‘Think about the start of labour, when you’re not quite sure what’s
happening.
W here are you? W here do you feel safe to labour? There's a contraction
now – what position are you in?
I f you're the woman's birth companion, how do you see yourself helping
her with this contraction?
I t's eight hours later in the labour now, and you're both in hospital. W hat
is the room like? How are you feeling? W hen you have a strong contraction,
how are you coping with it and what are you, as the person supporting her,
doing at this point?
Can you imagine the moment when your baby is born? How do you feel?
Ecstatic? Exhausted? Very emotional? Confused?
Your baby needs to be close to you both. How are you ge ing to know
him or her now?'
Our Health and Wellbeing
The birth of the first child has been shown to precipitate a sudden deterioration in
couples' relationship functioning (D oss et al 2009). A s the baby is completely
dependent on the mother to stay alive physically and to develop emotionally and
cognitively, it is vital that the mother should feel supported. For most women, the
person most likely to offer that support is her partner. However, tiredness, an
overwhelming sense of new responsibility, worries about diminished income, lack of
couple time without the baby – all these factors contribute to minor tensions between
couples escalating into major arguments. Understanding how to change vicious circles
into virtuous ones gives parents a model to which they can refer in the critical early
months of their baby's life. Figure 8.3 illustrates how fathers' involvement with their
baby, or lack of involvement, can make mothers feel supported and content with their
relationship with their partner, or unsupported and discontented. Helping fathers
learn basic babycare skills in antenatal sessions is a very useful strategy for enabling
them to play a full part in the early weeks of their new babies' lives when mothers are
most in need of help.
FIG. 8.3 (A) Unsupportive cycle. (B) Supportive cycle. Adapted from OneplusOne e-learning modules,
Transition to Parenthood Information Sheet (2005) and Supporting Couple Relationships (2008), reproduced with
permission OneplusOne.
D epending on how many sessions the antenatal course involves and how strong a
relationship the group leader is able to build up with the people a ending, there may
be scope for more in-depth work on relationships, such as exploring how individuals
typically respond when unhappy with their partner's behaviour – criticism, contempt,
defensiveness, stonewalling (Gottman 1994) and strategies for tackling conflict.
The theme of O ur Health and Wellbeing also involves looking at mental illness
starting in the postnatal period, antenatal depression that gets worse after the birth of
a baby (rather than talking about ‘postnatal depression’, which is not recognized in
The D iagnostic and S tatistical Manual of Mental D isorders I V [D S M I V] American
(
Psychiatric A ssociation 1994) as a separate diagnosis) and looking at how mothers and
fathers can keep themselves mentally healthy. I t is very important to have an
emphasis on mental health as everyone has to work at that, but only a few people will
experience clinical depression. This topic provides another opportunity to look at
lifestyles and the contribution a good diet, taking some exercise and a moderate intake
of alcohol and other stimulants make to feeling mentally strong and able to cope.
Caring for Our Baby
Caring for O ur Baby covers both the physical care of the baby and the emotional. The
importance of helping parents acquire skills to be able to meet the daily physical
needs of their baby has already been mentioned. Feeding is a huge area to cover and
the risk of information overload is a very real one. A s always with topics that are
potentially information-heavy, the group leader needs to be clear in her own mind as
to what are the most important things to get across, and then provide additional
information in response to the questions uppermost in parents' mind at the time. I n
terms of breastfeeding, it may be that the group leader feels the need to give very li le
information, but to address some common fears (it's going to hurt; I won't have
enough milk; how do I know my baby's ge ing sufficient milk?) and focus on ensuring
that everyone in the group knows where she or he would get help if problems arise.
While brief antenatal information giving sessions on breastfeeding have been found to
greatly increase fathers' understanding of how breastfeeding works and their support
of mothers (W ol erg et al 2004), it is the couples' confidence to ask for help and their
knowledge of where to find it that may be key in helping the woman to have a
successful and enjoyable experience of feeding her baby.
The majority of parents are capable of meeting their baby's emotional and learning
needs if left to their own devices and not sidetracked by manuals which they
erroneously believe know more about how to look after their baby than they do. S ome
parents will have very li le of this innate understanding however, having been the
recipients of very poor parenting or none at all. A ll parents like learning about how
babies communicate and what they enjoy, about how babies comfort themselves and
what is happening when babies ‘look away’ from their parents' faces. Helping parents
rediscover nursery rhymes (as illustrated in Box 8.8), poems for children and singing
will give them ideas, or reinforce innate ideas, about what babies need to develop trust
in human relationships and to start to learn their own language. Baby massage is a
wonderful way of ensuring that mothers, fathers and babies have ‘conversations’.
Box 8.8
C a ring for O ur B a by
Activity
A sk group participants to split into smaller groups and set up a
competition (adult learners enjoy competitions every bit as much as
children do!) How many nursery rhymes can they write down in a minute.
(The average is around eight.)
Congratulate everyone. A sk each group to choose one nursery rhyme
they all know and sing it to the other groups. D iscuss how the rhythms of
nursery rhymes exaggerate the rhythms of normal speech and fire the
baby's brain to make ‘language connections’.
Who Is There for Us? People and Resources
Very li le time is devoted by maternity care professionals to antenatal education and
even though more is likely to be required as government takes up the challenge of
supporting new parents be er, there is never likely to be enough time to discuss
everything that might be relevant to parents. With this in mind, the group leader has
to take responsibility for knowing where to signpost parents who want more
information or help now, or in the future. S ignposting will probably be a part of every
topic covered in the antenatal course and what kind of signposting will depend on the
needs and interests of the particular group of parents participating in the course.
Some examples of signposting are given in Box 8.9.
Box 8.9
W ho I s T he re for U s? S ignpost ing pe ople a nd
re source s
• To health and social care professionals
• To benefits agencies
• To groups for parents with particular needs
• To Children's Centres
• To buggy push/baby swim groups
• To parent and baby groups
• To Internet chat rooms
• To high-quality Internet sites
• To books
• To NICE (National Institute of Health and Care Excellence) guidelines
• To research
Defining learning outcomes
There is never enough time for antenatal sessions. This being the case, it is very
important that group leaders are clear about what it is they want to achieve (their
aims) and what they want participants to learn. A ims have already been discussed in
this chapter. Learning outcomes are vital for ensuring that the group leader and the
group remain on task and all leave the session feeling they have gained something in
terms of enhanced adulthood (Knowles 1984). They are not all about head knowledge.
There is also learning that takes place in the heart and learning that is physical.
Therefore, a list of learning outcomes for an individual session will include learning in
various ‘domains’. I n order to ensure that leaders define the learning that will have
taken place, rather than the process by which it will be achieved, every learning
outcome needs to begin with the stem: ‘by the end of this session, participants will be able
to …’ (rather than, ‘by the end of this session, participants will have …’).
Learning outcomes for a session covering the relationship between unborn babies
and their mother, start of labour, comfort positions for labour, healthy eating during
and after pregnancy, and looking after myself and my partner might be expressed as
follows:
By the end of this session, participants will be able to …
• describe the importance of relaxation during pregnancy (and after)
• state five signs that labour is about to start or has started
• demonstrate three positions that might make contractions easier to manage
• suggest two easy-to-make, inexpensive and nutritious meals for the first months after
the baby is born
• agree with their partners how to divide household chores and babycare between
them
• list Internet sites where they can find more information about healthy eating, and
list sessions that provide more opportunities to practise self-help skills for labour.
Maximizing attendance at antenatal sessions
I f antenatal education is to be universally available to all pregnant women and their
partners, the way in which it is provided needs to be tailored to the needs of local
communities. Time and again, when accounts are given of successful groups, it is
evident that their success lies in group leaders having identified where and when to
run sessions, and topics specifically relevant to the people attending.
W omen and men who are highly motivated to a end antenatal sessions, perhaps
because their experiences of education have led them to value it, and, more
pragmatically, because they are not dependent on public transport for access, tend to
go to all the sessions that are on offer. They will go to sessions led by midwives at the
hospital or clinic, and also to the N CT. They may also a end yoga for pregnancy and
aquanatal classes. O ther parents-to-be, a very significant minority, have no antenatal
education.
The reasons for nona endance have been explored, notably by Cliff and D eery
(1997) in an article entitled ‘Too like school’. These researchers identified the following
barriers to attendance:
• young age
• less privileged socioeconomic background
• perception that the content of sessions was not relevant.
A S wedish study (Fabian et al 2004) of nona endance at antenatal sessions found,
against a background of 93% a endance of first-time mothers, that primigravid
nonattenders were:
• more likely not to speak Swedish as their first language
• to be smokers
• to have considered abortion
• to have missed several antenatal checks.
Multigravid women who did not attend were:
• poorly educated
• pregnant with an unplanned baby
• abnormally frightened of childbirth.
These studies are helpful in terms of identifying the population of women less likely
to a end antenatal sessions and some of the reasons why. Perhaps the most important
reason would seem to be the fear of being judged – for smoking, for having considered
a termination, for failing to a end antenatal clinic appointments, for not having
planned the pregnancy and for not having done well at school. I t is difficult to
persuade women that they will not be judged until they have had at least one non-
judgemental, respectful and person-centred experience of adult education. This
requires them to come to a session. Planning to ensure sessions are as welcoming as
possible to local women is therefore vital if the considerable psychological, as well as
physical, barriers that many face are to be overcome.
Availability of the intended participants is the first thing to take into account:
• When are women, and the people whom they want with them at the birth and who
will be helping them care for the baby, free to attend sessions?
• Can women drive to sessions or do they take public transport?
• Which community centres are the best used, and safest (for both participants and
group leaders)? Children's Centres may be ideal in terms of their location and
facilities, but not all are open in the evening when sessions may be best suited to
working mothers and fathers.
Planners also need to find out what is already available in the community for
pregnant women. I f successful hypnobirthing sessions are running, or women
regularly a end aquanatal classes at the local leisure centre, or meet at a school where
basic maths and English are being taught to women who missed out on education in
childhood, or socialize at A sian W omen's groups, it may be possible to link antenatal
sessions to these activities.
W hile the Expert Reference Group carried out a stakeholders' review (summarized
in D H 2011) of what people wanted to talk about and learn in their antenatal sessions
and reflected the findings in the Preparation for Birth and Beyondprogramme's themes,
some women will have very specific needs that may be best addressed in groups run
just for them. W omen asylum seekers will need help in understanding the UK
maternity care system. I n areas where smoking rates are very high and there is a
significant problem with drug abuse, antenatal education may need to focus on
helping women manage these problems as well as prepare for labour, birth and early
parenting. There may be areas where facilitating women-only antenatal sessions is
appropriate, and areas where large numbers of women belong to faith communities
that preclude their attending sessions on certain days of the week.
I f women are unlikely to a end sessions for cultural reasons, antenatal education
can be provided through home-based learning materials. There is a vast range of
information sheets, video clips and online activities that can be brought together in a
‘pack’ and offered to pregnant women. A small group of dedicated midwives, using
their in-depth knowledge of the communities they serve, could, with a li le time,
compile such a pack. Consulting with local childbirth and parenting educators, social
workers, faith leaders and youth workers may help ensure that both the content of the
pack and the way in which it is presented maximize its use and usefulness.
Young mothers may prefer to a end sessions with peers of their own age. There is
evidence that they may feel inhibited at antenatal group sessions with older mothers
who are in stable relationships. The most vulnerable young women may be offered the
Family–N urse Partnership (FN P) programme, which is often delivered through S ure
S tart Children's Centres. This is an evidence-based intervention providing education
and support from pregnancy through to the baby's second year of life. FN P nurses,
who work closely with midwives and health visitors, aim to build a strong, trusting
relationship with young mothers to help them achieve a healthy pregnancy and
provide a physically and emotionally safe environment for their babies. The insights
gained from many years of running and evaluating the FN P in the UK informed the
work of the Expert Reference Group in devising thePreparation for Birth and Beyond
antenatal education package.
Personal invitation seems to be the most effective means of encouraging a endance
at antenatal group sessions. The invitation is likely to be delivered by the midwife, and
she should be very clear that it is an invitation both to the mother and to the person
the mother would most like to bring with her. I f this is the father, and the midwife
knows him, using his name when issuing the invitation is both polite and an excellent
way of gaining his goodwill. Texting women with the time and venue for each
antenatal session is very useful, especially when reaching out to pregnant teenagers.
Le ers addressed to both parents can be sent out, but must start with their names,
rather than ‘Dear parents’.
Including fathers
Research into the impact on fathers of a ending antenatal sessions where their needs
are identified and responded to, and the focus is on their transition to parenthood
equally with the mothers', is very positive. S tudies have reported be er couple
relationships (D iemer 1997), mothers reporting greater satisfaction with the division
of labour in relation to home and babycare tasks (Ma hey et al 2004), and greater
parental sensitivity (Pfannenstiel and Honig 1995).
There are various key strategies for a racting fathers to antenatal group sessions
and to retaining their a endance. First, it is important to ensure that the invitation to
a end is addressed both to the mothers and the fathers. Fathers D irect (now The
Fatherhood I nstitute) (2007) recommends avoiding the term ‘parent’ as this is
commonly interpreted by both men and women as meaning mothers. The I nstitute
also recommends not using the words ‘classes’, ‘groups’ or ‘ education’ in the name of
the programme, but instead to use a title that indicates a practical focus, such as ‘How
to H ave a Baby and Look After I’.t I t is essential to provide sessions at times that make it
possible for the fathers in the area that is being targeted to a end. Fathers who work
away from home, or undertake long daily commutes, will need weekend sessions.
There may be a possibility to run fathers' sessions at the workplace, given a
sympathetic employer.
S essions need to provide opportunity for fathers to talk to each other. This means at
least occasionally spli ing the group by gender to allow for male bonding. W hen men
are in a single-sex group, they interrupt each other with supportive comments, but
supportive comments decrease as the number of female members in the group
increases (S mith-Lovin and Brody 1989). W hen sessions have included single-sex small
group work, group members are more likely to discuss issues with their partners after
the class has ended (S ymon and Lee 2003). W hole-group sessions need to include the
men's perspective on every topic. For example, ‘start of labour’ needs to consider both
how the mothers may feel and the fathers. ‘Keeping mentally healthy’ needs to be
about more than what the fathers can do to support the mothers, but also about what
they can do to look after themselves, as shown in Box 8.10.
Box 8.10
F a t he rs' pe rspe ct ive s
The Fatherhood I nstitute (formerly Fathers D irect) suggests that expectant
fathers commonly have the following issues uppermost in their minds:
• What happens if something is wrong with the baby?
• What can I do to help my partner through the pregnancy?
• What happens if something goes wrong at the birth?
• What if I am not ready to be a father?
• What will happen to our relationship?
• How can we still earn enough money?
S ource: Fathers D irect, 2007. I ncluding new fathers: a guide for maternity
professionals. Fathers Direct, London.
Young fathers have been shown to want:
• reassurance and to grow in self-confidence
• help with decision-making
• greater self-awareness
• childcare knowledge, skills and awareness
• social contact and new friends
• practical information and advice
• ‘political’ recognition
Source: Key issues raised by the Trust for the Study of Adolescence (2005). The Young Fathers Project:
A project to develop and evaluate a model of working with young vulnerable fathers. TSA, Brighton.
I t is very important to make sure that visual aids depict fathers as often as mothers,
and that there are handouts and literature available that are pitched specifically at
them.
How many mothers and fathers in the group?
Traditionally, antenatal classes provided in hospitals have been open to all who wish
to a end, resulting in extremely large groups. This almost certainly proves to be an
unfavourable learning environment. The sessions in Ho and Holroyd's study (2002)
were a ended by between 48 and 95 women. The women identified that it was
impossible to engage in questioning and discussion, impossible to have their personal
problems addressed, impossible to make friends and impossible for the educators to
seek appropriate feedback from them.
Groups function best when they are composed of about 8 to 16 people. This ensures
that the more shy members can contribute if they want to, and gives everyone an
opportunity to be heard and have his or her personal needs addressed. I t may be
acceptable to offer information to larger groups but the expense of bringing people
together has to be questioned if what is going to be achieved could equally well have
been achieved by giving a handout at the antenatal clinic.
How many sessions and how long?
A 2007 survey of antenatal education (Nolan 2008) found that women wanted to a end
more than one antenatal session. They felt that meeting over a number of weeks gave
them the opportunity to get to know other women, and made it more likely that
friendships would continue into the postnatal period. I n addition, a single session was
considered simply inadequate to cover the many topics on which they wanted
information and which they wanted to discuss.
I nformation is retained according to its perceived relevance to learners. A ntenatally,
mothers and fathers will be interested especially in issues relating to pregnancy,
labour, birth and the first weeks of their new baby's life. Following the birth, as they
begin to experience all the dimensions of their new role, the need for more
information on some topics, and for support from other new parents and health
professionals becomes apparent. For this reason, antenatal groups that continue into
the postnatal period offer midwives a wonderful opportunity to help mothers and
fathers cope with problems that could only be dimly anticipated antenatally.
I nformation about infant feeding, sleeping, weaning and emotional development
becomes immediately relevant in the postnatal period. Listening to the stories of
people whom parents have already met in their antenatal group provides a wonderful
way of normalizing experiences. The ideal therefore is to move away from antenatal
education to one of transition to parenthood education, with sessions starting from mid-
pregnancy and continuing into the first 3–6 months of the babies' lives. W hile this may
sound utopian, it would be reasonable to argue that this level of support might well
reduce demands on community midwives, specialist community public health nurses
(health visitors) and General Practitioners (GPs), and lead to a reduction in the
incidence of mental ill health and relationship breakdown following childbirth. O ne
study (N olan et al 2012) has noted that women can manage anxiety about their baby's
development if they can ‘compare notes’ with other women and gain a broad concept
of what is ‘normal’.
The length of individual sessions may well be determined by the availability of the
venue. S horter sessions may be more tolerable for heavily pregnant women and tired
fathers, but whatever the length of the session, it is important to recognize certain key
features of adult learning. The average a ention span of an adult is about 10 minutes.
This means that activities, discussions and information-giving that continue for longer
than this may result in a diminishing return as far as learning is concerned. I n order to
retain people's interest, every session needs a variety of learning opportunities and the
leader needs to set a pace that is acceptable to both activists and reflectors (Honey and
Mumford 1982).
The brain needs water, glucose and protein in order to be able to function. A break
half way through the session allows time for parents to socialize and to have a drink
and something to eat – thus enhancing a ention and learning power when they return
to the group.
The aim of the group leader is to achieve a number of balances in each session:
• between her doing the talking and the mothers and fathers doing the talking
• between people sitting in their seats and moving around
• between work done with the whole group and work done in small groups
• between single-sex small group work and mixed small group work
• between focusing on themes to do with pregnancy and birth and those to do with
living with a new baby
• between group participants determining the agenda and how long to give to each
topic, and the group leader leading the session.
Effective evaluation of any session could be carried out using the bullet-point list
above. However, in order to see herself as group members are seeing her, it is
important for the group leader to have a skilled outsider present at her sessions
occasionally, someone who can give detailed feedback on which she can build so as to
provide ever-more effective learning opportunities.
Conclusion
I t is anticipated that antenatal education will once again become widespread
throughout the UK, be properly funded, valued by midwives and valuable to mothers
and fathers. W hile there are many questions for midwives to answer in terms of how
best to provide sessions that will be relevant and useful to mothers and fathers from
the communities they serve, what potential group participants want is very clear.
• They want sessions that cover a variety of topics from pregnancy to birth to feeding
and caring for their babies and looking after themselves.
• They do not want just one class that is rushed and does not answer their questions.
• They want to be part of a small group where they can make friends.
• They do not want huge numbers at classes because they do not feel able to ask
questions and cannot interact with other people.
• They want group leaders to use up-to-date videos and teaching aids that help them
prepare for labour, birth and parenting in the 21st century.
Mothers and fathers are very quick to spot poor facilitation skills and biased
teaching. This places a requirement upon midwife lecturers to ensure that their
students acquire group skills during their pre-registration or post-registration
programmes.
The best classes, in the view of mothers and fathers:
• are where the facilitator respects their right to make up their own minds about what
they want in labour and how they will care for their babies;
• welcome questions;
• provide lots of opportunities for talking;
• provide information in a way that empowers them rather than frightening them; and
• are structured, responsive to their individual needs, relaxed and fun (based on Nolan
2008).
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th edn. American Psychiatric Association: Arlington, VA; 1994.
Children's Society. The Good Childhood Report 2012. The Children's Society:
London; 2012.
Cliff D, Deery R. Too much like school: social class, age, marital status and
attendance/non-attendance at antenatal classes. Midwifery. 1997;13(3):139–145.
Cohen N, Muir E, Lojkasek M, et al. Watch, wait, and wonder: testing the
effectiveness of a new approach to mother–infant psychotherapy. Infant Mental
Health Journal. 1999;20(4):429–451.
Craig L, Sawrikar P. Work and family balance: transitions to high school. Unpublished
Draft Final Report. Social Policy Research Centre, University of New South
Wales; 2006.
DCSF (Department for Children, Schools and Families). The Early Years:
foundations for life, health and learning. DCSF: London; 2012.
DH (Department of Health). The Child Health Promotion Programme: pregnancy
and the first five years of life. DH/DCSF: London; 2008.
DH (Department of Health). Healthy lives, brighter futures: the strategy for children
and young people's health. DH/DCSF: London; 2009.
DH (Department of Health). Preparation for birth and beyond. [available at]
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
2011 [(accessed 3 May 2013)] .
Diemer G. Expectant fathers: influence of perinatal education on coping, stress
and spousal relations. Research in Nursing and Health. 1997;20:281–293.
Doss BD, Rhoades GK, Stanley SM, et al. The effect of the transition to
parenthood on relationship quality: an 8-year prospective study. Journal of
Personality and Social Psychology. 2009;96(3):601–619.
Fabian HM, Rådestad IJ, Waldenström U. Characteristics of Swedish women who
do not attend childbirth and parenthood education classes during pregnancy.
Midwifery. 2004;20(3):226–235.
Fathers Direct. Including new fathers: a guide for maternity professionals. Fathers
Direct: London; 2007.
Ford G. The complete sleep guide for contented babies and toddlers. Vermilion:
London; 2006.
Glover V, O’Connor TG. Effects of antenatal stress and anxiety: implications for
development and psychiatry. British Journal of Psychiatry. 2002;180:389–391.
Gottman J. Why marriages succeed or fail. Bloomsbury: London; 1994.
Ho I, Holroyd E. Chinese women's perceptions of the effectiveness of antenatal
education in the preparation for motherhood. Journal of Advanced Nursing.
2002;38(1):74–85.
Honey P, Mumford A. Manual of learning styles. P Honey: London; 1982.
Jackson D. Three in a bed: the benefits of sleeping with your baby. Bloomsbury:
London; 2003.
Janis IL. Psychological stress: psychoanalytic and behavioral studies of surgical
patients. Academic Press: New York; 1958.
Knowles M. Andragogy in action. Jossey–Bass: London; 1984.
Liedloff J. The continuum concept: in search of happiness lost. Da Capo Press:
Cambridge, MA; 1986.
Matthey S, Kavanagh DJ, Howie P, et al. Prevention of postnatal distress or
depression: an evaluation of an intervention at preparation for parenthood
classes. Journal of Affective Disorders. 2004;79(1-3):113–126.
McMillan AS, Barlow J, Redshaw M. Birth and beyond: a review of the evidence about
antenatal education. University of Warwick: Warwick;
2009 www.dh.gov.uk/en/Healthcare/Children/Maternity/index.htm.
Nolan M. Antenatal survey (1). What do women want? The Practising Midwife.
2008;11(1):26–28.
Nolan M, Mason V, Snow S, et al. Making friends at antenatal classes: a
qualitative exploration of friendship across the transition to motherhood.
Journal of Perinatal Education. 2012;21(3):178–185.
Pfannenstiel AE, Honig AS. Effects of a prenatal ‘Information and insights about
infants’ program on the knowledge base of first-time low-education fathers
one month postnatally. Early Childhood Development and Care. 1995;111:87–105.
Renkert S, Nutbeam D. Opportunities to improve maternal health literacy
through antenatal education: an exploratory study. Health Promotion
International. 2001;16(4):381–388.
Smith-Lovin L, Brody C. Interruptions in group discussions: the effects of gender
and group composition. American Sociological Review. 1989;54(3):424–435.
Spiby H, Henderson B, Slade P, et al. Strategies for coping with labour: does
antenatal education translate into practice? Journal of Advanced Nursing.
1999;29(2):388–394.
Stamler LL. The participants’ views of childbirth education: is there congruency
with an enablement framework for patient education? Journal of Advanced
Nursing. 1998;28:939–947.
Stapleton H, Kirkham M, Thomas G. Qualitative study of evidence based leaflets
in maternity care. British Medical Journal. 2002;324:639.
Symon A, Lee J. Including men in antenatal education: evaluating innovative
practice Evidence Based. Midwifery. 2003;1(1):12–19.
Talge NM, Neal C, Glover V. Antenatal maternal stress and long-term effects on
child neurodevelopment: how and why? Journal of Child Psychology and.
Psychiatry. 2007;48(3/4):245–261.
Trust for the Study of Adolescence (TSA). The Young Fathers Project: a project to
develop and evaluate a model of working with young vulnerable fathers. TSA:
Brighton; 2005.
Wadhwa PD, Sandman CA, Porto M, et al. The association between prenatal
stress and infant birth weight and gestational age at birth: a prospective
investigation. American Journal of Obstetrics and Gynecology. 1993;169(4):858–865.
Wolfberg AJ, Michels KB, Shields W, et al. Dads as breastfeeding advocates:
results from a randomized controlled trial of an educational intervention.
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Further reading
Department of Health. Preparation for birth and beyond: a resource pack for leaders of
community groups and activities. DH: London;
2011 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic
This package encapsulates a fresh approach to antenatal education and considers
relationships and emotions across the transition to parenthood as well as preparation
for labour and birth. Lots of practical activities for use with diverse groups of parents
are described and copyright free worksheets can be downloaded..
Gerhardt S. Why love matters: how affection shapes a baby's brain. Routledge:
London; 2004.
This inspiring book explains how newborn babies’ brains are moulded in response to
their earliest experiences with their mothers and other primary caregivers. It explains
why positive interaction is essential for babies’ healthy social and emotional
development..
Sunderland M. What every parent needs to know: the incredible effects of love, nurture
and play on your child's development. Dorling Kindersley: London; 2007.
This well-referenced book provides an accessible account of the latest findings from
neurobiology regarding how the baby's brain develops in utero and during the first
years of life..
*
Please note that although the Nursing and Midwifery Council replaced the term ‘Health Visitor’ with the title of
‘Specialist Community Public Health Nurse’ in 2002, the former continues to be widely used in practice and for the
purposes of this chapter will be used throughout.
C H AP T E R 9
Change and adaptation in pregnancy
Irene Murray, Jenny Hassall
CHAPTER CONTENTS
Physiological changes in the reproductive system 144
The uterus 144
The cervix 148
The vagina 149
Changes in the cardiovascular system 149
Anatomical changes in the heart and blood vessels 149
Haematological changes 153
Changes in the respiratory system 157
Changes in the central nervous system 159
Changes in the urinary system 159
Changes in the gastrointestinal system 161
Changes in metabolism 164
Maternal weight 165
Musculoskeletal changes 167
Skin changes 167
Changes in the endocrine system 168
Placental hormones 168
The pituitary gland and its hormones 169
Thyroid function 169
Adrenal glands 170
Diagnosis of pregnancy 171
Common disorders arising from adaptations to pregnancy 171
References 173
Anatomical and physiological adaptations occurring throughout pregnancy
affect virtually every body system. The timing and intensity of the changes
vary between systems but all are designed to support fetal growth and
development, and prepare the woman for birth and motherhood. The
midwife's appreciation of the physiological adaptations to pregnancy and
recognition of abnormal findings is fundamental in the management of all
pregnancies, enabling her to provide appropriate midwifery care to each
woman, including those affected by pre-existing illness. A common feature
of these changes is the dynamic and symbiotic partnership between the
uteroplacental unit and the woman influenced by physical, mechanical,
genetic and hormonal factors. Many aspects of the physiology of pregnancy
remain poorly understood and controversies continue to be researched.
(Changes in the woman's emotional state due to hormonal factors are
discussed in Chapter 25 and changes in the breast are detailed in Chapter
34.)
The chapter aims to:
• provide an overview of the adaptation of each body system during pregnancy and the
underlying hormonal changes
• identify the physiological changes that mimic or mask disease in pregnancy
• provide the rationale for common disorders in pregnancy in order for the midwife to
facilitate appropriate advice
• review the diagnosis of pregnancy.
Physiological changes in the reproductive system
The uterus
The uterus plays a remarkable role in pregnancy by stretching and expanding to
accommodate and nurture the growing fetus (Hudson et al 2012). This expansion and
activation takes place in the middle muscle layer of the uterine wall, the myometrium,
which is partly covered and protected by an outer layer of peritoneum, the perimetrium.
An internal layer, the endometrium, lines the uterine wall (Abbas et al 2010).
Perimetrium
The perimetrium is a thin layer of peritoneum composed of connective tissue that
comprises collagen and elastin fibres, which is draped over the uterus and uterine
tubes and is continuous laterally with the broad ligaments (I mpey and Child 2012)
(see Chapter 3). D uring pregnancy, the peritoneal sac is greatly distorted as the uterus
enlarges and rises out of the pelvis, drawing up the two folds of broad ligament on
either side. S tretching of the peritoneum makes it difficult to localize pain late in
pregnancy which may delay diagnosis of disease (Casciani et al 2012).
By the third trimester the ligaments and uterine tubes appear lower on the sides of
the uterus. The tubes run downwards, with the fimbriae spread out on its surface and
bound to the sides of the uterus by the narrowed broad ligaments. The ovaries have
become abdominal structures lying laterally to the gravid uterus (S tandring et al 2008).
A s the uterus expands there is increasing stress and tension on the round ligaments
which run almost perpendicularly downwards from the fundus. S pasm of the round
ligaments may cause painful cramps which are usually more pronounced on the right
side due to the dextrorotation of the uterus (see below) and are relieved by more
gradual movement (Beckman et al 2010).
Myometrium
The myometrium is the muscular wall of the uterus that undergoes dramatic
remodelling during pregnancy to provide support for the growing fetus and ultimately
to expel it during labour (Ciarmela et al 2011). I t is composed mainly of bundles of
smooth myometrial cells (myocytes) embedded in a supporting extracellular matrix
(ECM). The myocytes are elongated, spindle-shaped cells which are functionally
different between upper and lower uterine segments having a contractile phenotype in
the upper segment and a more relaxed phenotype in the lower segment (Mosher et al
2013). S mooth muscle cells increase in length from 50 µm in the non-pregnant uterus
to about 500 µm or longer in the pregnant uterus (A bbas et al 2010). Each bundle of
myocytes is approximately 300 µm in diameter and is further organized into fasciculi
each of which measures 1–2 mm in diameter (Blanks et al 2007). The ECM is composed
of tension-bearing proteins such as collagen, fibronectin and elastin, all of which
increase significantly in mass and composition under the influence of progesterone
and oestrogen, providing a scaffold for the smooth muscle cells, mast cells, blood and
lymphatic vessels (Åkerud 2009). The increase in elastin in particular assists in
accommodating the physical strain within the uterine muscle during pregnancy. Both
myocytes and the ECM play an important role in contractility and are synchronously
regulated to enable the uterus to change from the relative quiescence of pregnancy to
maximal contractility during labor.
Phases of myometrial development
Myometrial development in pregnancy begins with an early proliferative phase
activated by oestrogen and other hormones (S hynlova et al 2010), resulting in a rapid
increase in myocytes (hyperplasia) by at least 10-fold. This is followed by a synthetic
phase when myocytes increase in size (hypertrophy) and further remodelling of the
ECM (S hynlova et al 2009). Myometrial hypertrophy and hyperplasia is initiated and
finalized early in gestation. S ubsequent enlargement in length and volume is mainly
through mechanical stretch, which transforms the uterus into a relatively thin-walled
muscular organ capable of accommodating fetal growth and movement. I n the
contractile phase hypertrophy stabilizes and the muscle prepares for the labour phase of
intense coordinated contractions (Shynlova et al 2009).
Myometrial layers
The classic description of three layers of myometrium (stratum supravasculare, stratum
vasculare and stratum subvasculare) found in most major texts was observed during
research in other species such as the mouse. I n spite of extensive investigation since
the end of the 19th century, the debate continues concerning the organization of
human myometrial muscle fibres. Young and Hession (1999) described the bulk of the
myometrium (stratum vasculare) to be composed of a thick layer of myocytes organized
into cylindrical, sheet-like and fibre bundles or fasciculata with communicating bridges
that merge and intertwine to form an interlacing network and a contiguous pathway
allowing coordinated contraction. The myocytes within each bundle all contract and
relax in a longitudinal direction only (as with a spring). These fasciculi are well
ordered, running transversely across the fundus of the uterus, obliquely down the
anterior and posterior walls of the uterus and transversely across the lower uterine
segment (Fig. 9.1). O ther investigators describe a homogenous structure of one
continuous layer of smooth muscle cells organized in large interwoven bundles where
longitudinal and circumferential muscle fibres are mixed with fasciculi running at
right angles within them (Miftahof and Nam 2011).
FIG. 9.1 Myometrium showing the very thin outer layer, the transitional layer and the inner bulk of
myometrium with the arrangement of the fasciculata running transversely across the fundus
between the fallopian tubes, obliquely down anterior and posterior walls and transversely around
the lower uterine segment.
The inner third of the myometrium (stratum subvasculare) and its underlying
endometrium is known as the endo–myometrial junctional zone (A guilar and Mitchell
2010). I n the non-pregnant state it measures less than 5 mm thick but during
pregnancy it becomes indistinct. The peristaltic waves of the junctional zone change
direction depending on the stage of parturition thus playing an integral part in both
sperm transport and implantation (A guilar and Mitchell 2010). Failure in the
remodelling of the junctional zone segment of the spiral arteries during placentation
can result in impaired placental perfusion which may lead to pregnancy complications
(Brosens et al 2010).
There is li le change in the myometrial thickness of the uterine body across
pregnancy in spite of the increased volume. The mean thickness is 0.6 cm at 15 weeks
and 0.7 cm at 36 weeks with only a very slight decline in later weeks. At term the
pregnant uterus is described as a thin, soft biological shell or bioshell with readily
indentable walls through which the fetus can easily be palpated (Cunningham et al
2010). I t is pear-shaped and measures about 40 cm in height although the dimensions
vary considerably depending on maternal height, weight, parity and ethnic origin
(Gardosi 2012) (Table 9.1). D uring normal pregnancy the weight of the uterus
increases 10- to 20-fold from about 44 g in the primigravida to 1100 g at term. I t
increases with successive pregnancies and may weigh more than 110 g in a non-
pregnant woman who is para 5 or more (Abduljalil et al 2012).
Table 9.1
Increases in weight and size of the uterus during pregnancy
Sources: Cunningham et al 2010; Abduljalil et al 2012
There is a dynamic balance in pregnancy between forces promoting uterine
quiescence with a cervix that remains closed or contractility with a cervix that softens
and dilates (Petraglia et al 2010). The quiescent phase is controlled by prostacyclin,
corticotropin-releasing hormone (CRH), relaxin, parathyroid hormone, nitric oxide and
a complex interplay of signals between fetus and mother (Mesiano et al 2011).
Progesterone's relaxing effect blocks the myometrial response to oxytocin. The
changing oestrogen and progesterone concentration within the uterus causes an
increase in the expression of calcium and potassium channels which dampens
electrical activity (S oloff et al 2011). Cell-to-cell gap junctions are present in very low
density, indicating poor coupling and limited electrical conduction between the cells.
The fragmented bursts of irregular, poorly coordinated, low electrical activity that
takes place over several minutes are known as Braxton H icks contractions, initially
described by Braxton Hicks in 1872. They are painless, non-rhythmic uterine
contractions that are easily palpated from about 12 weeks' gestation and are
unpredictable, sporadic and of variable intensity. D uring the last few weeks of
pregnancy they may become more rhythmic, increase in frequency and may occur
every 10–20 minutes. The woman is usually unaware of Braxton Hicks contractions
unless the uterus is particularly sensitive, which may cause some degree of pain. S ome
women may find them very uncomfortable such that they may confuse them with false
labour (Cunningham et al 2010).
I n contrast to many other species, progesterone levels remain relatively high
throughout pregnancy decreasing only after the birth of the placenta. A wakening of
the quiescent uterus is due therefore not to withdrawal of progesterone but rather to
resistance of the tissues to its action (Mesiano et al 2011). A s term approaches,
progesterone resistance increases, gap junction density rises and excitation of
myocytes causes the forceful, synchronous contractions of labour.
Endometrium (decidua)
Remodelling of the endometrium begins spontaneously in stromal cells adjacent to
spiral arterioles during the mid-secretory phase of the menstrual cycle. I f implantation
occurs the endometrial cells undergo a transformation known as the decidual reaction
which extends into the junctional zone and forms the decidua of pregnancy. The primary
function of decidualization is to provide nutrition and an immunologically privileged
site for the early embryo. Triggered by maternal immune cells the decidual cells swell
due to the accumulation of glycogen and lipid (Moore et al 2013). Their secretions
dampen the local immune response to the invading trophoblast enhancing its
invasiveness (Gellersen et al 2013) (see Chapter 5). I mplantation of the trophoblast
usually occurs on the anterior or posterior wall of the body of the uterus where the
decidua is better developed than in the cervix or isthmus.
Profound changes take place in cellular function during decidualization. S pindle-
shaped endometrial stromal cells become round and produce hormones, growth
factors and cytokines. Uterine glands and arteries become coiled and the recognizable
pa ern of three distinct layers can be identified: a superficial compact layer, an
intermediate spongy layer and a thin basal layer (see Chapter 5). Under the influence
of progesterone, the decidua achieves maximum thickness at 6 weeks' gestation then
gradually becomes less distinct until it is not identifiable by 10 weeks (W ong et al
2009). Effective decidualization is essential for the formation of a functional placenta.
Blood flow to the body of the uterus and placenta from a convoluted network of
uterine and ovarian arteries and veins is fully established by the end of the first
trimester. Remodelling of spiral arteries into large low-resistance uteroplacental
vessels begins after implantation and by 7 weeks' gestation the diameter of the vessels
almost doubles in size to accommodate the massive increase in uterine perfusion from
45 ml to 750 ml per minute at term. By mid-pregnancy 90% of uterine blood supply is
flowing into the intervillous spaces of the placenta (Brosens et al 2012).
I n early pregnancy the tips of the spiral arteries are plugged by the invading
trophoblast cells so there is li le blood flow into the placenta. With increasing
trophoblast invasion the tips of the spiral arteries are enormously dilated, particularly
beneath the implantation site, often reaching a four-fold increase of 2–3 mm in
diameter. Loss of smooth muscle in their walls and their elastic lamina results in their
dilatation and conversion into flaccid conduits (Burton et al 2009). A bout 120 spiral
arteries enter the intervillous space and extend from the decidua to the myometrium
(Pijnenborg et al 2011). They also become longer as the uterus enlarges
circumferentially due either to longitudinal growth or progressive straightening of the
coiled vessel. Transformation of these spiral arteries has a profound effect on the rate
and constancy of delivery of maternal blood to the placenta at an optimal pressure and
velocity.
The passage of blood through the dilated uterine arteries of the pregnant uterus
produces a soft blowing sound like the continuous murmur of the sea, known as the
uterine souffle . I t can be detected from 15 weeks' gestation, is synchronous with the
maternal pulse and heard most distinctly near the lower portion of the uterus and in
both inguinal regions. I n contrast, the placental souffle can be heard over the placenta
and is produced by the blood flowing through it. This should not be confused with the
funic souffle , a muffled swooshing sound produced by the pulsation of blood as it is
propelled through the arteries in the umbilical cord. A lthough synchronous with the
fetal heart rate and found in the immediate vicinity of the placenta, it is quite different
to the very distinct sound of the fetal heart.
Changes in uterine shape and size
Making comparisons between the uterus and fruit is a fairly reliable mental
benchmark for uterine sizing in early pregnancy. At 5 weeks' gestation the uterus feels
like a small unripe pear. By 8 weeks it feels like a large navel orange. By 10 weeks it is
about the size of a grapefruit and by 12 weeks it is the size of a cantaloupe melon (Sage-
Femme Collective 2008). Traditionally, gestational age was assessed by comparing
uterine height with abdominal landmarks (Hargreaves et al 2011). A lthough the
current standard practice of symphysis-fundal height measurement is flawed, its
continued use is advised until proven alternatives are found (Neilson 2009).
12th week of pregnancy
For the first few weeks of pregnancy the uterus maintains its original pear shape but
as pregnancy advances the corpus and fundus become globular and by 12 weeks it is
almost spherical. Thereafter it increases in length more rapidly than in width and
becomes ovoid in shape. By the end of the 12th week it can usually be palpated just
above the symphysis pubis (Cunningham et al 2010). Changes in uterine position are
normal during pregnancy. The fundus of the uterus is able to move relatively freely in
all planes and is frequently retroverted in the first trimester (Fig. 9.2).
FIG. 9.2 Changes in the uterus from non-pregnant to 16 weeks' gestation. From Hanretty K 2010
Obstetrics illustrated, 7th edn. Churchill Livingstone, Edinburgh, p 34, with permission of Churchill Livingstone,
Elsevier.
16th week of pregnancy
Between 12 and 16 weeks' gestation, the fundus becomes dome-shaped. W hen the
uterus enlarges it comes into contact with the anterior abdominal wall and the bladder
is displaced superiorly (Theodorou and Laren akis 2012). A s it rises it rotates to the
right (dextrorotation) due to the rectosigmoid on the left side of the pelvis, and tension
is exerted on the broad and round ligaments (Cunningham et al 2010).
20th week of pregnancy
By the 20th week of pregnancy the uterine fundus is at the level of the umbilicus. The
uterus is an ovoid shape and the round ligaments appear to be inserted slightly above
the middle of the uterus and the uterine tubes elongate.
30th week of pregnancy
The enlarging uterus displaces the intestines laterally and superiorly. The caecum and
appendix, which have been progressively rising upwards from 12 weeks, now reach the
iliac crest. The abdominal wall supports the uterus and maintains the relation between
the long axis of the uterus and the axis of the pelvic inlet. I n the supine position the
uterus falls back to rest on the vertebral column, the inferior vena cava and aorta
(Cunningham et al 2010).
36th week of pregnancy
By the end of the 36th week the enlarged uterus almost fills the abdominal cavity. The
fundus is at the tip of the xiphoid cartilage which is pushed forward and continues to
rise almost to the liver (Cunningham et al 2010). The diaphragm is raised by about
4 cm and the anteroposterior diameter of the thoracic cavity increases (Theodorou and
Laren akis 2012). With the gradual upward displacement of the abdominal organs
there is stretching of the abdominal and peritoneal cavity. The liver is no longer
palpable having been forced upwards, backwards and to the right by the expanding
uterus. The transverse colon, stomach and spleen are crowded into the vault of the
abdominal cavity and the small intestines lie above, behind and to the sides of the
uterus.
38th week of pregnancy
Between 38 and 40 weeks the increase in myometrial tone leads to smoothing and
shortening of the lower uterine segment. The uterus becomes more rounded with a
decrease in fundal height although this is influenced by the lie of the fetus. Tension on
the uterine tubes and broad ligaments increase (Cunningham et al 2010).
Uterine divisions
The development of the uterine divisions in pregnancy is asymmetric (Hamdi et al
2010). The muscular upper uterine segment of the uterus grows faster in the first
seven months of pregnancy while the lower uterine segment grows more rapidly
towards the end of pregnancy. D uring the first trimester the isthmus hypertrophies
and triples in length to about 3 cm (S tandring et al 2008). I n the second trimester the
walls of the isthmus are of a similar thickness to the walls of the body. By term the
walls of the lower uterine segment may be as little as 0.4 cm thick.
I n the primigravida, during the last two weeks of pregnancy, the low-intensity
Braxton Hicks contractions cause shortening of the passive lower segment in
preparation for cervical dilatation. The contractile upper segment of the corpus pulls
the isthmus open over the presenting part converting it into a thinned out cone of
circular fibres to develop into the lower uterine segment. This is detected clinically
when the previously floating presenting part becomes fixed in the pelvic inlet. I n the
multigravida, the lower uterine segment usually develops in the early part of labour.
I n all cases, the isthmus changes from a sphincter into a thinned out tendon-like
structure that pulls the cervix open. With the development of the lower uterine
segment a transverse depression or ridge forms at its junction with the thickened
upper uterine segment. This ridge becomes the physiological retraction ring during the
second stage of physiological labour. I t is a landmark that is used to ensure that the
incision at caesarean section is in the less vascular lower uterine segment where there
is less risk of dehiscence in subsequent pregnancies compared to the classical
caesarean section scar (Standring et al 2008).
D escent of the fetal head into the pelvic brim (engagement) at 38 weeks' gestation in
the primigravida has traditionally been considered a reassuring sign that labour will
proceed normally without risk of dystocia. The primigravida with an unengaged head
at term or onset of labour is more likely to need intervention (I qbal and S umaira 2009).
I n A frican women, engagement often does not occur until labour is well established,
perhaps because of their shape of pelvis or stronger pelvic support structures, but this
should not preclude a normal birth. D escent of the fetal head into the pelvic inlet
causes a change in shape of the abdomen and is accompanied by the feeling of the
baby dropping known as lightening (Cunningham et al 2010). The woman may feel a
sense of relief as the rib cage expands more easily, enabling her to breathe more
deeply and to tolerate more substantial meals. A lthough heartburn may reduce, there
may be an increase in other symptoms. S harp pains may occur in the rectum and
cervix, and constipation is common. I ncreased pressure of the fetal head on the
bladder may lead to urinary frequency and an increased risk of urinary incontinence
(Gabbe et al 2012).
The cervix
The cervix has been described as the gatekeeper of pregnancy as it is transformed from a
closed, rigid, collagen-dense structure with a closed os in early pregnancy to one that
is soft, distensible and effaced at the time of birth (Larsen and Hwang 2011). I t is less
contractile than the lower uterine segment as it contains less smooth muscle. The
initial softening phase of the cervix, which is dependent on progesterone, begins at
conception and continues until approximately 32 weeks. This softening in early
pregnancy was first described by Hegar in 1895 and became known as H egar's sign.
There are changes in the structural organization of cervical tissue leading to a decline
in tensile strength and an increase in compliance. Crvical ripening is a more accelerated
phase occurring in the final weeks of pregnancy. Collagen is reduced or disorganized
leading to degradation of the ECM. The cervix becomes thin, more elastic and pliable
(Hassan et al 2011). I ncreased blood flow to the cervix results in a bluish-purple
coloration known as Goodell's sign (Geraghty and Pomeranz 2011). These changes are
intricately timed to coincide with uterine contractions and the initiation of cervical
dilatation (Larsen and Hwang 2011). Pro-inflammatory agents, anti-inflammatory
cytokines, prostaglandins, stromal factors and nitric oxide all contribute to the
inflammatory process of cervical ripening. The gradual remodelling of the cervix
enables progressive softening to take place while at the same time ensuring the cervix
remains closed (Timmons et al 2010). The glands of the cervix undergo such marked
hypertrophy and hyperplasia that by the end of pregnancy they occupy half of the
entire cervical mass. They become everted so that the tissue tends to become red and
velvety and bleeds even with minor trauma such as taking Papanicolaou smears (Pap
test). The basal cells near the squamocolumnar junction are more prominent in shape
and size due to oestrogen which renders the Pap smear less efficient (Cunningham
et al 2010).
The endocervical mucosal cells produce copious amounts of a tenacious mucus
which creates an antibacterial plug in the cervix. The consistency of the mucus changes
during pregnancy under the influence of progesterone. W hen cervical mucus is spread
and dried on a glass slide it is characterized by crystallization or beading. I f there is
leakage of amniotic fluid ferning may be visualized due to arborization (a branching,
treelike arrangement) of the crystals (Cunningham et al 2010).
Taking up or effacement of the cervix is the shortening of the cervical canal from
about 2 cm in length to a circular orifice with paper-thin edges. Muscle fibres at the
level of the internal os are pulled upwards to become part of the lower uterine
segment. This funneling process takes place from above downwards because there is
less resistance in the lower uterine segment and cervix. The centrifugal pull on the
cervix can be visualized on transvaginal sonography whereby the relationship of the
cervical canal to the lower uterine segment changes from a T shape to the notched Y
shape. With further effacement the uterine segment then becomes a V shape and
ultimately a U shape (I ams 2010). I n the primigravida effacement usually takes place
prior to the commencement of labour but in the multigravida effacement may take
place simultaneous with cervical dilatation (Cunningham et al 2010).
There is still no agreement about what constitutes a normal length of cervix,
however a cervical length of less than 2.5 cm is strongly predictive of preterm birth
regardless of gestational age. D ifferences in cervical length may be associated with
race, maternal age, parity and past obstetric history (Slager and Lynne 2012).
The vagina
I ncreased blood flow to the vagina results in a bluish-purple coloration of the vagina
known as Chadwick's sign (Geraghty and Pomeranz 2011). I n preparation for the
distension that occurs in labour, the vaginal walls undergo striking changes: the
mucosa thickens, the connective tissue loosens and the smooth muscle cells
hypertrophy. The increased volume of vaginal secretions due to high levels of
oestrogen results in a thick, white discharge known as leucorrhoea (Cunningham et al
2010). The dominant vaginal flora is the Lactobacillus acidophilus (D oderlein's bacillus).
D uring pregnancy the higher levels of oestrogen favour an increase in the activity and
proliferation of the lactobacilli, a byproduct of which is lactic acid which leads to the
increased vaginal acidity of pregnancy (pH varying from 3.5 to 6). This is particularly
important in protecting women from genital tract infection in pregnancy which may
lead to perinatal complications (Donati et al 2010).
Changes in the cardiovascular system
D uring pregnancy profound but predominantly reversible changes occur in maternal
haemodynamics and cardiac function. These complex adaptations are necessary to:
• meet evolving maternal changes in physiological function
• promote the growth and development of the uteroplacental–fetal unit
• compensate for blood loss at the end of labour.
These physiological adaptations are extensive, with all components undergoing a
degree of modification in pregnancy (Table 9.2). I t is critical to achieve a balance
between fetal requirements and maternal tolerance. I n most women, these demands
are effectively accommodated by physiological adaptations without compromising the
mother.
Table 9.2
A summary of the key components of the cardiovascular system and adaptations
in pregnancy
Component Key change in pregnancy
The heart Increases in size
Shifted upwards and to left
Arteries Dramatic systemic and pulmonary vasodilatation to increase blood flow
Capillaries Increased permeability
Veins Vasodilatation and impeded venous return in lower extremities
Blood Haemodilution
Increased capacity for clot formation
Adapted from Torgersen and Curran 2006
Anatomical changes in the heart and blood vessels
The heart is enlarged by chamber dilatation and a degree of myocardial hypertrophy
in early pregnancy leading to a 10–15% increase in ventricular wall muscle (Monga
2009). The progressive blood volume expansion throughout pregnancy results in
increased diastolic filling (particularly in the left ventricle) and progressive distension
of the heart chambers. D espite cardiac enlargement, efficiency is maintained by
lengthening of myocardial fibres and reduction in after load facilitated by peripheral
vasodilatation. These structural changes in the heart mimic exercise-induced cardiac
remodelling (Baggish and W ood 2011), which occurs in response to physical training,
and, similarly, they are reversible after pregnancy.
The enlarging uterus raises the diaphragm, and the heart is correspondingly
displaced upward and to the left to produce a slight anterior rotation of the heart on
its long axis. This partially accounts for pregnancy variations in key parameters used
for cardiac assessment, including electrocardiography (ECG) and radiographic
assessments and can give an exaggerated impression of cardiac enlargement (Gordon
2012). Atrial or ventricular extrasystoles are relatively common in pregnancy along
with increased susceptibility to supraventricular tachycardia, however it is imperative
that signs of severe disease such as angina or resting dyspnoea are not overlooked
(Adamson et al 2011).
Within 5 weeks of conception changes in maternal blood vessels are evident,
including an increase in aortic size and venous blood volume. Compliance of the
entire vasculature is increased, partially due to the softening of the collagen and
smooth muscle hypertrophy (Blackburn 2012). W hile influenced by progesterone,
relaxin and endothelial-derived relaxant factors such as nitric oxide and prostacyclin,
the exact mechanism underlying these changes is not yet fully understood.
A longside these anatomical changes are complex physiological changes which are
summarized in Table 9.3. They are accompanied by widespread peripheral
vasodilatation resulting in the high flow, low resistance haemodynamic state with
marked haemodilution characteristic of a healthy pregnancy.
Table 9.3
Key physiological changes in the cardiovascular system in pregnancy
Sources: Nelson-Piercy 2009; Blackburn 2012
Blood volume
The increase in total blood volume (TBV) is essential to:
• meet the demands of the enlarged uterus with a significantly hypertrophied vascular
system and provide extra blood flow for placental perfusion
• supply extra metabolic needs of the fetus
• protect the woman (and fetus) against the harmful effects of impaired venous return
• provide extra perfusion of maternal organs
• counterbalance the effects of increased arterial and venous capacity
• safeguard against adverse effects of excessive maternal blood loss at birth.
The first step is extreme vasodilatation for which several possible explanations are
suggested; the dramatically vasodilated, uteroplacental vasculature contributes to this
change supported by evidence that fetal weight correlates directly with the rise in
blood volume (Blackburn 2012). This only partially explains the reduced systemic
vascular resistance, since a significant proportion of the decrease occurs outside the
uteroplacental circulation. I ncreased vasodilatation is probably facilitated by a
systemic and renal vasodilator unique to pregnancy. Current studies suggest that
relaxin is also a key factor (Conrad 2011). Vasodilatation is partly mediated by rising
pregnancy hormone levels, particularly progesterone and oestrogen. These hormones
are associated with the stimulation of nitric oxide production and enhancement of
endothelial function which induce the renin–angiotensin–aldosterone system (RA A S )
and stimulates sodium and water retention (Monga 2009). The RA A S is important in
fluid and electrolyte homeostasis and maintaining arterial blood pressure (Fig. 9.3). I t
has also been postulated that hormonal factors and expansion of blood volume
associated with pregnancy may affect sympathetic nervous activity, inhibiting both its
vasoconstrictor effect and baroreflex control of heart rate (Fu and Levine 2009).
FIG. 9.3 The renin–angiotensin–aldosterone system (RAAS). From Wallace W 2005 Endocrine
function. In: Montague S, Watson R, Hubert R (eds) Physiology for nursing practice, 3rd edn. Elsevier, p 232, with
permission of Elsevier.
Vasodilatation causes an underfilling of the maternal circulation which subsequently
initiates fluid and electrolyte retention, expansion of the plasma and extracellular fluid
volumes and a concurrent increase in cardiac output. This occurs prior to full
placentation and is accompanied by a parallel increase in renal blood flow and
glomerular filtration rate. Fluid balance and osmoregulation are regulated through the
modification of homeostatic mechanisms to accommodate and maintain these
changes. There is a marked increase in all components of the RA A S leading to
increased fluid and electrolyte retention. O estrogen reduces the transcapillary escape
rate of albumin, which promotes intravascular protein retention and shifts
extracellular fluid volume distribution while lowering the osmotic threshold for
antidiuretic hormone (A D H) release. Levels of A D H appear to remain relatively stable
despite heightened production, owing to a three- to four-fold increase in metabolic
clearance as a consequence of the placental enzyme vasopressinase, which inactivates
ADH and oxytocin.
Atrial natriuretic peptide (A N P) and brain natriuretic peptide (BN P) secreted in
response to heart dilatation, raised end diastolic pressure and volume, have similar
physiologic actions, both acting as antagonists to the RA A S . Gestational modifications
of A N P and BN P are controversial and research has been unable to confirm when
plasma levels are modified. Reported increases do not reach pathological levels
associated with heart failure. I nconsistencies in study findings may be due to postural
effects, namely aortocaval compression by the enlarged uterus on maternal
haemodynamics (Gordon 2012) (see Box 9.1).
Box 9.1
S upine hypot e nsive syndrom e
I n later pregnancy (from 24 weeks) the gravid uterus occludes the inferior
vena cava and laterally displaces the subrenal aorta, this is particularly so
when the mother lies supine. This aortocaval compression has a profound
effect on venous return to the heart.
Turning from a lateral to a supine position can reduce maternal cardiac
output by 10–30% (Gordon 2012). The event is often concealed, because
only 10% of pregnant women will exhibit supine hypotension syndrome
(Bamber and D resner 2003). The majority of women are able to compensate
by raising systemic vascular resistance and heart rate. Blood from the lower
limbs may also return through the development of paravertebral collateral
circulation, however if these are not well developed or adequately perfused,
the pregnant woman may experience supine hypotensive syndrome. This
occurs in around 10% of the childbearing population and consists of
hypotension, bradycardia, dizziness, light-headedness and nausea, if the woman
remains in the supine position too long. The fall in blood pressure may be
severe enough for the woman to lose consciousness due to reduced cerebral
blood flow.
Pregnant women usually avoid lying supine, however they are often
subjected to such a position during maternity care with technicians
reporting unawareness of this condition (McMahon et al 2009).
The consequent aortocaval compression can be relieved by placing a
wedge under the woman's hip or by tilting the operating table to displace
the uterus. Compression of the aorta may lead to reduced uteroplacental
and renal blood flow and fetal compromise.
Cardiac output
The profound increase in cardiac output (30–50%) ensures blood flow to the brain and
coronary arteries is maintained, while distribution to other organs is modified as
pregnancy advances. I ncreased cardiac output is due to increases in stroke volume and
heart rate. The relative contributions of these factors vary with gestational age. The
increase in heart rate mainly occurs during the first trimester, thus contributing to
early changes in cardiac output. I ncreases in stroke volume facilitate second trimester
increases in cardiac output, augmented by plasma volume expansion. The stroke
volume increases by 10% during the first half of pregnancy, reaching a peak at 20
weeks that is maintained until term (Nelson-Piercy 2009) (Fig. 9.4).
FIG. 9.4 Key changes in cardiac function in pregnancy. Data from Cunningham et al 2010.
Cardiac output in pregnancy is extremely sensitive to changes in body position. This
increases with advancing pregnancy, as the gravid uterus impinges on the inferior
vena cava, thereby decreasing blood return to the heart (see Box 9.1). Large variations
in cardiac output, pulse rate, blood pressure and regional blood flow may follow slight
changes of posture, activity or anxiety.
Blood pressure and vascular resistance
W hile cardiac output is raised, arterial blood pressure is reduced by 10% in pregnancy.
The decrease in systemic vascular resistance accounts for this, particularly in the
peripheral vessels. The decrease begins at 5 weeks' gestation, reaches a nadir in the
second trimester (a 21% reduction) and then gradually rises as term approaches
(Blackburn 2012). N umerous modifications occur in the mechanisms controlling
vascular activity. A gents responsible for peripheral vasodilatation include
prostacyclin, nitric oxide and progesterone and vasoactive prostaglandins. The
changes are not limited to the uteroplacental circulation but are apparent throughout
the body in a healthy pregnancy. I ncreased heat production further contributes to the
reduced resistance, stimulating vasodilatation in heat loss areas particularly.
Early pregnancy is associated with a marked decrease in diastolic blood pressure but
minimal reduction in systolic pressure. With reduced peripheral vascular resistance
the systolic blood pressure decreases an average of 5–10 mmHg below baseline levels
and the diastolic pressure reduces 10–15 mmHg by 24 weeks' gestation. Thereafter
blood pressure gradually rises, returning to the pre-pregnant levels at term. D espite
increased blood volume systemic venous pressures do not rise significantly. The
exception to this is in the legs due to the gravid uterus impeding venous return.
Regional blood flow
A s blood volume increases with gestation, a substantial proportion (10–20%) is
distributed to the uteroplacental unit. Renal vasodilatation early in pregnancy initiated
prior to implantation in the luteal phase (Gordon 2012) results in a dramatic increase
in renal blood flow and glomerular filtration rate which facilitates efficient excretion.
As a percentage of total cardiac output blood flow to the brain, coronary arteries and
liver is reduced, the overall increase in cardiac output compensates for this and the
blood flow to these regions is not significantly changed. Pulmonary blood flow
increases secondary to the increase in cardiac output, further facilitated by reduced
pulmonary vascular resistance. Blood flow in the lower limbs decelerates in late
pregnancy by compression of the iliac veins and inferior vena cava by the enlarging
uterus and the hydrodynamic effects of increased venous return from the uterus.
Reduced venous return and increased venous pressure in the legs contributes to the
increased distensibility and pressure in the veins of the legs, vulva, rectum and pelvis,
leading to dependent oedema, varicose veins of the legs, vulva and anus (see Box 9.2).
These changes are more pronounced in the left leg due to compression of the left iliac
vein by the overlying right iliac artery and the ovarian artery, accounting for 85% of
venous thrombosis in pregnancy occurring in the left leg (Nelson-Piercy 2009).
Box 9.2
Va ricosit ie s
Varicosities develop in approximately 40% of women, and are usually seen
in the veins of the legs, but may also occur in the vulva and as
haemorrhoids in the anal area.
The effects of progesterone and relaxin on the smooth muscles of the
vein walls and the increased weight of the growing uterus all contribute to
the increased risk of valvular incompetence. A family tendency is also a
factor (Blackburn 2012).
S ome suggestions for alleviating them include: spraying the legs with hot
and cold water, resting with the legs elevated and wearing supportive
stockings.
A rise in temperature by 0.2–0.4 °C occurs as a result of the effects of progesterone
and the increased basal metabolic rate (BMR). To eliminate the excess heat produced
there is an increased blood flow to the capillaries of the mucous membranes and skin,
particularly in the hands and feet. This peripheral vasodilatation explains why
pregnant women are often heat-intolerant: more prone to perspire, to nasal congestion
and to nosebleeds.
Haematological changes
I n parallel with the 30–45% increase in maternal blood volume, plasma volume
increases by 50% (1250–1600 ml) over the course of the pregnancy (Monga 2009),
followed by a relatively smaller increase in red blood cell volume (Table 9.4). These
changes are responsible for the hypervolaemia of pregnancy leading to numerous
modifications to parameters commonly assessed in blood tests (Table 9.5). Changes
are detectable at 6–8 weeks. I n pregnancy, plasma volume, placental mass and fetal
birth weight positively correlate with these changes (Rasmussen and Yaktine 2009).
Excessive increases in plasma volume have been associated with multiple pregnancy,
prolonged pregnancy, maternal obesity and large for gestational age babies, while
inadequate increases have been associated with pre-eclampsia.
Table 9.4
Key haematological changes in pregnancy
Source: Llewellyn-Jones 2010
Table 9.5
Normal values in pregnant/non-pregnant women
Source: Ramsay 2000
Red cell mass (the total volume of red cells in circulation) increases during
pregnancy by approximately 18% in response to increased levels of erythropoietin
stimulated by maternal hormones (prolactin, progesterone, human placental lactogen
and oestrogen) and oxygen requirements of maternal and placental tissue
(Cunningham et al 2010). This homeostatic mechanism is discrete from that which
controls fluid balance and increased plasma volume. Therefore, in spite of the
increased production of red blood cells, the marked increase in plasma volume causes
dilution of many circulating factors. A s a result the red cell count, haematocrit and
haemoglobin concentration all decrease, resulting in apparent anaemia, characteristic of
a healthy pregnancy (Fig. 9.5). This trend reverses towards term as red cell mass
continues to increase after 30 weeks when the plasma volume expansion has
plateaued. The disproportionate increase in plasma volume is advantageous: i.e. by
reducing blood viscosity, resistance to blood flow is reduced leading to improved
placental perfusion and reduced maternal cardiac effort (Cunningham et al 2010).
FIG. 9.5 Key haematological changes in pregnancy. Data from Cunningham et al 2010.
Red blood cells become more spherical with increased diameter due to the fall in
plasma colloid pressure encouraging more water to cross the erythrocyte cell
membrane. Mean cell volume (MCV) also increases due to the higher proportion of
young larger red blood cells (reticulocytes). The exact increase in red cell mass remains
inconclusive, partly because assessments have been influenced by routine iron
medication.
W hile total haemoglobin increases from 85 to 150 g the mean haemoglobin
decreases. I n healthy women with adequate iron stores this reduces by about 20 g/l
from an average of 133 g/l in the non-pregnant state to 110 g/l in early pregnancy. I t is
at its lowest at around 32 weeks' gestation when plasma volume expansion is maximal,
and after this time rises by approximately 5 g/l, returning to 110 g/l around the 36th
week of pregnancy. A haemoglobin level below 105 g/l at 28 weeks should be
investigated (N ational I nstitute for Health and Clinical Excellence [N I CE] 2008 ) (see
Chapter 13).
Iron metabolism
I ron requirements increase significantly in pregnancy, with estimates for the total iron
requirements of pregnancy ranging from 500 to 1150 mg (Cao and O'Brien 2013). W hile
there is an initial net saving from amenorrhoea, in late pregnancy iron requirements
increase dramatically to 3–8 mg iron/day. A bout 500 mg are required to increase the
maternal red blood cell mass, 300 mg are transported to the fetus, while the remaining
200 mg are utilized in compensating for insensible loss in skin, stool and urine. I n
spite of the moderate increase in iron absorption from the gut, woman require an iron-
rich diet and have approximately 500 mg of stored iron prior to conception to
accommodate the requirements of pregnancy. S ince this amount is not available from
body stores in most women, the red cell volume and haemoglobin level decrease with
the rising plasma volume.
Many women conceive with insufficient iron reserves, but research to date has not
fully established the benefits and drawbacks of iron supplementation or the optimal
biomarkers for interpreting circulating iron status. In spite of this apparent imbalance,
even with severe maternal iron deficiency anaemia, the placenta is able to provide
sufficient iron from maternal serum for fetal production of haemoglobin. Hepcidin has
recently been identified as a key hormone in the homeostasis of maternal, placental
and fetal iron levels and studies have identified the differential metabolism of haem
a n d non-haem sources in pregnancy (Young et al 2012). Furthermore the impact of
neonatal iron status on long-term health is only recently being fully appreciated and
warrants further study (Cao and O'Brien 2013).
Plasma protein
Haemodilution leads to a decrease in total serum protein content within the first
trimester which remains reduced throughout pregnancy. D espite oestrogen reducing
the transcapillary escape rate of albumin, concentration declines abruptly in early
pregnancy and then more gradually (see Table 9.5). A lbumin is important as a carrier
protein for hormones, drugs, free fa y acids and unconjugated bilirubin, and its
influence in decreasing colloid osmotic pressure. A 10–15% fall in colloid osmotic
pressure allows water to move from the plasma into the cells or out of vessels, and
plays a part in the increased fragility of red blood cells and oedema of the lower limbs
(N elson-Piercy 2009). I t is now accepted that peripheral oedema in the lower limbs in
late pregnancy is a feature of physiological, uncomplicated pregnancy.
Clotting factors
I n pregnancy, adaptations occur in the coagulation system to protect the woman from
peripartum haemorrhage while also maintaining the uteroplacental interface. The
cumulative effect of these is commonly described as the characteristic hypercoagulable
state of pregnancy. The increased tendency to clot is caused by increases in clo ing
factors and fibrinogen accompanied by reduced plasma fibrinolytic activity and an
increase in circulating fibrin degradation products in the plasma. D ue to these
changes pregnant women have a five-to six-fold increased risk for thromboembolic
disease (Gordon 2012).
From 12 weeks' gestation there is a 50% increase in synthesis of plasma fibrinogen
concentration (Factor I ) rising to 200% pre-pregnancy levels at term (Thornton and
D ouglas 2010). This is critical for the prevention of haemorrhage at the time of
placental separation. The development of a fibrin mesh to cover the placental site to
control the bleeding requires 5–10% of all the circulating fibrinogen. W hen this
process is impaired, for example by inadequate uterine action or incomplete placental
separation, compounded by placental blood flow of up to 700 ml/min at term, there is
rapid depletion of fibrinogen reserves, putting the woman at risk of haemorrhage.
Coagulation factors VI I , VI I I and X increase in pregnancy, while factors I
(prothrombin) and V remain constant or show a slight fall. Both the prothrombin time
(normal 10–14 secs) and the partial thromboplastin time (normal 35–45 secs) are
slightly shortened as pregnancy advances. The clo ing times of whole blood, however,
are not significantly different in pregnancy to non-pregnant values. The platelet count
declines slightly as pregnancy advances, which is explained by haemodilution and
increased consumption in the uteroplacental circulation. The increased production of
platelets results in a slight increase in mean platelet volume (MPV), which is due to
immature platelets being larger than old ones resulting in an overall increase in
average size. S ubstantial increases in MCV could indicate excessive platelet
consumption and is often used as a marker for hypertensive disease.
A decrease in some endogenous anticoagulants (antithrombin, protein S and
activated protein C resistance) occur in pregnancy along with the physiological
vasodilatation of pregnancy, this contributes to a six-fold increase in the risk of
thromboembolism in pregnancy (Nelson-Piercy 2009).
White blood cells (leucocytes) and immune function
Pregnancy presents a paradox for the woman's immune system as the mechanisms
that are essential to protect her from infection have the potential to destroy the
genetically disparate conceptus. I t is clear that the immunological relationship
between the mother and the fetus involves a two-way communication involving fetal
antigen presentation and maternal recognition of and reaction to these antigens by the
immune system (Chen et al 2012). There is evidence that progesterone plays a major
role in the immunological tolerance seen in pregnancy.
The total white cell count rises from 8 weeks' gestation and reaches a peak at 30
weeks. This is mainly because of the increase in numbers of neutrophil
polymorphonuclear leucocytes, monocytes and granulocytes, the la er two producing
a far more active and efficient phagocytosis function. This enhances the blood's
phagocytic and bactericidal properties. N umbers of eosinophils, basophils,
monocytes, lymphocytes and circulating T cells and B cells remain relatively constant.
Lymphocyte function is depressed, and natural killer cytokine activity is reduced
regulated by progesterone, particularly in the latter stages of pregnancy. Chemotaxis is
suppressed resulting in a delayed response to some infections. There is decreased
resistance to viral infections such as herpes, influenza, rubella, hepatitis, poliomyelitis
and malaria. The metabolic activity of granulocytes increases during pregnancy,
possibly resulting from the stimulation of rising oestrogen and cortisol levels (Gordon
2012).
The maternal immune response is biased toward an enhancement of innate
(humoral) immunity and away from cell-mediated response that could be harmful to
the fetus. The stimulus for these changes is predominantly hormonal involving
progesterone, human placental lactogen (hPL), prostaglandins, corticosteroids, human
chorionic gonadotrophin (hCG), prolactin and serum proteins.
Changes in the respiratory system
To accommodate increased oxygen requirements and the physical impact of the
enlarging uterus intricate changes occur in respiratory physiology. These are mediated
by an interaction of hormonal, biochemical and mechanical factors and are
summarized in Table 9.6. Progressive increases in maternal and fetal metabolic
demands are reflected in a marked increase in resting oxygen consumption reaching a
20–30% peak from non-pregnant values at term.
Table 9.6
Summary of changes in respiratory function
Source: Nelson-Piercy 2009
The driving force for change is the respiratory stimulatory effect of progesterone
initiating hyperventilation by increasing sensitivity to carbon dioxide through
lowering the threshold at which the respiratory centre is stimulated (Jensen et al 2009).
O vercompensation to respiratory demand causes arterial oxygen tension to increase
and arterial carbon dioxide tension to decrease, accompanied by a compensatory
decline in serum bicarbonate; mild respiratory alkalosis is consequently
physiologically normal in pregnancy (Bobrowski 2010) (see Box 9.3).
Box 9.3
B re a t hle ssne ss
The respiratory changes can be extremely uncomfortable and may lead to
dyspnoea, dizziness and altered exercise tolerance. Up to 75% of pregnant
women with no underlying pre-existing respiratory disease experience
some dyspnoea, possibly due to an increased awareness of the
physiological hyperventilation (N elson-Piercy 2009). This physiological
dyspnoea often occurs early in pregnancy and does not interfere with daily
activities and usually diminishes as term approaches.
A lthough mechanical impediment by the uterus is often blamed,
hyperventilation is due to altered sensitivity to CO2. A lthough it is not
usually associated with pathological processes, care must be taken not to
dismiss this lightly and miss a warning sign of cardiac or pulmonary
disease (Hegewald and Crapo 2011).
Breathlessness can be alleviated by maintaining an upright posture and
holding hands above the head while taking deep breaths. W omen may
need to modify their physical activity levels to accommodate these
symptoms, however studies have shown that exercising in pregnancy can
help to alleviate them (Lewis et al 2010).
From early pregnancy, the overall shape of the chest alters as the anteroposterior
and transverse diameters increase by about 2 cm resulting in a 5–7 cm expansion of
the chest circumference. The lower ribs flare outwards prior to any mechanical
pressure from the growing uterus. This progressively increases the subcostal angle,
from 68° in early pregnancy to 103° at term (Fig. 9.6). A lthough the expanding uterus
causes the diaphragm to rise by up to 4 cm above its usual resting position,
diaphragmatic movement during respiration is not impaired as chest wall mobility
increases and lower ribs flare, increasing the thoracic space. Changes are mediated by
progesterone and relaxin which increase ribcage elasticity by relaxing ligaments in a
similar mechanism to that occurring in the pelvis. I nspiratory and expiratory
maximum pressures appear to remain stable throughout pregnancy. Lemos et al (2010)
have suggested that the stretching of the muscles involved in ventilating the lungs is
accompanied by the significant addition of sarcomeres (the basic unit of a muscle),
thereby maintaining muscle strength. Progesterone also facilitates bronchial and
tracheal smooth muscle relaxation, thereby reducing airway resistance. This improves
air flow and explains why the health of women with existing respiratory problems
rarely deteriorates in pregnancy.
FIG. 9.6 Displacement of the ribcage in pregnancy (dark) and the non-pregnancy state (light)
showing elevated diaphragm, the increased transverse diameter and circumference, flaring out of
ribs and the increased subcostal angle. From de Swiet M 1998 The respiratory system. In: Chamberlain G,
Broughton Pipkin F (eds) Clinical physiology in obstetrics, 3rd edn. Blackwell Science, Oxford, p 115, with
permission from Wiley Publishing Ltd.
Expansion of the rib cage causes the tidal volume to increase by 30–40% gradually
rising from approximately 8 weeks' gestation to term (Jensen et al 2009). S tudies report
that the normal respiratory rate of 14–15 breaths/min may demonstrate minimal
increase in pregnancy, though pregnant women do breathe more deeply, even at rest.
T h e minute volume that facilitates gas exchange is increased by 30–40%, from 7.5–
10.5 l/min, and minute oxygen uptake increases appreciably as pregnancy advances
(Cunningham et al 2010). The enhanced tidal volume contributes to an increase in
inspiratory capacity while vital capacity is unchanged. A s a result, the functional
residual capacity is decreased by 20%. This reduces the amount of used gas mixing with
each new inspiration thereby enhancing alveolar gas exchange by 50–70%. W hile
making ventilation more efficient this may result in rapid falls in arterial oxygen
tension even with short periods of apnoea which is further compounded by the
reduced buffering capacity. W hether from obstruction of the airway or inhalation of a
hypoxic mixture of gas the consequence of these adaptations is that pregnant women
have less reserve if they become hypoxic.
Blood volume expansion and vasodilatation of pregnancy result in hyperaemia and
oedema of the upper respiratory mucosa, which predispose the pregnant woman to
nasal congestion, epistaxis and even changes in voice. The changes to the upper
respiratory tract may lead to upper airway obstruction and bleeding making both
mask anaesthesia and tracheal intubation more difficult. These can be further
exacerbated by fluid overload or oedema associated with pregnancy-induced
hypertension or pre-eclampsia.
Blood gases
Changes in respiratory function result in a state of compensated respiratory alkalosis.
A rterial oxygen partial pressure (PaO2) is slightly increased from non-pregnant values
(98–100 mmHg) to pregnant values of (101–104 mmHg). I n addition, the
hyperventilation of pregnancy causes a 15–20% decrease in maternal arterial carbon
dioxide partial pressure (PaCO2) from an average of 35–40 mmHg in the non-pregnant
woman to 30 mmHg or lower in late pregnancy. Because fetal PaCO2 is 44 mmHg these
changes not only safeguard adequate oxygenation but also maintain an exaggerated
carbon dioxide gradient from fetus to mother. This facilitates the transfer of CO2 from
the fetus to the mother and the subsequent expiration of CO2 from the maternal lungs.
I t is important that clinicians consider these changes when undertaking assessment of
maternal blood gases. A PaCO2 of 35–40 mmHg which might ordinarily be considered
borderline low is markedly abnormal in a pregnant woman and can even represent
impending respiratory failure (Nelson-Piercy 2009).
The body has a considerable capacity for storing carbon dioxide in blood, largely as
bicarbonate. To compensate, renal excretion of bicarbonate is significantly increased
which may limit the buffering capacity in pregnancy. The fall in PaCO2 is matched by
an equivalent fall in plasma bicarbonate concentration. A lthough maternal arterial pH
changes very li le, the resulting mild alkalaemia (arterial pH 7.40–7.45) further
facilitates oxygen release to the fetus.
Changes in the central nervous system
A daptations of the central nervous system (CN S ) are probably the least well
understood compared to other body systems. The adaptive changes encompass
diverse scientific disciplines, including neuroendocrinology, neuroscience, physiology
and psychology such that failure of adaptation can lead to disorders that have
profound and long lasting consequences for the woman. Russell et al (2001) affirm that
the hormonal fluctuations occurring throughout pregnancy may remodel the female
brain, increasing the size of neurones in some regions and producing structural
changes in others. These manifest in various ways, e.g. the substantial increase in size
and activity of the pituitary gland by 30–50%.
A daptations in neural circuitry in the maternal brain are initiated by pregnancy
hormones. O estrogen and progesterone readily enter the brain to act on nerve cells
changing the balance between inhibition and stimulation. O ther pregnancy hormones,
such as relaxin, prolactin and lactogen, also have an impact. Progression of pregnancy
is signalled to the brain by the pa ern of secretion of these hormones culminating in a
complex interplay of communications between the mother and fetoplacental unit.
Up to 80% of pregnant women report symptoms of ‘baby brain’. There is growing
evidence that fetal microchimeric cells participate in the maternal response to injury.
A lthough it is known that hormonal changes during pregnancy can affect
neurogenesis, there is no substantive evidence that pregnancy itself influences certain
areas in the brain into being more receptive for fetal cells. Consequently, Tan et al
(2011) suggest that further studies are required to determine whether there is any
biological significance to this.
A pregnant woman's sleep pa ern can be affected by both mechanical and
hormonal influences. These include nocturia, dyspnoea, nasal congestion, stress and
anxiety as well as muscular aches and pains, leg cramps and fetal activity (see Box 9.4).
Box 9.4
S le e p dist urba nce s
Various hormonal and mechanical influences promote insomnia leading to
disturbed sleep during pregnancy, i.e. sleep fragmentation with greater
amounts of light sleep and fewer periods of deep sleep. These disturbances
tend to worsen as pregnancy advances, with up to 90% of women reporting
frequent night awakenings (Wilson et al 2011) that for some continue
postpartum. A s a consequence, sleep disturbance has been associated with
increased labour length and caesarean section rates and may also
contribute to the tendency for some women becoming depressed
postpartum compared to other periods in their life (Goyal et al 2007).
I nterventions include establishing sleep–wake habits, avoiding caffeine,
relaxation techniques, massage, heat and support for lower back pain,
modifying sleep environment, limiting fluids in the evening and avoiding
passive smoking. S leep medications should be avoided, although psycho-
educational interventions are being explored as a potentially affective
alternative (Kempler Sharp et al 2012).
Changes in the urinary system
The striking anatomical and physiological changes occurring in the urinary system are
critical for an optimal pregnancy outcome. S ystemic vasodilatation in the first
trimester and an increase in blood volume and cardiac output results in a massive
vasodilatation of the renal circulation that increases the renal plasma flow (RPF)
(Baidya et al 2012). A ccording to Pipkin (2012), there is an 85% increase in RPF above
non-pregnant values after 6 weeks' gestation; this falls in the second trimester to about
65%.
I n a healthy pregnancy the kidneys lengthen by up to 1.5 cm and kidney volume
increases by as much as 30% (A bduljalil et al 2012). Growth is less in the right kidney
due to its proximity to the liver and greater in the left kidney due to increased blood
supply via the shorter left renal artery (Ugboma et al 2012). D ilatation of the renal
pelvis and ureters (hydronephrosis of pregnancy) with reduced peristalsis starts as early
as 7 weeks' gestation, peaks at between 22 and 26 weeks and by the third trimester is
marked in approximately 90% of women. I t is due to relaxation of the smooth muscle
of the urinary collecting system under the influence of progesterone (Pepe and Pepe
2013). Hydronephrosis is usually only present above the pelvic brim due to
compression and lateral displacement of the ureters after the uterus rises out of the
pelvis. D ilatation is asymmetric, being greater on the right side due to dextrorotation
of the uterus and dilatation of the right ovarian vein complex, and less on the left side
due to the cushioning effect of the sigmoid colon. The ureters also become longer and
are thrown into single or double curves of various sizes (Cunningham et al 2010).
D ilated ureters with reduced peristalsis and mechanical obstruction by the enlarged
uterus all contribute to urinary stasis leading to the increased risk of urinary tract
infection in pregnancy. More than 200 ml of urine can collect in the ureters serving as
an excellent reservoir for pathogenic bacteria (A nsari and Rajkumari 2011) (Fig. 9.7)
( s e e Chapter 13). O ther factors that increase the potential for colonization and
susceptibility for ascending infection are alkaline urine, increased bladder volume,
reduced detrusor tone, vesico-ureteric reflux and dysfunctional ureteric valves.
Glucose excretion in the urine which increases in pregnancy 100-fold due to the
increased glomerular filtration rate (GFR) also provides an excellent medium for
bacterial proliferation (see Box 9.5).
FIG. 9.7 Changes in urinary tract in pregnancy and the factors predisposing women to urinary
tract infection in pregnancy.
Box 9.5
A sym pt om a t ic ba ct e riuria
A symptomatic bacteriuria is defined as the presence of more than 100 000
organisms per ml in two consecutive urine samples in the absence of
declared symptoms. It occurs in 2–10% of the pregnant population.
I f not treated, up to 20% of women will develop a lower urinary tract
infection (UTI ) and the condition will develop into pyelonephritis in 30% of
pregnant women if not properly treated (A sali et al 2012; Law and Fiadjoe
2012).
I t is usually caused by Escherichia coli (E. coli) and has been associated
with adverse pregnancy outcomes such as preterm birth, miscarriage and
pregnancy-induced hypertension.
S ignificant anatomical changes also occur in the bladder. The blood vessels in the
mucosa increase in size and become more tortuous. A fter 12 weeks' gestation the
bladder trigone is elevated causing thickening of the posterior margin due to the
increased uterine size, hyperaemia of all pelvic organs and hyperplasia of the bladder
muscle and connective tissues. The trigone becomes deeper and wider as pregnancy
progresses leading to reduced bladder capacity. To compensate for this the urethra
lengthens by about 0.5 cm and the bladder tone increases to help maintain continence
(Cunningham et al 2010). I n spite of this, urinary incontinence can be troublesome in
pregnancy (see Box 9.6).
Box 9.6
U rina ry incont ine nce
Up to 46% of pregnant women admit to experiencing symptoms of urinary
incontinence, which tend to become more prevalent as pregnancy
progresses The most common type is stress urinary incontinence (S UI ), due
mostly to multiparity, age and raised body mass index (BMI).
Pelvic floor exercises are the most important means of managing urinary
incontinence (Law and Fiadjoe 2012).
U rinary hesitancy may occur in up to 27% of women in the first two
trimesters of pregnancy. Urodynamic studies have shown that 8% of
pregnant women may develop detrusor overactivity, with 31% showing
decreased compliance (Fiadjoe et al 2010).
A s the uterus enlarges the bladder becomes distorted and is drawn upwards
anteriorly, becoming an abdominal organ by the third trimester (Fiadjoe et al 2010).
W hen engagement of the head takes place in the primigravida the base of the bladder
is pushed forward and upward converting the normal convex surface into a concavity
that complicates diagnostic tests. The pressure of the presenting part impairs drainage
of blood and lymph from the bladder base causing oedema and greater susceptibility
to trauma and infection (Cunningham et al 2010).
A s a result of renal vasodilatation and increased RPF, the GFR increases by 25% by
the second week after conception and by 45% by the 9th week, only rising thereafter by
another 5–10%, from which it remains elevated until term. The filtered load of
metabolites increases markedly and tubular reabsorption is unable to compensate.
This has a profound effect on the concentration of certain plasma metabolites (Pipkin
2012).
Creatinine clearance, which measures glomerular filtration, is one of the main
physiological parameters of renal function (A bduljalil et al 2012). I t increases
significantly by 4 weeks, peaks at 9–11 weeks and then is sustained until the 36th week
of gestation after which it reduces by 15–20%. A s renal clearance of creatinine and
urea increases plasma levels decrease from 70 µmol/l and 5 µmol/l respectively in the
non-pregnant woman to mean values of 50 µmol/l and 3 µmol/l before rising again
near term. D ue to the increased GFR there is also increased uric acid clearance. A s
tubular reabsorption of uric acid is decreased, serum uric acid concentration falls by
about 25% in early pregnancy but during the second half of pregnancy it rises again as
the kidney excretes a progressively smaller proportion of filtered uric acid. Thus
normal laboratory reference ranges may reflect renal impairment in a pregnancy
(Pipkin 2012).
D ue to the changes in glomerular permeability and altered tubular reabsorption
proteinuria is common in pregnancy, with increases of 300 mg per day being
considered normal (Baidya et al 2012). Urinary calcium excretion is also two to three
times higher in pregnancy even though tubular reabsorption is enhanced. To counter
this, intestinal absorption doubles by week 24, after which it stabilizes. Although there
is an increased filtration of potassium in pregnancy, Pipkin (2012) purports that it is
reabsorbed effectively in the renal tubules.
The increased GFR also causes an increased filtration of glucose. Tubular capacity to
reabsorb glucose is decreased, resulting in a 10-fold increase in glucose excretion
(Baidya et al 2012). A s a consequence, glycosuria can be detected in around 50% of
pregnant women. Clinicians should be aware that although glycosuria may be
common in pregnancy, it should not be overlooked as some women may have diabetes
mellitus (Cunningham et al 2010).
By day an increased urinary output leads to frequency and urgency of micturition
affecting 81% of women by the third trimester. The accumulation of oedema in the
lower extremities by day is reabsorbed more quickly at night, particularly in the lateral
recumbent position, resulting in increased diuresis at night with more dilute urine by
the third trimester in up to 66% of pregnant women.
Changes in the gastrointestinal system
A natomical and physiological changes take place in each organ of the gastrointestinal
system. I nfluenced by oestrogen and progesterone the gums become highly
vascularized, oedematous, have less resistance to infection and are more easily
irritated. Bleeding and tender gums are commonly reported by women in pregnancy
and can be a sign of periodontal disease. Minor trauma or inflammation occurring in
the presence of bacterial plaque can lead to gingivitis. This can develop into a localized
hyperplasia known as pyogenic granuloma or pregnancy epulis, a benign vascular lesion
of the skin and mucosa occurring in up to 10% of pregnant women (S aravanan et al
2012). S uch a lesion is purplish-red to pink in colour and is a reactive inflammatory
mass of loose granulation tissue rich in capillary vessels, endothelial and
inflammatory cells situated between the upper maxillary teeth. I t is usually painless
but may ulcerate due to trauma and become painful. A lthough the lesion normally
regresses postpartum, it may recur in the same place in subsequent pregnancies. I n a
minority of cases, surgical excision may be required.
Peridontal infections occur more frequently in women who smoke or who have
diabetes. W hether suppurative and painful or silent they will lead to loss of bone
support for the teeth (S aravanan et al 2012). A lthough there is li le evidence that
dental caries increases more rapidly during pregnancy, good oral and dental hygiene
consisting of brushing and flossing during pregnancy is essential for the overall health
of mother and baby (Kloetzel et al 2011; Kumar et al 2013). The fetus draws the calcium
required from the maternal skeleton rather than the systemic circulation. I t is the
increased acidity of the saliva in pregnancy which predisposes temporarily to dental
caries and erosion (see Box 9.7). A more acidic oral environment develops as a result of
dietary changes, the urge to snack frequently, increased consumption of
carbohydrates, substance misuse, poor oral hygiene and an increase in the frequency
of vomiting. The higher incidence of untreated decay and teeth extraction in the grand
multigravida may relate more to socio-behavioural causes rather than biological
(Russell et al 2010). I t is recommended by D etman et al (2010) that improved oral
health education is required to remove persisting misconceptions about dental care in
pregnancy.
Box 9.7
P t ya lism
Ptyalism is the excessive production of saliva throughout pregnancy. I ts
cause is unknown but progesterone and/or hCG may be responsible for the
increased viscosity which reduces with advancing gestation. Gastric acid is
also thought to affect the volume of saliva.
Ptyalism causes a bad taste in the mouth and women complain that
swallowing the excessive or thickened saliva perpetuates a sense of nausea
and that they need to spit it out. Ptyalism may either diminish during sleep
or cause the woman to waken more frequently at night. I f associated with
hyperemesis gravidarum it may continue until term.
Central nervous system depressants (e.g. barbiturates), anticholinergics
(e.g. belladonna alkaloid), or phosphorylated carbohydrate have been
recommended to improve the woman's distress. Using gum or ice are
temporary coping strategies the woman can use. A lthough ptyalism has not
previously been considered a serious condition, it has recently been
postulated that it may lead to adverse perinatal outcomes (S uzuki and Fuse
2013).
Upper gastrointestinal symptoms complicate the majority of pregnancies, with most
women complaining of either heartburn, nausea and vomiting of pregnancy or both.
N ausea and vomiting of pregnancy is experienced by 70–85% of pregnant women and
many feel that their distressing symptoms are trivialized (N aumann et al 2012) (see
Box 9.8).
Box 9.8
N a use a a nd vom it ing
N ausea and vomiting (morning sickness) has varying levels of severity and
has far-reaching effects for some women in terms of ability to carry out day-
to-day tasks, care for children and take part in full-time employment.
S ymptoms usually begin in the 4th week of pregnancy with a marked
increase between 5 and 10 weeks when hCG levels are at their highest,
followed by a steady decline until 20 weeks (Jarvis and Nelson-Piercy 2011).
N ausea and vomiting is associated with enlarged placental size with
increased amounts of hCG that occurs in the female fetus, multiple
pregnancy or hydatidiform mole. I t is more prevalent in younger women,
multigravida, multiple pregnancies, alcohol use during pregnancy
(N aumann et al 2012) or those with eating disorders. However, it has been
suggested that nausea and vomiting is a protective mechanism against the
ingestion of harmful substances.
The possible causes are varied and include: genetic, cultural, endocrine,
environmental and psychosocial factors as well as reduced gastric
oesophageal pressure and delayed gastric emptying due to the effects of
progesterone (Jarvis and Nelson-Piercy 2011).
Pregnancies complicated by nausea and vomiting are less likely to result
in miscarriage (J arvis and N elson-Piercy 2011). I t does not appear to
adversely affect the fetus and no significant difference has been found in
birthweight, gestational age, or premature birth (N aumann et al 2012).
There is currently limited evidence in the form of RCTs to demonstrate the
effectiveness of various treatments which makes it difficult for
professionals to offer clear guidance (Ma hews et al 2010). W omen should,
however, be advised of the lower level evidence demonstrating
considerable relief of nausea and vomiting with vitamin B6 (Koren et al
2011).
A cascade of complex interacting factors, including hormones, is thought to
influence the hypothalamic control of food and the pregnancy-induced increase in
appetite. However, women often eat significantly more than is required. Riley (2011)
affirms that excessive weight gain is associated with higher fetal birthweights and
postpartum weight retention.
O ral and olfactory cravings and aversions in pregnancy are well documented but
much of the data is conflicting, making conclusions about their cause difficult.
Cravings and aversions vary between high- and low-income countries. Common
cravings are fruit, strongly flavoured or savoury food, liquorice, potato crisps, cheese
and milk. Common aversions are tea and coffee, fried foods, eggs and sweet foods
later in pregnancy (Patil and Young 2012). I nvestigation into cravings and aversions is
required since there is increasing evidence that some micronutrients in early
pregnancy can influence postnatal development of obesity and chronic diseases
(Weigel et al 2011) . Pica, which describes persistent eating of non-food substances
such as earth, chalk or soap, occurs frequently in pregnancy but should not be
diagnosed unless it is of unusual extent or causes health concerns (see Box 9.9).
Box 9.9
P ica
Pica is the persistent craving and compulsive consumption of substances
such as ice, clay, soap, coal or starch. I t has been reported to be as high as
74% in Kenya but as low as 0.02% in Denmark.
The consequences for mother and baby remain unknown (López et al
2012). However, if lead enters the bloodstream due to pica in pregnancy
following previous exposure, the elevated maternal lead levels are
associated with significant risks for mother and baby. I mmigrant women
are at particular risk of this and they should therefore be screened
antenatally for potential prior exposure to lead in their country of origin
(Alba et al 2012).
The increased abdominal pressure due to the enlarging uterus causes a shift in
pressure gradient between the abdomen and the thorax (Bredenoord et al 2013). The
angle of the gastro-oesophageal junction is altered and the lower oesophageal
sphincter is displaced into the negative pressure of the intrathoracic cavity. These
mechanical changes, along with the relaxing effects of progesterone which reduces
gastrointestinal transit, all contribute to the reflux of gastric contents into the lower
oesophagus leading to heartburn (Naumann et al 2012) (see Box 9.10).
Box 9.10
H e a rt burn
Up to 85% of pregnant women experience heartburn in pregnancy.
Troublesome symptoms of retrosternal and epigastric pain, regurgitation
and acid taste in the mouth can all affect the woman's quality of life.
I ncreasing gestational age, heartburn before pregnancy and multiparity
may also predispose women to gastro-oesophageal reflux in pregnancy
which usually resolves after the birth of the baby (Katz et al 2013).
I n most pregnant women reflux symptoms can be managed by lifestyle
modifications such as small frequent meals, not eating or drinking late at
night, sleeping semi-recumbent or on the left side, avoiding food and
medication causing reflux, chewing gum and abstinence from alcohol and
tobacco.
I ntermi ent use of antacids such as Gaviscon® (Recki Benckiser),
metoclopramide, sucralfate and H2 receptor blockers (ranitidine) are all safe
to use in pregnancy (Cuckson and Germain 2011). For women with severe
symptoms, a proton pump inhibitor (PPI) such as omeprazole should be the
treatment of choice as it is the most effective, with no safety concerns for
the fetus.
Gastric acid production is reduced in pregnancy secondary to increased levels of
progesterone. The gastric pH and volume in pregnant and non-pregnant women show
no differences in the proportion of women meeting at risk criteria (pH <2.5, volume
>25 ml) for pulmonary aspiration of gastric contents. I n addition, studies using serial
gastric ultrasound examinations have demonstrated no change in gastric emptying in
healthy pregnant women throughout all trimesters compared with non-pregnant
women (A bduljalil et al 2012). The risk of aspiration in pregnant women, however, is
still increased because of the reduced pressure at the lower oesophageal sphincter
(Reitman and Flood 2011).
Progesterone combined with the pressure of the gravid uterus on the rectosigmoid
colon decreases motility of the small intestine and colon and increases transit time in
the second and third trimesters. This leads to frequent complaints of bloating and
abdominal distension (see Box 9.11), constipation and haemorrhoids (see Box 9.12).
Box 9.11
A bdom ina l dist e nsion
A bdominal distension and a bloated feeling occur when nutrients and
fluids remain in the intestinal tract for longer, particularly in the third
trimester due to the prolonged transit time. I ncreased flatulence may also
occur due to decreased motility and pressure of the uterus on the bowel
(Blackburn 2012). The increased sodium and water absorption secondary to
the increased aldosterone levels during pregnancy leads to reduced stool
volume and further prolonged colonic transit time The functional changes
that occur with the enlarging uterus may mechanically limit colonic
emptying, which is probably the main reason for constipation in late
pregnancy.
Box 9.12
C onst ipa t ion a nd ha e m orrhoids
Constipation affects up to 40% of pregnant women, further exacerbated by
factors such as dehydration, poor dietary intake, opiate analgesia and iron
supplements. Treatment consists of non-pharmacological measures such as
increased fluid intake and dietary fibre and temporary cessation of oral iron
(Cuckson and Germain 2011).
There are no definitive guidelines on laxative prescribing in pregnancy,
but the British N ational Formulary (2013) suggests that if dietary and
lifestyle measures fail, bulk-forming laxatives should be prescribed first,
then an osmotic laxative such as lactulose or macrogols (polyethylene
glycols), followed by a stimulant such as senna if required.
Constipation indirectly predisposes to the development of haemorrhoids,
which occur in up to 85% of women in late pregnancy. Haemorrhoids are
varicosities of the anal and perianal venous plexus. They are caused by the
rise in intra-abdominal pressure and restriction of venous return in the
lower extremities and pelvis due to the enlarging uterus and the resulting
venous stasis, stagnation of blood and arteriovenous shunting in the
compressed rectal veins.
Pregnancy may be the first time that haemorrhoids become symptomatic,
presenting with pain, bleeding and irritation. For many women symptoms
will resolve soon after the birth but for others it may become worse.
Treatment consists of the correction of constipation and the application of
topically applied local anaesthetic, anti-inflammatory or emollient creams
and suppositories. I n more severe cases oral flavonoids or phlebotonics
may be beneficial for strengthening and improving the tone of blood vessel
walls. O ccasionally surgery may be required (Avsar and Keskin 2010; Perera
et al 2012).
I dentifying the position of the appendix in the later stages of pregnancy can be
challenging due to anatomical alterations. The enlarging uterus displaces the appendix
and caecum superiorly to the level of the liver and laterally to the right upper quadrant
of the abdomen. The tip of the appendix may be close to the right flank in late second
trimester and consequently localizing the pain of appendicitis can be difficult. As Wild
et al (2013) conclude, clinicians should be mindful that the gravid uterus often leads to
atypical presentations of appendicitis in pregnancy.
The gall bladder enlarges in pregnancy and emptying is slower due to reduced
motility. This promotes bile stasis and increased concentrated bile content which can
predispose to physiological cholestasis and pruritis (Abduljalil et al 2012; Pipkin 2012).
The large residual volume of bile is more saturated with cholesterol resulting in the
retention of cholesterol crystals and increased risk of gallstone formation, particularly
in the multigravida (Cuckson and Germain 2011).
Liver size is unchanged but by the third trimester it is forced into a more superior
posterior position to the right (J oshi et al 2010). I ncreased hepatic perfusion after 26
weeks' gestation is due to the increase in portal venous return (A bduljalil et al 2012).
Reference ranges for many liver function tests are altered and would be considered
abnormal in the non-pregnant woman. S erum albumin concentration falls due to
plasma volume expansion. Gestation-specific alkaline phosphatase rises due to
increased placental secretion, while aminotransferase and gamma-glutamyl
transaminase are reduced (Cuckson and Germain 2011) (see Table 9.5).
Changes in metabolism
A well-integrated metabolic shift is required by the woman to provide for the
increased physiological demands of pregnancy, labour and lactation, increased BMR,
increased cost of physical activity, and to ensure provision of adequate nutrients
critical for maintaining a healthy, viable and optimally growing fetus ( Hadden and
McLaughlin 2009). These adaptations are orchestrated within a few weeks of
conception by oestrogen and progesterone originating from the fetoplacental unit and
by prolactin and hPL from the maternal pituitary gland (Freemark 2010) (see Chapter
6). Energy metabolism changes during the course of pregnancy, differs considerably
between women and is influenced by body mass index (BMI ), maternal age, stage of
gestation, BMR and level of physical activity (B lumfield et al 2012). I n order to give
appropriate advice on diet and nutrition, clinicians should be aware of the religious
teachings and eating habits of immigrant women, particularly those from the I ndian
subcontinent where pregnant Muslim women are expected to observe total fasting
during Ramadam. Estimates of energy costs range from 80 000 kcal to an actual saving
of 10 000 kcal in different parts of the world (Hadden and McLaughlin 2009). With less
physical activity occurring in pregnancy, women should not eat for two. The Scientific
A dvisory Commi ee on N utrition (S A CN ) (2012)recommends that a daily increase of
191 kcal should be sufficient for most women during the last trimester of pregnancy.
The BMR increases during pregnancy because of the increased mass of metabolically
active tissues as well as new tissue synthesis which leads to increased oxygen
consumption, increased cardiac output and expansion of blood volume. Average
increases in BMR have been observed to be around 5% in the first trimester, 10% in the
second trimester and 25% in the third trimester (S A CN 2012). The increased maternal
BMR plus energy released by the developing fetus and uteroplacental unit lead to
changes in temperature regulation with increased heat production particularly in the
first trimester.
The changes in carbohydrate metabolism are the most dramatic of all. The
production of glucose from carbohydrate in the maternal diet increases while glucose
intolerance restricts its uptake to guarantee sufficient availability of glucose for the
fetus as its primary source of energy for cellular metabolism (McGowan and McAuliffe
2010). N ormally the maternal blood glucose is 10–20% higher than fetal blood glucose.
This gradient, along with resistance to the glucose-lowering effects of insulin, favours
transfer of a continuous, uninterrupted supply of glucose to the fetus through the
placenta by diffusion. I nsulin resistance is a normal physiological adaptation of
pregnancy manifest by a fasting plasma insulin that triples as pregnancy progresses
due to placental hormones (cortisol, growth hormone, hPL).
D uring early pregnancy increased levels of oestrogen and progesterone promote
pancreatic beta cell hyperplasia causing a rapid increase in insulin production. This
lowers plasma glucose by moving it into cells and by inhibiting hepatic glucose
release, but also reduces plasma amino acids and free fa y acids. These adjustments
result in a sparing of glucose for the fetus (Hadden and McLaughlin 2009).
Hyperinsulinaemia leads to a decline in fasting plasma glucose levels by 10–15%,
higher postprandial glucose values and increased uptake of glucose by muscles for
storage as glycogen, increased storage of fats and decreased lipolysis. Following a meal
containing glucose, pregnant women demonstrate prolonged hyperglycaemia,
hyperinsulinaemia and a greater suppression of glucagon, the purpose of which is to
ensure a sustained postprandial supply of glucose to the fetus (Hauth et al 2011). This
is followed by a progressive reduction in glucose resulting in relative fasting
hypoglycaemia known as accelerated starvation. O mi ing meals or prolonged periods
between food intake can provoke this condition, resulting in deleterious effects for
both woman and fetus, such that pregnancy is described as a diabetogenic state (Pipkin
2012).
N ormal glucose ranges during pregnancy are 3.4–5.5 mmol/l except immediately
after meals, when levels can rise to 6.5 mmol/l (McGowan and McAuliffe 2010). I n
response to a 75 g glucose load the recommendation by the I nternational A ssociation
of D iabetes and Pregnancy S tudy Groups Consensus Panel for cut-off points in the
diagnosis of gestational diabetes is a fasting glucose of 5.1 mmol/l, at 1 hour post
prandial a value of 10.0 mmol/l, and 8.5 mmol/l at 2 hours post prandial (Me ger et al
2010). I n late pregnancy when the rate of weight gain reduces, maternal energy
metabolism shifts from carbohydrate to lipid oxidation, thus further sparing glucose
for the fetus to ensure a continuous supply of fuel when its needs are greatest
(Herring et al 2012).
Complex changes take place in lipid metabolism during pregnancy influenced by
oestrogen, progesterone, hPL and insulin resistance. I ncreased lipid synthesis and
appetite in the first two trimesters of pregnancy lead to hyperlipidaemia, hypertrophy
of adipocytes and the accumulation of fat in maternal depots. A dipose tissue becomes
more responsive to insulin, which facilitates increased fat storage (Hadden and
McLaughlin 2009). I t is usual for women to build up an increased store of 2–5 kg fat
mainly in the second trimester (Abduljalil et al 2012).
Maternal tissue lipid is used as an energy source in order to spare glucose and
amino acids for the fetus. By 36 weeks fasting plasma triglycerides are two to four
times the pre-pregnancy level. Maternal hypertriglyceridaemia contributes to fetal
growth and development and serves as an energy depot for maternal dietary fa y
acids (Hadden and McLaughlin 2009). Cholesterol is also available for fetal use to
build cell membranes and as a precursor of bile acids and steroid hormones. Plasma
cholesterol levels decline slightly in early pregnancy and then rise steadily, as do other
lipids. Elevated free fa y acid levels have been associated with excess fetal adiposity
and childhood obesity (Hadden and McLaughlin 2009).
The protein intake of a pregnant woman is particularly important. A mino acids are
required by both woman and fetus for energy and growth (Hadden and McLaughlin
2009). A bout half the protein gained is deposited in the fetus and the remainder
accumulates in the placenta, uterine muscle, breast and other maternal tissues in late
pregnancy. In most cases total serum protein content reduces within the first trimester
due to increased placental uptake, increased insulin levels, diversion of amino acids
for gluconeogenesis and transfer of amino acids to the fetus for use in glucose
formation. By 20 weeks the mean serum albumin in healthy pregnant women
decreases from 46 to 38 g/l. This reduces the plasma oncotic pressure and predisposes
to oedema. Following a meal the amino acid levels rise briefly. These changes in amino
acids occurring after fasting further reflect accelerated starvation (Hadden and
McLaughlin 2009).
W hen women consume adequate amounts of calcium in the diet, parathyroid
hormone (PTH) levels decrease in the first trimester. By 36 weeks calcium absorption
doubles to support maternal and fetal bone mineralization with the fetus
accumulating 250–350 mg of calcium per day. This increase in maternal calcium
absorption leads to a physiological hypercalciuria after meals which can increase the
risk of renal calculi (Hacker et al 2012). Guidance on calcium intake in pregnancy
varies between countries. W hile the UK does not recommend supplementation
(O lausson et al 2012), other countries advise calcium supplementation to reduce the
risk of excessive bone loss, pre-eclampsia and preterm birth (Hacker et al 2012).
Vitamin D supplementation is advised due to the re-emergence of rickets and the low
vitamin D status of many women, particularly women of S outh A sian, A frican,
Caribbean or Middle Eastern family origin. Global recommendations advise
supplementation with 10–50 µg of vitamin D per day (NICE 2008; Olausson et al 2012).
Maternal weight
A healthy pre-conception body weight should be a ained as maternal diet and
nutritional status at the time of conception influence fetal outcome and the risk of
later chronic disease (Riley 2011) (see Chapter 13). A variety of components contribute
to weight gain during pregnancy (Table 9.7). The fetus accounts for approximately 27%
of the increase in weight, the placenta, amniotic fluid and uterus 20%, the breasts 3%,
blood volume and extravascular fluid 23%, and maternal fat stores 27% ( Herring et al
2012). Most weight is gained in the second and third trimesters at rates of 0.45 kg and
0.40 kg per week respectively compared with 1.6 kg throughout the first trimester
(S A CN 2012). I n early to mid-pregnancy, underweight and normal weight women
deposit fat on their hips, back and upper thighs, which are important as a calorie
reserve for late pregnancy and lactation (Herring et al 2012).
Table 9.7
Distribution of average increase in weight
A lthough there are guidelines for clinicians to advise women about weight
management during childbirth (N I CE 2010), there remains an absence of official
recommendations in the UK for specific weight gain parameters. Consequently the
United S tates (US ) I nstitute of Medicine (I O M) 2009 guidelines Rasmussen
( and
Yaktine 2009) are often used by UK health professionals as a guide based on W orld
Health O rganization (W HO ) cut-off points. D ifferent levels of weight gain are
recommended depending on the women's pre-pregnancy BMI (R iley 2011). W omen
with a BMI ofless than 18.5 should gain 12.5–18 kg; healthy women who have a BMI
between 18.5 and 24.9 should gain 11.5–16 kg during pregnancy; those with a BMI
between 25.9 and 29.9 should gain 7–11.5 kg and women with a BMI over 30 should gain
only 5–9 kg (Rasmussen and Yaktine 2009).
Total body water increases gradually with gestational age from 6 to 8 l due to
retention of extracellular water and sodium which helps to maintain normal blood
pressure. This leads to oedema and increased hydration and swelling of connective
tissue (Pipkin 2012). The most marked expansion occurs in extracellular fluid volume
and accounts for 8–10 kg of the average maternal weight gain during pregnancy
(O'Donoghue 2011). This increase is important in expanding the plasma volume to fill
the increased vascular bed in normal pregnancy. I t activates the RA A S which
stimulates increased reabsorption of sodium and water in the renal tubules thus
maintaining normal blood pressure.
Fluid balance is maintained in pregnancy by a decrease in both plasma osmolality
and thirst threshold so that pregnant women feel the urge to drink at a lower level of
plasma osmolality than non-pregnant women. Plasma oncotic pressure is also reduced
and, along with compression of pelvic and femoral vessels by the gravid uterus and
prostaglandin-induced vascular relaxation, may contribute to the development of
peripheral oedema (O'Donoghue 2011).
Physiological oedema of the lower leg is found in about 80% of all women in late
pregnancy which causes discomfort, a feeling of heaviness, night cramps and painful
paraesthesia. Regular foot massage is suggested to provide effective relief (Çoban and
Şirin 2010). Fluid retention and accumulation of fat may result in larger shoes being
required in the last trimester of pregnancy (Ponnapula and Boberg 2010).
The placenta and fetus follow different growth pa erns during gestation. W hile
fetal growth is very slow in the first trimester during organogenesis, placental growth
is more rapid, reaching peak growth at 28–30 weeks' gestation. With the onset of fetal
insulin secretion at 24–26 weeks' gestation fetal growth then increases more rapidly,
with the highest growth achieved close to term (A bduljalil et al 2012; Kumar et al
2012). A birth weight between 3 kg and 4 kg is associated with optimal maternal and
fetal outcomes (Herring et al 2012). A mniotic fluid volume during pregnancy is a
dynamic process, accounting for 6% of gestational weight.
The weight of the breasts increases during pregnancy, with considerable variability
between women (Riley 2011). Changes in the breasts are summarized in Table 9.8.
Table 9.8
Breast changes in chronological order
Time of
Changes
occurrence
3–4 weeks Prickling, tingling sensation due to increased blood supply particularly around the nipple
6–8 weeks Increase in size, painful, tense and nodular due to hypertrophy of the alveoli. Delicate, bluish surface veins
become visible just beneath the skin
8–12 weeks Montgomery's tubercles become more prominent on the areola. These hypertrophic sebaceous glands secrete
sebum, which keeps the nipple soft and supple. The pigmented area around the nipple (the primary areola)
darkens, may enlarge and become more erectile
16 weeks Colostrum can be expressed. The secondary areola develops with further extension of the pigmented area that is
often mottled in appearance
Late Colostrum may leak from the breasts and progesterone causes the nipple to become more prominent and mobile
pregnancy
Musculoskeletal changes
Relaxation of pelvic joints commences at 10–12 weeks gestation. A n increased
concentration of relaxin increases pelvic laxity and may be responsible for loosening
pelvic ligaments and increasing instability, causing some degree of discomfort for the
woman (A ldabe et al 2012). The increase in weight and the anterior shift in the centre
of gravity lead to biomechanical changes and the characteristic waddling gait of
pregnancy. Progesterone and oestrogen change the structure of connective tissue and
increase mobility of joint capsules and spinal segment as well as pelvic joint structure
in preparation for birth (Yousef et al 2011). There is decreased neuromuscular control
and coordination, decreased abdominal strength, increased spinal lordosis and
changes in mechanical loading and joint kinetics. A ll of these influence postural
control and may be related to the increased risk of falling (McCrory et al 2010). There
is a significant increase in the angles of thoracic kyphosis, lumbar lordosis and pelvic
inclination (Yousef et al 2011).
Because of the many changes in load and body mechanics many women experience
low back pain (see Box 9.13). Hormonal and biomechanical imbalances in addition to
an increased functional demand on the ankle plantar flexors during pregnancy
exacerbate leg cramp syndrome. This is caused by the sudden involuntary spasm of the
gastrocnemius muscle. Treatment for leg cramps is not usually required, however a
balanced diet and calcium gluconate supplements may help to relieve symptoms
(Ponnapula and Boberg 2010).
Box 9.13
B a ck pa in
A s a result of the many changes in load and body mechanics, many women
experience low back pain. The stretched abdominal muscles lose their
ability to maintain posture so that the lower back has to support the
majority of the weight.
W omen who exercise prior to and during pregnancy can strengthen
abdominal, back and pelvic muscles to improve posture and increased
weight-bearing ability. Exercise in the second half of pregnancy focusing on
abdominal strength, pelvic tilts and water aerobics are particularly effective
in reducing low back pain. Pelvic girdle support belts and corsets are also
useful in supporting the back. S imple home remedies such as heat pads
and over-the-counter medication may ease the pain before muscle relaxants
or opioids are prescribed. However, many women experience low back pain
and inflammation in the first trimester before mechanical changes have
occurred, suggesting that some pain may be due to the effects of relaxin
rather than mechanical load.
Skin changes
Pregnancy causes a variety of common changes in skin, hair and nails, which in the
majority of cases is a normal physiological response modulated by hormonal,
immunologic and metabolic factors (see Box 9.14). Those a ributed to hormonal
changes are often seen in women on the combined oral contraceptive pill (Farage et al
2009). Certain changes have been shown to have a genetic predisposition, particularly
striae gravidarum (stretch marks) and pigmentation changes.
Box 9.14
H a ir growt h
Hair growth has been shown to follow a common pa ern in pregnancy.
W omen commonly report a thickening and increased volume of scalp hair.
S timulated by oestrogen, the growing period for hairs is increased in
pregnancy so the woman reaches the end of pregnancy with many over-
aged hairs. This ratio is reversed after birth, so that sometimes alarming
amounts of hair are shed during brushing or washing. N ormal hair growth
is usually restored by 6–12 months. Mild hirsutism is common during
pregnancy, particularly on the face ( Muallem and Rubeiz 2006). A ctions
that may help include reducing damage to the hair by not combing when it
is wet, and avoiding hairstyles that pull and stress hair, using shampoos
and conditioners that contain biotin and silica. D iet that is high in fruit and
vegetables containing flavonoids and antioxidants may provide protection
for the hair follicles and encourage growth.
A lmost all women note some degree of skin darkening as one of the earliest signs of
pregnancy. W hile the exact physiology remains unclear, it is generally a ributed to an
increase in melanocyte stimulating hormone, progesterone and oestrogen serum
levels. Hyperpigmentation is more marked in dark-skinned women, being pronounced
in areas that are normally pigmented, e.g. areola, genitalia and umbilicus. This also
occurs in areas prone to friction, such as the axillae and inner thighs, and in recent
scars.
T he linea alba is a line that lies over the midline of the rectus muscles from the
umbilicus to the symphysis pubis. Hyperpigmentation causes it to darken resulting in
t h e linea nigra. Pigmentation of the face affects up to 50–70% of pregnant women
(Bolanca et al 2008) and is known as chloasma or melasma, or mask of pregnancy. I t is
caused by melanin deposition into epidermal or dermal macrophages, further
exacerbated by sun exposure. The chloasma usually regresses postpartum but may
persist in approx 10% of women and may be aggravated by oral contraceptives, which
should thus should be avoided in susceptible women (Bolanca et al 2008). I f chloasma
persists postpartum, Katsambas and S tratigos (2001) suggest that it can be treated
with a variety of topical agents, including hydroquinone, tretinoin, kojic acid and vitamin
C.
A s maternal size increases in pregnancy, stretching occurs in the collagen layer of
the skin, particularly over the breasts, abdomen and thighs. I n some women, this
results in striae gravidarum caused by thin tears occurring in the dermal collagen.
These appear as red stripes changing to glistening, silvery white lines approximately 6
months postpartum. The aetiology of striae has yet to be defined but may be
compounded by adrenocorticoids, oestrogens and relaxin which modify collagen and
possibly elastic tissue. Longstanding a empts to identify an effective treatment
remain inconclusive. Recent studies using olive oil and cocoa bu er have been unable
to demonstrate any significant reduction in the incidence or severity of striae
gravidarum (Osman et al 2008; Soltanipoor et al 2012).
Pruritus in pregnancy is characterized by intense itching either with or without a
rash. I t occurs in up to 20% of pregnancies (N elson-Piercy 2009) with numerous
potential differential diagnoses, including infection, eczema, or related to drug
therapy. A lthough it usually clears spontaneously after pregnancy, pruritus should be
investigated to exclude obstetric cholestasis which can have serious fetal and maternal
consequences if untreated (see Chapter 13).
Angiomas or vascular spiders (minute red elevations on the skin of the face, neck,
arms and chest) and palmar erythema (reddening of the palms) frequently occur,
possibly as a result of high oestrogen levels. They are rarely of clinical significance and
usually resolve spontaneously within a few months postpartum. N evertheless changes
may mask more serious conditions such as malignant neoplasms or herpes gestationis. I t
is therefore imperative to assess for specific dermatoses of pregnancy which may be
associated with maternal disease and fetal mortality and morbidity if severe and left
untreated.
Changes in the endocrine system
The changes in all compartments of the endocrine system and their timing are critical
for the initiation and maintenance of pregnancy, for fetal growth and development
and for parturition (Feldt-Rasmussen and Mathiesen 2011) (see Chapter 5). Hormone
levels are influenced by and vary according to parity, BMI , age, gestation, ethnicity and
smoking.
Placental hormones
H uman chorionic gonadotrophin (hCG) produced by the placental syncytiotrophoblast
and cytootrophoblast cells and by the pituitary gland is a hormone with multiple
functions during pregnancy (Cole 2012). I t can be detected in maternal serum from the
8th day after ovulation so is useful as a diagnostic marker for pregnancy. The unique
role of this hormone is to rescue the corpus luteum from involution so that it can
continue to produce progesterone which in turn maintains the decidua (Feldt-
Rasmussen and Mathiesen 2011). S ecretion of hCG commences at implantation, peaks
at concentrations of 100–200 I U/ml at 8–10 weeks then declines to 20 I U/ml by 20
weeks' gestation, remaining stable until labour (Fig. 9.8).
FIG. 9.8 Variations in plasma hormone concentrations during a normal pregnancy. From Heffner L,
Schust D 2010 The reproductive system at a glance. Wiley–Blackwell, Oxford, ch 20, with permission of Wiley–
Blackwell.
Human chorionic gonadotrophin drives hemochorial placentation and nutrient
transfer to the fetus and promotes the development and growth of uterine spiral
arteries, the formation of the umbilical circulation in villous tissue and the formation
of the umbilical cord. I t is also important in preventing rejection of fetoplacental
tissue during pregnancy (Cole 2012).
Relaxin is produced by the corpus luteum and contributes to the process of
decidualization and to the vasodilatation of healthy pregnancy (Conrad 2011).
H uman placental lactogen (hPL) is secreted into the maternal circulation by the
syncytiotrophoblast and can be detected in the maternal circulation as early as 6
weeks' gestation with concentrations increasing up to 30-fold throughout pregnancy.
This hormone regulates maternal carbohydrate, lipid and protein metabolism and
fetal growth. Maternal glucose uptake and glycogen synthesis are increased along with
glucose oxidation and insulin secretion as a result of hPL function: producing
maternal diabetogenic effects. I t also acts to promote the growth of breast tissue in
preparation for lactation (Braun et al 2013).
The placenta secretes over 20 different oestrogens into the maternal circulation but
the major ones are oestradiol, oestrone and oestriol, the la er being the most
predominant in pregnancy. W hilst oestrogens are produced primarily by the
developing follicles and corpus luteum, they are also produced by the placenta, liver,
adrenal glands, fat and breast cells. O estrogen concentrations greatly increase during
pregnancy, reaching levels 3–8 times higher than those observed in the non-pregnant
woman. O estradiol concentrations peak at around 6–7 weeks' gestation when the
production and secretion shifts from the corpus luteum to the placenta. I t then rises
steadily throughout pregnancy, particularly in the second and third trimesters.
Oestrogen increases uterine blood flow and facilitates placental oxygenation and
nutrition to the fetus. I t also prepares the breasts for lactation, affects the RA A S and
stimulates the production of hormone-binding globulins in the liver (Myatt and Powell
2010). I t is also responsible for changes in the nasal, gingival and laryngeal mucosa
when it peaks during the third trimester.
Progesterone is a pro-gestational hormone. I t is the key hormone in the initial stages
of pregnancy and is essential for creating a suitable endometrial environment for
implantation and maintenance of the pregnancy (Mesiano et al 2011). Progesterone is
produced predominantly by the corpus luteum in the first 9 weeks, after which
production shifts to the placenta. Concentrations plateau around 8–10 weeks and
remain relatively stable until around 16 weeks, when they begin to rise again. At 32
weeks there is a second rise in levels due to placental use of fetal precursors. At term
the placenta produces about 250 mg progesterone per day.
Progesterone promotes decidualization, inhibits smooth muscle contractility,
maintains myometrial quiescence and prevents the onset of uterine contractions
(Feldt-Rasmussen and Mathiesen 2011). A decrease or disruption of its production or
activity promotes cervical re-modelling and initiates labour (Mesiano et al 2011). I t is
the precursor of some fetal hormones and plays an important role in suppressing the
maternal immunological response to fetal antigens thereby preventing rejection of the
trophoblast.
The pituitary gland and its hormones
The maternal pituitary gland enlarges two- to three-fold during pregnancy due to
hypertrophy and hyperplasia of the lactotrophs (prolactin-secreting cells) under the
influence of oestrogen. A s a result, prolactin levels increase. I nsulin-like growth factor
levels increase in the second half of pregnancy contributing to the acromegaloid
features of some pregnant women. Corticotrophin-releasing hormones rise several
hundred-fold by term. A drenocorticotrophic hormone (A CTH) and cortisol levels rise
progressively throughout pregnancy, with a further increase in labour. Free cortisol
rises three-fold with a two- to three-fold increase in urinary free cortisol which makes
diagnosis and treatment challenging in the event of pituitary or adrenal pathology
(Feldt-Rasmussen and Mathiesen 2011).
Maternal serum follicle stimulating hormone (FS H) levels during pregnancy are stable
and almost undetectable, possibly due to the excessive production of oestrogen by the
placenta. Maternal serum levels of leuteinizing hormone (LH) increase rapidly in the
first trimester to a maximum of 3 IU/l and then decline slowly until birth.
Prolactin is produced by the anterior lobe of the pituitary gland and by amniotic
fluid. I t stimulates mammary growth and development and lactation (Feldt-
Rasmussen and Mathiesen 2011) (see Chapter 34). Prolactin levels increase
progressively throughout pregnancy and by term serum levels are about 10 times the
non-pregnant level.
The posterior pituitary gland produces two hormones: vasopressin and oxytocin.
However, vasopressin does not play a significant role in pregnancy. Oxytocin levels are
low during pregnancy but increase in labour (Feldt-Rasmussen and Mathiesen 2011),
its function being to act on the myometrium to increase the length, strength and
frequency of contractions. I t is responsible for the milk-ejecting action of the posterior
lobe of the pituitary gland and is thought to play a role in regulating milk production
through control of prolactin (Chapter 34) and in the establishment of complex social
and bonding behaviours related to birth and care of the baby (Petraglia et al 2010).
Thyroid function
The thyroid gland is moderately enlarged during pregnancy due to hormone-induced
glandular hyperplasia and increased vascularity (Baba and A zar 2012). Thyroid size is
influenced by different factors, including iodine supply, genetics, gender, age, parity
and smoking. There is a positive correlation in pregnancy between thyroid volume and
BMI (G aberšćek and Zalatel 2011). The function of the thyroid gland is to produce
sufficient thyroid hormones necessary to meet the demands of peripheral tissues.
Maintaining euthyroidism during pregnancy is essential for the growth and
development of the fetus. I n the first trimester the fetus depends solely on thyroid
hormones and iodine from the mother, such that subtle changes in thyroid function
can have detrimental effects on the fetus.
Maternal thyroid function alters dramatically during pregnancy due to the
physiological changes of pregnancy and fetal requirements. S ince the fetal thyroid
does not function until mid-pregnancy the fetus is dependent on maternal thyroid
function for its normal brain development. I ncreased thyroxine production is required
for metabolic changes as well as transfer of thyroxine to the fetal brain cells
(Rebagliato et al 2010; Lazarus 2011). Healthy pregnant women are usually able to
adjust their thyroid function in pregnancy if an adequate store of iodine exists prior to
conception (Rebagliato et al 2010). However, maternal thyroid failure during the first
half of pregnancy has been associated with several pregnancy complications as well as
intellectual impairment in the child (Baba and Azar 2012).
The steep rise in hCG levels during the first trimester may result in an increased
production of thyroid hormones and thus decreased thyroid stimulating hormone (TS H)
levels (Fig. 9.9). Higher levels of oestrogen lead to a two- and three-fold increase in the
le ve ls of thyroxine-binding globulin (TBG) which causes a 50% increase in total
thyroxine. Total thyroxine (T4) and total triiodothyronine (T3) concentrations increase
sharply in early pregnancy and plateau early in the second trimester at concentrations
30–100% greater than pre-pregnancy values (Lazarus 2011; Baba and A zar 2012). I n the
second and third trimesters when stimulation by hCG declines, T3 and T4 levels
remain above the non-pregnant levels and TS H levels remain low, however this does
not result in hyperthyroidism due to the parallel increase in TBG.
FIG. 9.9 Change in thyroid function indices throughout getstation. The shaded area represents
the normal range of thyroid-binding globulin (TBG), total T4 thyroxine, thyroid stimulating hormone
(TSH) and free T4. hCG = human chorionic gonadotrophin. Reproduced with permission from Casey B
M, Leveno K J 2006 Thyroid disease in pregnancy. Obstetrics and Gynaecology 108:1283–9.
The increased GFR and renal blood flow improves the clearance ofrenal iodide. This
reflects the additional demand for iodine in pregnancy to protect the woman and
provide for the needs of the fetus. I odide levels increase a few weeks after conception
and reach a plateau during mid-pregnancy. I odine requirements intensify in
pregnancy because of the increase in synthesis of thyroid hormone, urinary iodine
excretion, placental transfer and metabolism of thyroid hormones. Total body iodine
stores decrease by 40% during pregnancy ranging from 15 mg to 50 mg of which two-
thirds is stored hormone in the thyroid gland (Rebagliato et al 2010). Excretion of
iodine in the urine rises and iodine deficiency is common in pregnancy even in areas
where there is generally sufficient iodine ( Kennedy et al 2010), consequently there is
an association with maternal goitre and reduced maternal thyroxine (T4) level (Lazarus
2011). S evere iodine deficiency leads to cretinism in the newborn therefore an adequate
intake of iodine is essential during pregnancy to maximize fetal outcome, particularly
appropriate maturation of the fetal brain to improve early neurological development
(Rebagliato et al 2010).
Routine iodine supplementation is advised in parts of the world where the risk of
iodine deficiency is endemic and should commence before conception (Kennedy et al
2010). I t is generally recommended that all pregnant women should increase their
intake of iodine to 250 µg per day before and during pregnancy but should not exceed
500 µg per day as a higher intake may cause thyroid dysfunction.
D ue to the many changes in thyroid function there is a real risk of misinterpretation
of thyroid function tests in pregnancy and it is recommended that pregnancy reference
ranges are used as markers (Feldt-Rasmussen and Mathiesen 2011). A s T4 and T3
levels define thyroid status in early pregnancy while TS H concentrations provide
indication of thyroid status in later pregnancy, Kennedy et al (2010) advises that
laboratories should establish their own trimester-specific reference ranges for thyroid
hormones and TSH.
Adrenal glands
A drenal metabolism changes significantly, with adrenal steroid levels increasing
throughout pregnancy. A drenocorticotrophic hormone (A CTH) levels escalate
dramatically, with the initial peak at 11 weeks, a significant rise after 16–20 weeks and
a final surge during labour. D espite these increases in plasma and urinary free cortisol
levels, pregnant women do not show any features of hypercortisolism. Renin and
angiotensin levels rise leading to elevated levels of angiotensin I I and aldosterone
(Feldt-Rasmussen and Mathiesen 2011) and plasma aldosterone levels increase 5- to 20-
fold during pregnancy, with a plateau at 38 weeks. A ldosterone secretion continues to
respond to physiological stimuli such as posture and varies according to salt intake.
The increase in aldosterone promotes sodium retention in the distal renal tubules.
Cortisol produced by the decidua acts in combination with hCG and progesterone
secreted by the conceptus to suppress maternal immune response (Feldt-Rasmussen
and Mathiesen 2011). There is a steady rise in serum cortisol as pregnancy advances,
which decreases the inflammatory response resulting in improvement in
dermatological and rheumatoid conditions. This rise in serum cortisol also causes
relative gestational immunosuppression which leads to reactivation of latent viral
infections, suggesting that endocrine and immune systems are closely related.
Diagnosis of pregnancy
W omen who are aware of their bodies might begin to suspect that they are pregnant
within the first few days of pregnancy but for most, the first sign is missing a period
(Table 9.9). O ther symptoms include nausea and vomiting, breast tenderness and
fullness, urinary frequency and fatigue. Most women use a home pregnancy test (HPT)
to determine their pregnancy status before seeking professional health care.
Table 9.9
Signs of pregnancy
Sign Time of occurrence Differential diagnosis
Possible (presumptive) signs
Early breast changes 3–4 weeks + Contraceptive pill
(unreliable in multigravida)
Amenorrhoea 4 weeks + Hormonal imbalance
Emotional stress
Illness
Nausea and vomiting 4–14 weeks Gastrointestinal disorders
Pyrexial illness
Cerebral irritation, etc.
Bladder irritability 6–12 weeks Urinary tract infection
Pelvic tumour
Quickening 16–20 weeks + Intestinal movement, wind
Probable signs
Presence of human chorionic
gonadotrophin (hCG) in:
Blood 9–10 days Hydatidiform mole
Urine 14 days Choriocarcinoma
Softened isthmus (Hegar's sign) 6–12 weeks
Blueing of vagina (Chadwick's sign) 8 weeks +
Pulsation of fornices (Osiander's sign) 8 weeks + Pelvic congestion
Tumours
Changes in skin pigmentation 8 weeks +
Uterine souffle 12–16 weeks Increased blood flow to uterus as in large uterine myomas or
ovarian tumours
Braxton Hicks contractions 16 weeks
Ballottement of fetus 16–28 weeks
Positive signs
Visualization of gestational sac by:
Transvaginal ultrasound 4.5 weeks
Transabdominal ultrasound 5.5 weeks
Visualization of heart pulsation by:
Transvaginal ultrasound 5 weeks
Transabdominal ultrasound 6 weeks
Fetal heart sounds by:
Doppler 11–12 weeks
Fetal stethoscope 20 weeks + No alternative diagnosis
Fetal movements
Palpable 22 weeks + Late
Visible pregnancy
Fetal parts palpated 24 weeks +
Visualization of fetus by X-ray 16 weeks +
(superseded by ultrasound)
Traditionally diagnosis has been based on history and physical examination. I ssues
that may confuse the diagnosis of early pregnancy are an atypical last menstrual
period, contraceptive use and a history of irregular periods. S po ing or light bleeding
is common in early pregnancy between weeks 6 and 7 (Hasan et al 2010), which may
further complicate the assessment. The signs of pregnancy described below are mainly
of historic significance. A lthough they may still be of value in some parts of the world,
they have generally been rendered obsolete in the developed world by more modern
and sophisticated methods.
Hegar's (or Goodell's) sign
S oftening of the lower parts of the isthmus is felt in contrast to a firm cervix at about
6–8 weeks' gestation on bimanual pelvic examination (Davis Jones 2011).
Chadwick's sign
The cervix, vagina, vulva and vaginal mucous membranes become darker or blue in
colour at 8 weeks' gestation (Geraghty and Pomeranz 2011). I t is caused by the greatly
increased blood supply to the pelvic organs. I t is also known as J acquemier's sign.
While this sign indicates pregnancy, it does not necessarily indicate viability.
Osiander's sign
S tronger pulsations can be felt in the lateral vaginal fornix due to increased blood
supply from the enlarged uterine artery (D avis J ones 2011). This may also occur in the
non-pregnant woman due to fibroids and pelvic inflammation.
Quickening
I t is a pivotal moment in pregnancy when the first flu ering movements of the
growing fetus are felt. Q uickening occurs at 18–20 weeks although many women
experience it at an earlier gestation. Fetal movements can begin to be palpated around
20 weeks (see Table 9.9).
Measurement of hyperglycosylated hCG (hCG-H) produced by trophoblast cells is
the principal form of total hCG made in early pregnancy and forms the basis for
pregnancy testing, using either maternal urine or serum. Urine pregnancy tests and
one-step point-of-care (PO C) tests are widely used both at home and in laboratories.
However, some serum hCG, PO C and HPTs poorly detect hCG-H, which limits the
use in early pregnancy testing; consequently, manufacturers have a empted to
produce a specific hCG-H assay, but without success (Brezina et al 2011). Reliability of
the HPT depends on the correct adherence to both instructions and timing of the test.
Tests routinely claim to have an accuracy of 99% in the detection of hCG
concentrations. The most accurate tests are First Response™ Early Result Pregnancy
Test (Church & D wight Co., I nc.) and Clear Choice™ At Home Pregnancy Tes
(Pharmatech Inc.) (Cole 2010).
Early pregnancy detection is critical as it allows prenatal care to begin during the
most vulnerable stages of fetal development. Research has shown that women who
access prenatal care early in their pregnancy have improved outcomes than women
who delay or have inadequate prenatal care (Quelopana et al 2009).
Common disorders arising from adaptations to pregnancy
Throughout this chapter reference has been made to the multitude of symptoms
produced by the physiological changes occurring in pregnancy. W hile deemed
physiological, women may experience these as unpleasant, and even distressing or
debilitating. D ue to their common, natural and non-pathological nature and the fact
that they generally resolve spontaneously, caregivers are often guilty of a dismissive or
trivializing approach towards them.
The two key issues for midwives to build into their practice are:
1. Ensure assessment of a woman's symptoms is accurate, differentiating clearly
between physiological and potentially pathological symptoms.
2. Develop a sympathetic approach to women experiencing these discomforts and
ensure appropriate advice is offered to ameliorate or better tolerate the symptoms
of pregnancy.
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C H AP T E R 1 0
Antenatal care
Helen Baston
CHAPTER CONTENTS
The aim of antenatal care 180
Historical background 180
Current practice 181
Access to care 182
Models of midwifery care 182
The initial assessment (booking visit) 183
Meeting the midwife 183
Communication 183
Personal information 184
Social circumstances 184
Menstrual history and expected date of birth 184
Obstetric history 185
Medical and surgical history 185
Family history 186
Lifestyle 186
Risk assessment 187
Physical examination 187
Weight 187
Blood pressure 188
Urinalysis 188
Blood tests 188
Other screening tests 188
The midwife's examination 189
Oedema 190
Varicosities 190
Abdominal examination 190
Ongoing antenatal care 196
Indicators of maternal wellbeing 196
Indicators of fetal wellbeing 196
Preparation for labour 198
Home visit and safe sleeping advice 199
References 199
Useful websites 202
Antenatal care is the care given to a pregnant woman from the time
conception is confirmed until the beginning of labour. The midwife facilitates
woman-centred care by providing her with accessible and relevant
information to help her make informed choices throughout pregnancy. The
foundation of this process is the development of a trusting relationship in
which the midwife engages with the woman and listens to her story.
The chapter aims to:
• describe current models of antenatal care
• explore the role of the midwife in providing woman-centred care, identifying the
woman's physical, psychological and sociological needs
• discuss the initial assessment visit, define its objectives and consider the significance
of the woman's health and social history
• describe the physical examination and psychological support of the woman provided
throughout pregnancy.
The aim of antenatal care
The aim of antenatal care is to monitor the progress of pregnancy to optimize
maternal and fetal health. To achieve this, the midwife critically evaluates the physical,
psychological and sociological effects of pregnancy on the woman and her family. This
process requires engagement by the midwife, as outlined in Box 10.1.
Box 10.1
K e y principle s of a nt e na t a l ca re by t he m idwife
• Developing a trusting relationship with the woman.
• Providing a holistic approach to the woman's care that meets her
individual need.
• Making a comprehensive assessment of the woman's health and social
status, accessing all relevant sources of information.
• Promoting an awareness of the public health issues for the woman and
her family.
• Exchanging information with the woman and her family, enabling them
to make informed choices about pregnancy and birth.
• Being an advocate for the woman and her family during her pregnancy,
supporting her right to choose care appropriate for her own needs and
those of her family.
• Identifying potential risk factors and taking the appropriate measures to
minimize them.
• Timely sharing of information with relevant agencies and professionals.
• Accurate, contemporaneous documentation of assessments, plans, care
and evaluation.
• Recognizing complications of pregnancy and appropriately referring
women to the obstetric team or relevant health professionals or other
organizations (see Chapters 11–14).
• Preparing the woman and her family to meet the challenges of labour and
birth, and facilitating the development of a birth plan.
• Facilitating the woman to make an informed choice about methods of
infant feeding and giving appropriate and sensitive advice to support her
decision (Chapter 34).
• Offering parenthood education within a planned programme or on an
individual basis (Chapter 8).
Historical background
A ntenatal care has been provided in the United Kingdom (UK) for almost a century
and was first offered in the late 1920s ( Ministry of Health 1929). The model of
antenatal care followed a regime of monthly visits until 28 weeks' gestation, then
fortnightly visits until 36 weeks, then weekly visits until the birth of the baby. This
model continued for decades but was eventually challenged in the 1980s by Hall et al
(1980), whose retrospective analysis demonstrated that conditions requiring
hospitalization, including pre-eclampsia, were neither prevented nor detected by
antenatal care; and intrauterine growth restriction was over-diagnosed. I t was felt that
reducing visits for those who did not need them would mean that more support could
be given to vulnerable women to improve their outcomes.
To evaluate the impact of reduced antenatal visiting, S ikorski et al (1996) conducted
a randomized controlled trial, with low-risk pregnant women, to compare the
acceptability and effectiveness of a reduced antenatal visit schedule of six to seven
routine visits with the traditional 13 routine visits. N o differences in clinical outcome
between the two groups were found, but twice as many women in the reduced-visit
group were dissatisfied with the frequency of a endance, compared with women who
received the full range of visits. The W orld Health O rganization trialled a system of
four routine antenatal visits for women assessed as being low risk (Villar et al 2001).
They found no statistically significant differences between the outcomes of pre-
eclampsia, severe anaemia, urinary tract infection and low birth-weight infants
between the intervention group and standard care, in the 24, 678 women enrolled in
the study.
Pa erns of visiting continue to be investigated and D owswell et al (2010) compared
standard care with reduced visiting schedules investigated in seven randomized
controlled trials. They concluded that for high income countries there was no
difference between the groups but for low to medium income countries, perinatal
mortality was increased in those receiving reduced visits and the authors conclude
that visits should not be reduced without close monitoring of the impact on neonatal
outcome. A s previous research had demonstrated (Clement et al 1996; Villar et al
2001), women prefer more scheduled visits, but as outlined in N ational I nstitute for
Health and Clinical Excellence (N I CE) (2008)guidance, women who had a midwife
willing to spend time with them and encourage them to ask questions were more
likely to be satisfied with reduced visits than those whose midwife did not offer this.
NICE (2003, 2008) has endorsed a schedule of seven visits for parous women and 10
for primigravid women and this pa ern is often reflected in the service specification
commissioned (see Box 10.2 for the N I CE 2008recommended visiting pa ern). The
midwife must continue to use her knowledge and judgement when providing care, as
there will be situations where deviation from the pathway will be necessary to ensure
safety for either the woman or her unborn baby. I n such situations, the midwife
should clearly document her rationale and ensure that she continues to evaluate the
care she provides or has requested from other members of the team. I f the deviation
falls outside the midwife's current remit, she is obliged to ‘call such health or social
care professionals as may reasonably be expected to have the necessary skills and
experience to assist you in the provision of care’ ( N ursing and Midwifery Council
[NMC] 2012: 15).
Box 10.2
A nt e na t a l visit ing pa e rn a s a dvoca t e d by N I C E
• Booking appointment(s) with midwife by 10 weeks if possible
• 10–14 weeks: ultrasound scan for gestational age
• 16 weeks: midwife
• 18–20 weeks: ultrasound scan for fetal anomalies
• 25 weeks: midwife (nulliparous women)
• 28 weeks: midwife
• 31 weeks: midwife (nulliparous women)
• 34 weeks: midwife
• 36, 38 weeks: midwife
• 40 weeks: midwife (nulliparous women)
• 41 weeks: midwife (discuss options)
Source: NICE 2008
Current practice
N ational evidence-based guidelines, in relation to antenatal care have been developed
and circulated in the UK since 2003. They were updated in 2008 and reviewed again in
2011 when it was decided that there was insufficient new evidence to warrant a change.
They are next due for review in 2014.
I n addition to full national clinical guidance, N I CE also produce ‘Q uality S tandards
that are ‘a concise set of statements designed to drive and measure priority quality
improvements within a particular area of care’ (N I CE 2012). The A ntenatal Q uality
S tandard comprises 12 statements and these are detailed in Box 10.3. They are a useful
framework for examining maternity services and provide benchmarks for audit and
commissioning purposes, although most of them relate to women with risk factors.
Box 10.3
A nt e na t a l Q ua lit y S t a nda rd: qua lit y st a t e m e nt s
Statement 1: Pregnant women are supported to access antenatal care,
ideally by 10 weeks 0 days.
Statement 2: Pregnant women are cared for by a named midwife
throughout their pregnancy.
Statement 3: Pregnant women have a complete record of the minimum
set of antenatal test results in their hand-held maternity notes.
Statement 4: Pregnant women with a body mass index of 30 kg/m2 or
more at the booking appointment are offered personalized advice from an
appropriately trained person on healthy eating and physical activity.
Statement 5: Pregnant women who smoke are referred to an evidence-
based stop smoking service at the booking appointment.
Statement 6: Pregnant women are offered testing for gestational diabetes
if they are identified as at risk of gestational diabetes at the booking
appointment.
Statement 7: Pregnant women at high risk of pre-eclampsia at the
booking appointment are offered a prescription of 75 mg of aspirin to take
daily from 12 weeks until at least 36 weeks.
Statement 8: Pregnant women at intermediate risk of venous
thromboembolism at the booking appointment have specialist advice
provided about their care.
Statement 9: Pregnant women at high risk of venous thromboembolism
at the booking appointment are referred to a specialist service.
Statement 10: Pregnant women are offered fetal anomaly screening in
accordance with current UK National Screening Committee programmes.
Statement 11: Pregnant women with an uncomplicated singleton breech
presentation at 36 weeks or later (until labour begins) are offered external
cephalic version.
Statement 12: N ulliparous pregnant women are offered a vaginal
examination for membrane sweeping at their 40- and 41-week antenatal
appointments, and parous pregnant women are offered this at their 41-
week appointment.
Source: NICE 2012 http://publications.nice.org.uk/quality-standard-for-antenatal-care-qs22/list-of-
quality-statements
Public health role of the midwife
Midwives have always held a privileged position in relation to their ability to influence
the health and wellbeing of women and their families. With access to women at a time
in their life when they may be open to change their behaviour to achieve a healthy
baby, midwives can offer support, information and referral. The public health remit of
the midwives was strengthened when their unique position to address inequality was
formally recognized in the government W hite Paper Saving Lives: O ur H ealthier N ation
(Department of Health [DH] 1999). I t has since been recognized as a significant part of
the midwife's role and deeply embedded in the Midwifery 2020 strategy (McN eill et al
2010) and future government policy (D H & N ational Health S ervice [N HS
Commissioning Board 2012).
There are a range of health behaviours that impact on life chances and these follow a
social gradient. By addressing these public health issues and working together with
other agencies, midwives can influence the future health of the population. Extending
the boundaries of midwifery care to offer social support can result in positive
outcomes in terms of lifestyle, employment and the growth and development of
children (Leamon and Viccars 2007). The Marmot Review (2010) examined strategies
that could be implemented in order to reduce inequalities in health. I t focused on the
challenges people face throughout the life course and highlighted the importance of
children ge ing ‘the best start in life’ (2010: 173). I t identified the need to give priority
to maternal health interventions and evidence-based parenting support programmes,
children's centres, advice and assistance.
Access to care
Early contact with the maternity services, ideally by 10 weeks' gestation, is important
so that appropriate and valuable advice relating to screening, nutrition and optimum
care of the developing fetus can be given. Medical conditions, infections and lifestyle
behaviours may all have a profound and detrimental effect on the fetus during this
time.
W omen are encouraged to access their midwife through their local health or
children's centre on confirmation or suspicion of a positive pregnancy test and should
be facilitated to do this. They do not require a formal referral from a General
Practitioner (GP). I t has been a longstanding conundrum that the people who are most
likely to need or benefit from health services are least likely to access them. O ften
referred to as ‘hard to reach’ groups, it might be more accurate to describe some
services as ‘hard to reach’ and particularly useful to do this when considering how
access to services can be increased.
Late booking for antenatal care has been recognized as a feature of many maternal
deaths (Lewis 2007; CMA CE [Centre for Maternal and Child Enquiries] 2011a ). The
recent Confidential Enquiry into Maternal D eaths (CMACE 2011a) noted improvement
and applauded the fact that recommendations from previous Confidential Enquiries
into Maternal D eaths reports are being acted on. However, late booking and poor
a endance remains a feature of many maternal deaths. I ndeed, 87% of the population
at the time of the report had booked by 13 weeks' gestation (DH 2010a) compared with
58% of the women who died from Direct and Indirect causes.
For some women, late booking cannot be avoided if they have arrived only recently
in the country. However, these women are particularly vulnerable as they may be naive
about how maternity services work, not knowing where they are located, be unable to
negotiate public transport and not speak English. S ervices can be made more
accessible if community-based outreach workers and bilingual link/advocacy workers
recruited from the target population are employed to provide care (Hollowell et al
2012).
Maternity services can also be difficult to access for indigenous women. They may
not recognize the importance of a ending early for care to enable valuable health and
social care screening to be undertaken. They may be juggling childcare demands with
work and financial pressures. Centralization of services may mean that the consultant
maternity unit is located in towns or cities, many miles from home. W hilst low-risk
women receive the majority of their care in the community, closer to home, for those
where there is a complication or a medical condition that requires close monitoring,
regular attendance at the consultant unit can be a real challenge.
A flexible approach to the timing of visits and the place of consultation has been
incorporated into many maternity services to address issues of access, choice and
maternal satisfaction (DH 2007). However, it is equally important that women perceive
antenatal care as a valuable resource and an opportunity to receive effective, relevant
care from staff who treat them with respect and kindness.
Models of midwifery care
W omen can choose from a variety of midwifery care options depending on local
availability and their level of risk. The majority of low-risk women receive antenatal
care in the community, either at a Children's Centre, GP surgery, or in their own home.
Hospital- or community-based clinics are available for women who receive care from
an obstetrician or physician in addition to their midwife. Midwifery teams, case
loading and independent midwifery (I M) are all examples of how antenatal care can be
provided flexibly to meet the needs of individual women. I n the UK from early in 2014
I Ms will be required to have professional indemnity insurance (PI I ) for all aspects of
midwifery care. The N MC Midwifery O rder 2001 will be amended, giving the N MC th
power to refuse the right to registration or remove from the register any I M who does
not have PII cover (DH 2013).
O ptions for place of birth include the home, a birth centre (stand-alone or
alongside) or a consultant-led unit. N ational maternity policy promotes birth at home
as an option for all women with low-risk pregnancies (D H 2007), but fundamental to
this is women's choice and local configuration of services. W omen who have identified
risk factors or develop complications during pregnancy will usually plan for a hospital
birth. However, some women with potentially complex needs may request midwifery-
led care, for a range of reason. They should have the opportunity to discuss their
hopes and expectations so that a mutually acceptable plan can be agreed, and
supported by appropriately skilled midwives.
The initial assessment (booking visit)
The purpose of this visit is to initiate the development of a trusting relationship that
facilitates the positive engagement of the woman with the maternity service; this is the
most important element of antenatal care. W hilst it is crucial that risk assessment and
identification of clinical relevant information is obtained, none of these can be
undertaken if the woman does not feel able to communicate with the midwife.
Meeting the midwife
The woman's first introduction to midwifery care is crucial in forming her initial
impressions of the maternity service. A friendly, professional approach will enable the
development of a positive partnership between the woman and the midwife. The
initial visit focuses on the exchange of information (Box 10.4) and identification of
factors that may require referral to another member of the multi-professional team
(Box 10.5). I t is a key opportunity for the midwife and the woman to get to know each
other. The midwife may meet other members of the family and in this way gain a more
informed view of the woman's circumstances. However, the midwife will also
recognize that there are occasions when the woman may need to spend time alone
with her to facilitate discussion, which she may not feel able to have in the presence of
family members.
Box 10.4
O bje ct ive s for t he init ia l a sse ssm e nt ( booking visit )
• To build the foundation for a trusting relationship in which the woman
and midwife are partners in care.
• To assess health by taking a detailed history and offering appropriate
screening tests.
• To ascertain baseline recordings of blood pressure, urinalysis, blood
values, uterine growth and fetal development to be used as a standard for
comparison as the pregnancy progresses.
• To identify risk factors by taking accurate details of past and present
midwifery, obstetric, medical, family and personal history.
• To provide an opportunity for the woman and her family to express and
discuss any concerns they might have about the current pregnancy and
previous pregnancy loss, labour, birth or puerperium.
• To give public health advice pertaining to pregnancy in order to maintain
the health of the mother and fetus.
• Make appropriate referral where additional healthcare or support needs
have been identified.
Box 10.5
F a ct ors t ha t m a y re quire a ddit iona l a nt e na t a l support
or re fe rra l t o a n obst e t ricia n/physicia n/ot he r he a lt h
profe ssiona l
Initial assessment
• Age less than 18 years or 40 years and over
• Grande multiparity
• Vaginal bleeding at any time during pregnancy
• Unknown or uncertain expected date of birth
• Late booking
Past obstetric history
• Stillbirth or neonatal death
• Baby small or large for gestational age
• Congenital abnormality
• Rhesus isoimmunization
• Pregnancy-induced hypertension
• Two or more terminations of pregnancy
• Three or more spontaneous miscarriages
• Previous pre-term labour
• Cervical cerclage in past or present pregnancy
• Previous caesarean section or uterine surgery
• Ante- or postpartum haemorrhage
• Precipitate labour
• Multiple pregnancy
Maternal health
• Previous history of deep vein thrombosis or pulmonary embolism
• Chronic illness, e.g. epilepsy, severe asthma, hepatic or renal disease,
cystic fibrosis
• Hypertension, cardiac disease
• History of infertility
• Uterine anomalies
• Family history of diabetes or genetic disorders
• Type I or Type II diabetes
• Substance abuse (drugs, alcohol or smoking)
• Psychological or psychiatric disorders
Examination at the initial assessment
• Blood pressure 140/90 mmHg or above
• Maternal obesity or underweight according to BMI
• Blood disorders
Source: NICE 2008
Communication
The midwife requires many skills to provide optimal antenatal care: fundamentally,
the ability to communicate effectively and sensitively. Listening skills involve focusing
on what the woman is saying and how she is saying it, considering the content and
tone. I n addition, non-verbal responses, including facial expression, body position and
eye contact, will influence the quality of the interaction and have the potential to
enhance or detract from the development of a positive relationship between woman
and midwife (Allison 2012).
The midwife can promote communication with the woman during discussion by
gentle questioning, open-ended statements and reflecting back keywords from what is
said, to encourage and facilitate exploration of what is meant (Rungapadiachy 1999).
Midwives also need to be aware of the language they use, avoiding unnecessary jargon
and technical language (Lucas 2006). Communication encompasses writing accurate,
comprehensive and contemporaneous records of information given and received and
the plan of care that has been agreed (N MC 2009). The midwife must also
communicate relevant information with the multiprofessional team (N MC 2008) and
with the GP and health visitor in particular (CMACE 2011a).
Taking an antenatal booking history involves a lot of questioning and data
collection. However, in completion of the documentation the midwife must be mindful
that she needs to have eye contact with the woman in order to facilitate discussion and
observe her responses to particular questions. General conversation about the
woman's experiences can be a more useful way of sharing information between
woman and midwife compared with asking a list of questions or filling in computer
data in a mechanistic manner (McCourt 2006).
Personal information
A s part of ge ing to know each other the midwife will introduce herself as the
woman's named midwife. S he will then clarify the woman's name and the relationship
to her of anyone accompanying her. I mportant details such as date of birth, address
and current occupation are wri en down and provide a useful means of breaking the
ice. The woman's age should be considered in relation to local guidelines. For example,
it may be a recommendation that women who are 40 years of age or more are offered
induction of labour at term (Royal College of O bstetricians and Gynaecologist [RCO G
2013a). I f this is the case, the woman will need to know what her care pathway will be
so that she can be fully involved in all decisions. The midwife will explain that she will
be asking lots of questions and encourage the woman to ask if anything is unclear.
Social circumstances
I t is useful to explore the woman's response to the pregnancy. S ome women may be
overwhelmed by having to care for a new baby along with other children, they may be
isolated or living in poverty. The woman may be a teenager, and experiencing conflict
with her parents, social stigma and accommodation concerns. The midwife will need
to have a contemporary knowledge of local services and initiatives, such as the Family–
N urse Partnership for pregnant teenagers (D H 2010b), social services and voluntary
agencies to make appropriate referrals, in partnership with the woman.
Many women live in complex circumstances and the midwife will sometimes need to
ask a range of questions to untangle the details. For example, what are their living
arrangements, are there any children from previous relationships and who has
custody, to identify if there are any child protection concerns that may need further
follow up.
I f the woman appears to have difficulty understanding information that is being
given, she may have a learning disability or difficulty. I t is important to liaise closely
with her GP to establish if any diagnosis has been made. Further referral and
engagement with social care services may be necessary to ensure that appropriate
advocacy and assessment is put in place. There are also many useful visual aids that
can support communication where written word is inappropriate.
D omestic abuse is also a possible concern, with a prevalence of 5% to 21% in
pregnancy (Leneghan et al 2012). I t is important for the midwife to explore this issue
sensitively and be aware of the signs or symptoms of domestic abuse. The woman may
only disclose information if she is alone hence the midwife should endeavour to
provide such opportunities and do so in a secure environment (N I CE 2008). S upport
can then be offered in collaboration with the multi-agency team.
I t may become clear that the woman and her unborn baby are potentially
vulnerable, for a range of reasons. I t is important that the midwife does not display a
negative a itude to vulnerable women as this can be a barrier for future access to care
(NICE 2010a). There are a range of agencies that can be engaged to provide additional
support, including link workers, social workers, health visitors and doulas, depending
on local provision. The midwife may need to consider implementation of the Common
A ssessment Framework (CA F) process in order to make the most appropriate request
for additional services (D epartment for Education [D fE] 2012). This should be
undertaken after the booking appointment in line with local policy and with the
mother's consent. A ny immediate cause for concern should be escalated in line with
national guidelines and local policy.
Menstrual history and expected date of birth
The next topic of conversation is the reason that has brought the woman to this
appointment. A n accurate menstrual history helps determine the expected date of
birth (ED B), enables the midwife to predict a birth date and subsequently calculate
gestational age at any point in the pregnancy. This is particularly important for the
timing of fetal anomaly screening and measuring fetal growth.
The ED B is calculated by adding 9 calendar months and 7 days to the date of the
first day of the woman's last menstrual period (known as N aegele's Rule). This method
assumes that:
• the woman takes regular note of regularity and length of time between periods;
• conception occurred 14 days after the first day of the last period; this is true only if
the woman has a regular 28-day cycle;
• the last period of bleeding was true menstruation; implantation of the ovum may
cause slight bleeding;
• breakthrough bleeding and anovulation can be affected by the contraceptive pill thus
impacting on the accuracy of a last menstrual period (LMP).
The duration of pregnancy based on N aegele's rule is 280 days. However, if the
woman has a 35-day cycle then 7 days should be added; if her cycle is less than 28 days
then the appropriate number of days is subtracted. A definitive ED B will be given
when the woman a ends for her ‘dating’ ultrasound scan at around 12 weeks of
pregnancy.
Obstetric history
Previous childbearing history is important in considering the possible outcome of the
current pregnancy and also in relation to how the woman feels about the future. I n
order to give a summary of a woman's childbearing history, the descriptive terms
gravida and para are used. ‘Gravid’ means ‘pregnant’, gravida means ‘a pregnant
woman’, and a subsequent number indicates the number of times she has been
pregnant regardless of outcome. ‘Para’ means ‘having given birth’; a woman's parity
refers to the number of times that she has given birth to a child, live or stillborn,
excluding termination of pregnancy. A grande multigravida is a woman who has been
pregnant five times or more, irrespective of outcome. A grande multipara is a woman
who has given birth five times or more.
Previous childbearing experiences
A sympathetic non-judgemental approach is required to elicit information and
encourage the woman to talk freely about her experiences of previous births,
miscarriages or terminations. Confidential information may be recorded in a clinic-
held summary of the pregnancy and not in the woman's handheld record if she
requests this. W here a woman has had a previous traumatic birth experience,
subsequent pregnancy may evoke panic and fear (N ilsson et al 2010). This impending
birth has the potential to heal or harm and the woman may benefit from being able to
talk through what happened and/or engage with a psychological intervention to enable
her to achieve closure (Beck and Watson 2010). W here a woman or her partner has lost
a child due to S udden I nfant D eath S yndrome (S I D S ) or has a close relative who ha
had this experience, she is likely to be very anxious about the prospect of this
happening again. Care of the N ext I nfant (CO N I ) is a programme of suppor
facilitated by The Lullaby Trust (previously Foundation for the S tudy of I nfant D eaths
FS I D ) and provided by health visitors L( ullaby Trust 2013). Eligible parents are offered
training in resuscitation, monitoring equipment and extra visits and it is paramount
that they are referred to the scheme in the antenatal period to ensure that this care can
be facilitated in a timely way to allay anxiety.
Repeated spontaneous fetal loss may indicate such conditions as genetic
abnormality, hormonal imbalance or incompetent cervix (see Chapter 12). The woman
and her partner are likely to be worried about the pregnancy and continuity of carer in
these circumstances will be particularly valuable. I f there is a history of unexplained
stillbirth, the woman should be referred for obstetric antenatal care (RCO G 2010).
S ome maternity units have special clinics for women who have experienced late fetal
loss and most have some means of alerting staff that a woman has previously lost a
baby, often with tear-drop sticker in the hospital case notes ( S A N D S [S tillbirth and
N eonatal D eath S ociety] 2012). S taff do need to be mindful of painful anniversaries
and be prepared for parents to express a range of emotions, depending on their own
particular circumstances (Chapter 26).
Medical and surgical history
D uring pregnancy both the mother and the fetus may be affected by a medical
condition, or a medical condition may be altered by the pregnancy; if untreated there
may be serious consequences for the woman's health (CMACE 2011a). For example:
• Women with a history of thrombosis are at greater risk of recurrence during
pregnancy, more when over 30 years; have a Body Mass Index (BMI) over 25; have
prolonged bed rest; a family history of venous thromboembolism (VTE); have a
caesarean birth or travel by air (Farquharson and Greaves 2006). Thromboembolism
is the second highest cause of direct maternal death in the UK (CMACE 2011a). All
women should have a documented risk assessment for VTE at booking, using a
structured tool, and repeated if hospitalized (RCOG 2009). Appropriate
thromboprophylaxis and expert referral can be initiated depending on the level of
risk identified (Chapter 13).
• Hypertensive disorders encompass gestational hypertension (pre-eclampsia and
eclampsia) and chronic/essential hypertension. Essential hypertension is the
underlying factor in 90% of chronic cases (Walfish and Hallak 2006). NICE (2010b)
have produced evidence-based guidelines to support monitoring, referral and care
(Chapter 13).
• Other conditions, including asthma, epilepsy, infections and psychiatric disorders
may require medication, which may adversely affect fetal development. Suicide is a
leading cause of maternal death (Lewis 2007; CMACE 2011a), therefore any
psychiatric illness prior to the pregnancy must be fully explored so that the most
appropriate multidisciplinary care can be offered (NICE 2007) (see Chapter 25). Major
medical complications such as diabetes and cardiac conditions require the
involvement and support of a medical specialist (Chapter 13).
• Previous surgery should be documented as it may highlight previous problems with
anaesthesia or other conditions or complications of relevance. Any surgery of the
spine should be noted as this may have an impact on the woman's ability to have an
epidural or spinal in labour. Breast surgery may impact on her ability to breastfeed
depending on the technique involved. Previous pelvic or abdominal surgery may have
consequences requiring specialist advice.
• The woman should be asked if she is taking any medication, either prescribed or
over the counter. She should be advised not to take supplements that contain vitamin
A and seek advice from the pharmacist before taking any medication throughout
pregnancy and when breastfeeding.
Family history
Birth outcomes are multifactorial and may relate to familial or ethnic predisposition as
well as economic and social deprivation. The risk of black and A sian mothers having a
stillbirth is 2.1 and 1.6 respectively when compared to white mothers (CMA CE 2011b).
Black A frican and black Caribbean women have a significantly higher maternal
mortality rate than white women, although the trend is declining. O verall, 42% of
direct deaths were from minority ethnic or black groups and 1 in 10 maternal deaths
were to non-English speaking woman (CMACE 2011a).
Genetic disease in the baby is more likely to occur if the biological parents are close
relatives such as first cousins. In a large prospective study (Bundey and Aslam 1993), it
is reported that the prevalence of recessive disorders in European babies was 0.28%,
compared with 3% in the British Pakistanis in the study. Hence, while there is an
increased risk of recessive genetic disorders in babies born to married cousins, most
babies are healthy. However, there is a lack of information for parents at risk and they
face the additional barriers of fear, stigma and language barriers (Khan et al 2010).
W here it has been identified that a couple are first cousins, genetic counselling should
be offered.
D iabetes, although not inherited, leads to a predisposition in other family members,
particularly if they become pregnant or obese. S creening for gestational diabetes is
now recommended for women with a BMI of 30 or more; previous baby weighing
4.5 kg or more; previous gestational diabetes and/or first-degree relative with diabetes
(NICE 2008). Hypertension also has a familial component and multiple pregnancy has
a higher incidence in certain families. S ome conditions such as sickle cell anaemia and
thalassaemia are more common in those of black Caribbean, A frican-Caribbean,
A frican, Pakistani, Cypriot, Bangladeshi and Chinese ethnicity N ( I CE 2008); and the
Family O rigin Q uestionnaire (FO Q ) is used at the booking visit to screen couples at
risk (Chapter 11).
Lifestyle
Healthy eating
General health should be discussed and good habits reinforced, giving further advice
when required. A ll women should be provided with information about healthy eating,
and vitamin D supplementation (10 micrograms per day) is suggested for all women
during pregnancy and breastfeeding to maintain bone and teeth health (N I CE 2008).
Particular recommendation should be given to women at risk of deficiency (NICE
2008). W omen should take 400 micrograms of folic acid each day prior to pregnancy
and until 12 weeks' gestation to reduce the risk of a neural tube defect. S ome women,
such as those on anticonvulsant medication, especially sodium valproate, are at
increased risk of having a fetus affected by a neural tube defect. I n such cases it is
recommended that the woman consults her GP and takes a higher dose of 5
milligrams (5 mg) of folic acid.
The midwife should advise the woman about eating a balanced diet during
pregnancy and not ‘eating for two’ ( NICE 2010c). I t is currently not recommended that
women a empt to lose weight during pregnancy. W omen should also be informed
about which foods they should avoid, e.g. pate, liver products and soft cheeses; food to
limit, e.g. tuna, caffeine; and foods where precaution is needed, e.g. sushi and eggs.
Full details can be found on the Food Standards Agency (2013) website.
Exercise
NICE (2010c) require health professionals to discuss how physically active a woman is
at her first antenatal visit, providing her with tailored information and advice. Usual
aerobic or strength conditioning exercise should be continued (RCO G 2006). N ot only
will this enhance general wellbeing, but also reduce stress and anxiety and prepare the
body for the challenge of labour. A ny activity that can cause trauma or physical injury
to the woman or fetus should be avoided (RCOG 2006). I n addition, N I C E(2010c) also
recommend at least 30 minutes of moderate activity each day, keeping sedentary
activities to a minimum. S exual intercourse during pregnancy may continue and has
been found to reduce the likelihood of preterm labour between 29 and 36 weeks (Sayle
et al 2001).
Smoking
A pproximately 13.3% of women are smokers at the time they give birth (D H 2011),
however the rate varies between cities and between wards within cities. S ome women
may be ready to cut down or give up smoking, while others may not want to change
their smoking behaviour (Prochaska 1992). The midwife can be influential in
motivating the woman to quit smoking by complying with N I CE guidelines (2010d).
S he should offer carbon monoxide (CO ) screening to all women at each antenatal
contact and refer women to a stop smoking service if they smoke or their CO level is 7
parts per million (ppm) or more. This provides an opportunity to provide non-
judgemental advice and support (Grice and Baston 2011). S moking in pregnancy is
associated with birth defects (Huckshaw et al 2011) and a range of conditions that
compromise the infant's health and wellbeing including: low birth weight, intellectual
impairment, respiratory dysfunction, S udden I nfant D eath S yndrome and premature
birth (Godfrey et al 2010).
N icotine replacement therapy should be discussed with women having difficulty
qui ing smoking (N I CE 2010d) but only used if she is abstaining from smoking. The
woman, her partner and other family members should be informed about the direct
and passive effects of smoking on the baby and aim to have a smoke-free home.
Family members should be directed to S top S moking S ervices as living with a smoker
makes it very difficult for pregnant women to quit (Koshy et al 2010).
Alcohol and drug misuse
The effects of excessive maternal alcohol on the fetus are marked, particularly in the
1st trimester when fetal alcohol syndrome can develop. This syndrome consists of
restricted growth, facial abnormalities, central nervous system problems, behavioural
and learning difficulties and is entirely preventable ( Thackray and Tifft 2001). I t is
recommended that pregnant women abstain from alcohol during the first trimester
and drink no more than one to two UK units once or twice a week thereafter (NICE
2008). The midwife also needs to ask prospective parents if they take illicit drugs,
regardless of their social status. Many maternity units have a substance misuse team
that can support the care of women who abuse alcohol/drugs. S uch care should be
provided by a named midwife or doctor who has specialized knowledge and
experience in this field (NICE 2010a).
Risk assessment
The booking assessment shapes the direction of a woman's antenatal pathway. I t is
where her ‘risk status’ ( CMA CE 2011a ) is determined and appropriate referral made.
The information gathered regarding the woman's obstetric, medical and social history
and current pregnancy enables the midwife to assess her risk status. The midwife
must also seek additional information from the GP (CMA CE 2011a ) and access
previous case notes to elicit all the relevant information. I f a risk factor is identified
(see Box 10.4) the woman should be referred to a consultant obstetrician, who will
discuss a plan for care for her based on the need to access additional expertise and
resources. Place of birth may also be influenced by the risk assessment but in all cases
the ultimate decision is taken by the woman. W here a woman choses a path of care
that could cause significant harm to her or her baby, the midwife should discuss the
evidence with her, document these discussions and inform someone in authority of
her concerns (N MC 2008: 5). The midwife should listen to a woman's rationale for
requesting a particular path of care and respect her right to decline treatment (NMC
2008:3). A dvice can always be sought from a supervisor of midwives, 24 hours a day
(NMC 2012).
Physical examination
Prior to conducting the physical examination of a pregnant woman, her consent and
comfort are primary considerations. O bservation of physical characteristics is
important. Poor posture and gait can indicate back problems or previous trauma to the
pelvis. The woman may be lethargic, which could be an indication of extreme
tiredness, anaemia, malnutrition or depression. I t is therefore important to look
holistically at the woman and her family and assess fetal growth and development by
recognized markers in conjunction with this knowledge.
Weight
O besity is literally a growing problem, with approximately 16% of women starting
pregnancy with a BMI of 30 kg/m2 (Heslehurst et al 2010). There are no evidence-based
UK guidelines regarding what constitutes normal weight gain in pregnancy (NICE
2010c). However, in the United S tates (US ) it is recommended that women of normal
BMI should gain between 11.5 and 16 kg (R asmussen and Yaktine 2009). Referral to an
obstetrician should be made if the woman's BMI is <18 kg/m2 or ≥30 kg/m2 (NICE
2008). W omen with a BMI in the obese range are more at risk of complications of
pregnancy. These may include gestational diabetes, pregnancy-induced hypertension
(PI H) and shoulder dystocia. There may also be difficultyin palpating the fetal parts
and defining presentation, position or engagement of the fetus. O verweight or
underweight women should be carefully monitored, have additional care from an
obstetrician, and be offered appropriate support, including nutritional counselling
within the multiprofessional team (see Chapter 13). W omen with a BMI of 30 or more
should be offered a glucose tolerance test. There is emerging evidence (Thangaratinam
et al 2012) that maternal and neonatal outcomes can be improved by lifestyle and
dietary interventions that reduce maternal weight gain, but is currently not advised to
lose weight during pregnancy.
Blood pressure
Blood pressure is taken in order to ascertain normality and provide a baseline reading
for comparison throughout pregnancy. S ystolic blood pressure does not alter
significantly in pregnancy, but diastolic falls in mid-pregnancy and rises to near non-
pregnant levels at term. The systolic recording may be falsely elevated if a woman is
nervous or anxious, if a small cuff is used on a large arm, the arm is unsupported or if
the bladder is full. The woman should be comfortably seated or resting in a lateral
position on the couch for the measurement. Brachial artery pressure is highest when
the subject is si ing and lower when in the recumbent position. Current opinion is
that Korotkoff V should be used (Walfish and Hallak 2006).
Urinalysis
At the first visit the woman should be offered screening to exclude asymptomatic
bacteriuria (N I CE 2008; N S C [N ational S creening Commi ee] 2012a ). Because the
condition is asymptomatic the woman is unaware of disease; treatment could reduce
the risk of pyelonephritis and preterm labour (Williams 2006) (see Chapter 11).
Urinalysis is performed at every visit to exclude proteinuria which may be a
symptom of pre-eclampsia (N I CE 2008) (see Chapter 13) . N I CE (2008) does not
currently recommend routine testing for glycosuria.
Blood tests
The midwife should explain why blood tests are carried out at the booking visit to
facilitate informed decision making about the tests that are available. There are many
views as to the ethical issues involved in screening. I t is important to gain informed
consent for any blood tests undertaken (N MC 2008) and offer appropriate counselling
before and after the screening is carried out.
The midwife should be fully aware of the difference between screening and
diagnostic tests, and their accuracy, and discuss these options with women. Blood tests
offered at the initial assessment include the following.
ABO blood group and Rhesus (Rh) factor
I t is important to identify the blood group, RhD status and red cell antibodies in
pregnant women, so haemolytic disease of the newborn (HD N ) can be prevented and
preparations made for blood transfusion if it becomes necessary. Blood will be taken
at booking and again at 28 weeks to determine if antibodies are present (N I CE 2008).
A ll Rh-negative women will be offered two doses of prophylactic anti-D 500
I nternational Units (I U) at 28 and 34 weeks' gestation or a single dose of 1500 I U at 28–
30 weeks' gestation (N I CE 2008). Threatened miscarriage, amniocentesis, chorionic
villus sampling, external cephalic version or any other uterine trauma are indications
for the administration of anti-D gammaglobulin within a 72 hours of the event in
pregnancy in addition to that given at 28 and 34 weeks (RCOG 2011a). A Kleihauer test
should be undertaken to assess how much anti-D is required (RCO G 2011a). I f the
titration demonstrates a rising antibody response then more frequent assessment will
be made in order to plan management by a specialist in Rhesus disease (see Chapter
11).
Full blood count
This is taken to observe the woman's general blood condition, and includes
haemoglobin (Hb) estimations. I f the mean cell volume (MCV) is found to be low on
the full blood count result, serum ferritin levels are also taken in order to assess the
adequacy of iron stores. I ron supplementation is not considered necessary in women
who are taking adequate dietary iron and who have a normal Hb and MCV at the
initial assessment.
There is evidence that supplementing non-anaemic women with iron can increase
the risk of hypertension and the small for gestational age birth rate (Ziaei et al 2007).
The decision to use supplements should be made on an individual woman's
circumstances and include clear information about dietary iron sources. Maximum
absorption of iron in meat or green leafy vegetables will be achieved by consuming
vitamin C at the same time and avoiding caffeine. The intestinal mucosa has a limited
ability to absorb iron and when this is exceeded extra iron is excreted in the stools.
Other screening tests
Venereal disease research laboratory (VDRL) test
This is performed for syphilis. N ot all positive results indicate active syphilis; early
testing will allow a woman to be treated in order to prevent infection of the fetus (see
Chapter 11).
HIV antibodies
Routine screening to detect HI V infection should be offered in pregnancy (N S C 2013)
as treatment in pregnancy is beneficial in reducing vertical transmission to the fetus
(Chapter 11). S pecialist teams should be involved in the subsequent care and
management of women with a positive diagnosis.
Rubella immune status
This is determined by measuring the rubella antibody titre (Chapter 11). W omen who
are not immune must be advised to avoid contact with anyone with the disease. The
live vaccination is offered postnatally, and subsequent pregnancy must be avoided for
at least 3 months.
Haemoglobinopathies
A ll women should be offered screening for sickle cell disease or thalassaemias early in
pregnancy. S ome ethnic groups have a higher incidence than others and the type of
screening will depend on the prevalence (N I CE 2008). I f a woman either has or is a
carrier of one of these diseases her partner's blood should also be tested. The couple
will be offered genetic counselling and management during pregnancy will be
explained (Chapter 11).
Hepatitis B
S creening is offered in pregnancy so that infected women can be offered postnatal
intervention to reduce the risk of mother-to-baby transmission (N I CE 2008) . Chapter
11 explores this issue in more detail.
Screening for fetal anomaly
The midwife will also explain to the woman the current options regarding fetal
anomaly screening and provide her with wri en information to enable her to make an
informed choice. S he will inform her about the routine dating and anomaly scans
which are part of the screening programme. See Chapter 11 for further details.
Infections NOT routinely screened for in pregnancy
Hepatitis C
This is currently not recommended as a routine screening test in pregnancy because
there is insufficient evidence regarding the prevalence and effectiveness of treatments
to reduce transmission to the baby (NSC 2013).
Chlamydia
I t is not recommended that all women are routinely screened (N S C 2011), however
women under 25 years of age are offered this as part of the N ational Chlamydia
Screening Programme (Public Health England 2013).
Cytomegalovirus and toxoplasmosis
These are not routinely tested in pregnancy because tests do not currently determine
which pregnancies may result in an infected fetus (N I CE 2008). Toxoplasmosis
screening is not recommended because the risks of screening may outweigh the
benefits; however, women need to be informed of how to avoid contracting the
infection (NICE 2008).
Group B streptococcus
T he N S C (2012b) reviewed this guidance and conclude that screening should not be
offered currently but might be a consideration in the future (see Chapter 11).
The midwife's examination
The midwife's general examination of the woman should be holistic and encompass
the woman's physical, social and psychological wellbeing. This antenatal contact gives
the midwife an opportunity to look at the woman's face and assess her health and
general wellbeing, including demeanour and signs of fatigue. I f at any time the
midwife notices any sign of ill health she should discuss this with the woman, and
advocate referral to the most appropriate health professional (NMC 2012).
The midwife should facilitate discussion about infant feeding throughout pregnancy
(UN I CEF [United N ations Children's Fund] 2012 ). W here breastfeeding peer support
is available, introductions should be made so that postnatal support can be more
easily accessed. Breastfeeding should be promoted in a sensitive manner, and
information given about the benefits to both mother and baby (Chapter 34). Most
women will not require an examination of their breasts. Current evidence does not
support the benefits of nipple preparation (see Chapter 34). The midwife may also
discuss the woman's experiences of breast changes so far in her pregnancy, and
expected changes as pregnancy progresses.
S ome women will appreciate information about the body changes taking place
during pregnancy. I ncreasing abdominal size may be an acceptable body change but
breast changes may not have been anticipated. For most women, breast size and
appearance are an important part of their body image. Partners may also be affected
by the changes and the midwife can encourage open and honest discussion between
the woman and her partner to help to resolve anxieties.
Bladder and bowel function may be discussed; dietary advice may be necessary at
this visit or later in the pregnancy with reference to how hormonal changes may alter
normal bowel and kidney function. Early referral within the multidisciplinary team
will be necessary if treatment is required or problems identified. Vaginal discharge
(leucorrhoea) increases in pregnancy; the woman may discuss any increase or changes
with the midwife. I f the discharge is itchy, causes soreness, is any colour other than
creamy-white or has an offensive odour then infection is likely, and should be
investigated further. Later in pregnancy the woman may report a change from
leucorrhoea to a heavier mucous discharge.
Early bleeding is not uncommon, however if this is reported the woman can be
referred to an Early Pregnancy A ssessment Unit for confirmation of pregnancy and
advice and appropriate care and follow-up. Ultrasound will usually confirm a
diagnosis. The woman may require anti-D immunoglobulin if she is Rhesus-negative
within 72 hours (see Chapter 22 for management of antepartum haemorrhage).
I n the past midwives have palpated the uterus once it has entered the abdomen,
from about 12 weeks' gestation; however, current guidelines suggest that because of
sophisticated scanning techniques there is no benefit in palpating the uterus prior to
24 weeks' gestation, at which time uterine growth can be measured (NICE 2008).
Oedema
This should not be evident during the initial assessment but may occur as the
pregnancy progresses. Physiological oedema occurs after rising in the morning and
worsens during the day; it is often associated with daily activities or hot weather. At
visits later in pregnancy the midwife should observe for oedema and ask the woman
about symptoms. O ften the woman may notice that her rings feel tighter and her
ankles are swollen. Pi ing oedema in the lower limbs can be identified by applying
gentle fingertip pressure over the tibial bone: a depression will remain when the
finger is removed. I f oedema reaches the knees, affects the face or is increasing in the
fingers it may be indicative of hypertension of pregnancy if other markers are also
present.
Varicosities
These are more likely to occur during pregnancy and are a predisposing cause of deep
vein thrombosis. The woman should be asked if she has any pain in her legs.
Reddened areas on the calf may be due to varicosities, phlebitis or deep vein
thrombosis. A reas that appear white as if deprived of blood could be caused by deep
vein thrombosis. The woman should be asked to report any tenderness that she feels
either during the examination or at any time during the pregnancy. Referral should be
made to medical colleagues as appropriate (N MC 2012). S upport stockings will help
alleviate symptoms although not prevent varicose veins occurring (NICE 2008).
Abdominal examination
A bdominal examination is carried out from 24 weeks' gestation to establish and affirm
that fetal growth is consistent with gestational age during the pregnancy. The specific
aims are to:
• observe the signs of pregnancy
• assess fetal size and growth
• auscultate the fetal heart when indicated
• locate fetal parts
• detect any deviation from normal.
Preparation
The woman should be asked to empty her bladder before making herself comfortable
on the couch. A full bladder will make the examination uncomfortable; this can also
make the measurement of fundal height less accurate. The midwife washes her hands
and exposes only that area of the abdomen she needs to palpate, and covers the
remainder of the woman to promote privacy and protect her dignity. The woman
should be lying comfortably with her arms by her sides to relax the abdominal
muscles. The midwife should discuss her findings throughout the abdominal
examination with the woman.
Inspection
The uterus is first assessed by observation. A full bladder, distended colon or obesity
may give a false impression of fetal size. The shape of the uterus is longer than it is
broad when the lie of the fetus is longitudinal, as occurs in the majority of cases. I f the
lie of the fetus is transverse, the uterus is low and broad.
The multiparous uterus may lack the snug ovoid shape of the primigravid uterus.
O ften it is possible to see the shape of the fetal back or limbs. I f the fetus is in an
occipitoposterior position a saucer-like depression may be seen at or below the
umbilicus. The midwife may observe fetal movements, or the mother may feel them;
this can help the midwife determine the position of the fetus. The woman's umbilicus
becomes less dimpled as pregnancy advances and may protrude slightly in later
weeks.
Lax abdominal muscles in the parous woman may cause the uterus to sag forwards;
this is known as pendulous abdomen or anterior obliquity of the uterus. I n the
primigravida it is a significant sign as it may be due to pelvic contraction.
Skin changes
S tretch marks from previous pregnancies appear silvery and recent ones appear pink.
A linea nigra may be seen; this is a normal dark line of pigmentation running
longitudinally in the centre of the abdomen below and sometimes above the
umbilicus. Scars may indicate previous obstetric or abdominal surgery or self-harm.
Palpation
The midwife's hands should be clean and warm; cold hands do not have the necessary
acute sense of touch, they tend to induce contraction of the abdominal and uterine
muscles and the woman may find palpation uncomfortable. A rms and hands should
be relaxed and the pads, not the tips, of the fingers used with delicate precision. The
hands are moved smoothly over the abdomen to avoid causing contractions.
Measuring fundal height
I n order to determine the height of the fundus the midwife places her hand just below
the xiphisternum. Pressing gently, she moves her hand down the abdomen until she
feels the curved upper border of the fundus (Fig. 10.1).
FIG. 10.1 Assessing the fundal height in finger-breadths below the xiphisternum.
Clinically assessing the uterine size to compare it with gestation does not always
produce an accurate result, although there are landmarks that can be used as an
approximate guide (see Fig. 10.2). From 25 weeks of pregnancy, the midwife should
commence serial symphysis fundal height (S FH) measurements (F ig. 10.3). S he uses a
tape measure (with the centimetres facing the mother's abdomen) held at the fundus
and extended down to the symphysis pubis, to take a single measurement. This should
be recorded in the pregnancy record and plo ed on a customized chart rather than a
population-based chart (RCOG 2013b).
FIG. 10.2 Growth of the uterus, showing the fundal heights at various weeks of pregnancy.
FIG. 10.3 Measuring fundal height. (From Morse K, Williams A, Gardosi J 2009 Fetal growth screening by
fundal height measurement. Best Practice & Research Clinical Obstetrics and Gynaecology 23:809–18.
www.perinatal.org.uk/FetalGrowth/FundalHeight.aspx. Reproduced with permission.)
Further investigation is warranted and an ultrasound scan will usually be required
alongside appropriate medical referral, if:
• a single measurement plots below the 10th centile; or
• serial measurements show slow growth by crossing centiles (RCOG 2013b).
I f the uterus is unduly big the fetus maybe large or it may indicate multiple
pregnancy or polyhydramnios. W hen the uterus is smaller than expected the LMP date
may be incorrect, or the fetus may be small for gestational age (S GA). Fetal growth
restriction (FGR) is associated with stillbirth and expert opinion suggests that early
detection and management can reduce the incidence by 20% (Imdad et al 2011).
Fundal palpation
This determines the presence of the breech or the head in the fundus. This
information will help to diagnose the lie and presentation of the fetus. Talking
through the palpation with the woman, making eye contact with her during the
procedure, the midwife lays both hands on the sides of the fundus, fingers held close
together and curving round the upper border of the uterus. Gentle yet deliberate
pressure is applied using the palmar surfaces of the fingers to determine the soft
consistency and indefinite outline that denotes the breech. S ometimes the bu ocks
feel rather firm but they are not as hard, smooth or well defined as the head. With a
gliding movement the fingertips are separated slightly in order to grasp the fetal mass,
which may be in the centre or deflected to one side, to assess its size and mobility. The
breech cannot be moved independently of the body but the head can (Fig. 10.4). The
head is much more distinctive in outline than the breech, being hard and round; it can
be balloted (moved from one hand to the other) between the fingertips of the two
hands because of the free movement of the neck.
FIG. 10.4 Fundal palpation. Palms of hands on either side of the fundus, fingers held close
together palpate the upper pole of the uterus.
Lateral palpation
This is used to locate the fetal back in order to determine position. The hands are
placed on either side of the uterus at the level of the umbilicus (Fig. 10.5). Gentle
pressure is applied with alternate hands in order to detect which side of the uterus
offers the greater resistance. More detailed information is obtained by feeling along
the length of each side with the fingers. This can be done by sliding the hands down
the abdomen while feeling the sides of the uterus alternately. Some midwives prefer to
steady the uterus with one hand, and using a rotary movement of the opposite hand,
to map out the back as a continuous smooth resistant mass from the breech down to
the neck; on the other side the same movement reveals the limbs as small parts that
slip about under the examining fingers.
FIG. 10.5 Lateral palpation. Hands placed at umbilical level on either side of the uterus.
Pressure is applied alternately with each hand.
‘Walking’ the fingertips of both hands over the abdomen from one side to the other
is another method of locating the fetal back (Fig. 10.6).
FIG. 10.6 ‘Walking’ the fingertips across the abdomen to locate the position of the fetal back.
Pelvic palpation
Pelvic palpation will identify the pole of the fetus in the pelvis; it should not cause
discomfort to the woman. N I C E(2008) recommend this is done only from 36 weeks
onwards.
The midwife should ask the woman to bend her knees slightly in order to relax the
abdominal muscles and also suggest that she breathe steadily; relaxation may be
helped if she sighs out slowly. The sides of the uterus just below umbilical level are
grasped snugly between the palms of the hands with the fingers held close together,
and pointing downwards and inwards (Fig. 10.7).
FIG. 10.7 Pelvic palpation. The fingers are directed inwards and downwards.
I f the head is presenting (towards the lower part of the uterus), a hard mass with a
distinctive round smooth surface will be felt. The midwife should also estimate how
much of the fetal head is palpable above the pelvic brim to determine engagement.
This two-handed technique appears to be the most comfortable for the woman and
gives the most information.
Pawlik's manoeuvre, where the practitioner grasps the lower pole of the uterus
between her fingers and thumb, which should be spread wide enough apart to
accommodate the fetal head (Fig. 10.8), is sometimes used to judge the size, flexion
and mobility of the head, but undue pressure must not be applied. I t should be used
only if absolutely necessary as it can be very uncomfortable for the woman: There is no
research evidence to support one method over the other.
FIG. 10.8 Pawlik's manoeuvre. The lower pole of the uterus is grasped with the right hand, the
midwife facing the woman's head.
Engagement
Engagement is said to have occurred when the widest presenting transverse diameter
of the fetal head has passed through the brim of the pelvis. I n cephalic presentations
this is the biparietal diameter and in breech presentations the bitrochanteric diameter.
I n a primigravid woman, the head normally engages at any time from about 36 weeks
of pregnancy, but in a multipara this may not occur until after the onset of labour.
Engagement of the fetal head is usually measured in fifths palpable above the pelvic
brim. W hen the vertex presents and the head is engaged the following will be evident
on clinical examination:
• only two- to three-fifths of the fetal head is palpable above the pelvic brim (Fig. 10.9);
FIG. 10.9 Descent of the fetal head estimated in fifths palpable above the pelvic brim.
• the head will not be mobile.
O n rare occasions, the head is not palpable abdominally because it has descended
deeply into the pelvis. If the head is not engaged, the findings are as follows:
• more than half of the head is palpable above the brim
• the head may be high and freely movable (ballotable) or partly settled in the pelvic
brim and consequently immobile.
I n a primigravid woman, it is usual for the head to engage by 37 weeks' gestation;
however this is not always the case. W hen labour starts, the force of labour
contractions encourages flexion and moulding of the fetal head and the relaxed
ligaments of the pelvis allow the joints to give. This is usually sufficient to allow
engagement and descent. Other causes of a non-engaged head at term include:
• occipitoposterior position
• full bladder
• wrongly calculated gestational age
• polyhydramnios
• placenta praevia or other space-occupying lesion
• multiple pregnancy
• pelvic abnormalities
• fetal abnormality.
Presentation
Presentation refers to the part of the fetus that lies at the pelvic brim or in the lower
pole of the uterus. Presentations can be vertex, breech, shoulder, face or brow (Fig.
10.10). Vertex, face and brow are all head or cephalic presentations.
FIG. 10.10 The five presentations.
W hen the head is flexed the vertex presents; when it is fully extended the face
presents; and when it is partially extended the brow presents (Fig. 10.11). I t is more
common for the head to present because the bulky breech finds more space in the
fundus, which is the widest diameter of the uterus, and the head lies in the narrower
lower pole. The muscle tone of the fetus also plays a part in maintaining its flexion and
consequently its vertex presentation.
FIG. 10.11 Varieties of cephalic or head presentation.
Auscultation
Listening to the fetal heart has historically been an important part of the process.
However, N I CE (2008)does not recommend routine listening other than at maternal
request because there is no clinical benefit. A Pinard's fetal stethoscope will enable the
midwife to hear the fetal heart directly and determine that it is fetal and not maternal.
The stethoscope is placed on the mother's abdomen, at right-angles to it over the fetal
back (Fig. 10.12). The ear must be in close, firm contact with the stethoscope but the
hand should not touch it while listening because then extraneous sounds are
produced. The stethoscope should be moved about until the point of maximum
intensity is located where the fetal heart is heard most clearly. The midwife should
count the beats per minute, which should be in the range of 110–160. The midwife
should take the woman's pulse at the same time as listening to the fetal heart to
enable her to distinguish between the two. I n addition, ultrasound equipment (e.g. a
sonicaid or D oppler) can be used for this purpose so that the woman and her
partner/children may also hear the fetal heartbeat.
FIG. 10.12 Auscultation of the fetal heart. Vertex right occipitoanterior.
Lie
The lie of the fetus is the relationship between the long axis of the fetus and the long
axis of the uterus (Figs 10.13–10.15). I n the majority of cases the lie is longitudinal due
to the ovoid shape of the uterus; the remainder are oblique or transverse. O blique lie,
when the fetus lies diagonally across the long axis of the uterus, must be distinguished
from obliquity of the uterus, when the whole uterus is tilted to one side (usually the
right) and the fetus lies longitudinally within it. W hen the lie is transverse the fetus
lies at right angles across the long axis of the uterus. This is often visible on inspection
of the abdomen.
FIG. 10.13 The longitudinal lie. Confusion sometimes exists regarding the lie seen
in (C), which gives the impression of an oblique lie, but the fetus is longitudinal in
relation to the uterus and merely moving the uterus abdominally rectifies the
presumed obliquity.
FIG. 10.14 Shows an oblique lie because the long axis of the fetus is oblique in
relation to the uterus.
FIG. 10.15 Shows a transverse lie with shoulder presentation.
FIGS 10.13–10.15 The lie of the fetus.
Attitude
A itude is the relationship of the fetal head and limbs to its trunk. The a itude
should be one of flexion. The fetus is curled up with chin on chest, arms and legs
flexed, forming a snug, compact mass, which utilizes the space in the uterine cavity
most effectively. I f the fetal head is flexed the smallest diameters will present and,
with efficient uterine action, labour will be most effective.
Denominator
‘D enominate’ means ‘to give a name to’; the denominator is the name of the part of
the presentation, which is used when referring to fetal position. Each presentation has
a different denominator and these are as follows:
• in the vertex presentation it is the occiput
• in the breech presentation it is the sacrum
• in the face presentation it is the mentum.
A lthough the shoulder presentation is said to have the acromion process as its
denominator, in practice the dorsum is used to describe the position. I n the brow
presentation no denominator is used.
Position
The position is the relationship between the denominator of the presentation and six
points on the pelvic brim (Fig. 10.16). I n addition, the denominator may be found in
the midline either anteriorly or posteriorly, especially late in labour. This position is
often transient and is described as direct anterior or direct posterior.
FIG. 10.16 Diagrammatic representation of the six vertex positions and their relative frequency. LOA, left
occipitoanterior; LOL, left occipitolateral; LOP, left occipitoposterior; ROA, right occipitoanterior;
ROL, right occipitolateral; ROP, right occipitoposterior.
A nterior positions are more favourable than posterior positions because when the
fetal back is at the front of the uterus it conforms to the concavity of the mother's
abdominal wall and the fetus can flex more easily. W hen the back is flexed the head
also tends to flex and a smaller diameter presents to the pelvic brim. There is also
more room in the anterior part of the pelvic brim for the broad biparietal diameter of
the head. The positions in a vertex presentation are summarized in Box 10.6 and shown
in Fig. 10.17.
Box 10.6
P osit ions in a ve rt e x pre se nt a t ion (F ig. 1 0 .1 6)
• Left occipitoanterior (LOA) The occiput points to the left iliopectineal
eminence; the sagittal suture is in the right oblique diameter of the pelvis.
• Right occipitoanterior (ROA) The occiput points to the right iliopectineal
eminence; the sagittal suture is in the left oblique diameter of the pelvis.
• Left occipitolateral (LOL) The occiput points to the left iliopectineal line
midway between the iliopectineal eminence and the sacroiliac joint; the
sagittal suture is in the transverse diameter of the pelvis.
• Right occipitolateral (ROL) The occiput points to the right iliopectineal
line midway between the iliopectineal eminence and the sacroiliac joint;
the sagittal suture is in the transverse diameter of the pelvis.
• Left occipitoposterior (LOP) The occiput points to the left sacroiliac joint;
the sagittal suture is in the left oblique diameter of the pelvis.
• Right occipitoposterior (ROP) The occiput points to the right sacroiliac
joint; the sagittal suture is in the right oblique diameter of the pelvis.
• Direct occipitoanterior (DOA) The occiput points to the symphysis pubis;
the sagittal suture is in the anteroposterior diameter of the pelvis.
• Direct occipitoposterior (DOP) The occiput points to the sacrum; the
sagittal suture is in the anteroposterior diameter of the pelvis.
I n breech and face presentations the positions are described in a similar
way using the appropriate denominator.
FIG. 10.17 Six positions in vertex presentation.
Findings
Findings
The findings from the abdominal palpation should be considered part of the holistic
assessment of the pregnant woman's health and fetal wellbeing. The midwife collates
all the information she has gathered from inspection, palpation and auscultation and
relays this to the woman. D eviation from the expected growth and development
should be discussed with the woman and referral to an obstetrician or appropriate
professional arranged and documented as appropriate (NMC 2012).
Ongoing antenatal care
The information gathered during the antenatal visits will enable the midwife and
pregnant woman to determine the appropriate pa ern of antenatal care (N I CE 2008).
The timing and number of visits will vary according to individual need and changes
should be made as circumstances dictate (e.g. as demonstrated in Box 10.7).
Box 10.7
R isk fa ct ors t ha t m a y a rise during pre gna ncy
• Any chronic or acute illness or disease in the woman Hb lower than
10.5 g/dl
• Proteinuria
• BP: single diastolic of 110 mgHg or two of 90 mmHg at least 4 hours apart;
two systolic of above 160 mmHg at least 4 hours apart
• Uterus large or small for gestational age
• Excess or decreased liquor
• Malpresentation
• Fetal movement pattern significantly reduced or changed
• Any vaginal, cervical or uterine bleeding
• Premature labour
• Infection
• Sociological or psychological factors
Indicators of maternal wellbeing
The woman's general health and wellbeing is observed throughout and the midwife
must remain vigilant for signs of domestic abuse, emotional fragility and social
instability. Endeavouring to maintain continuity of carer will be a key process for
identifying impending problems and for encouraging free exchange of information
between the woman and her midwife. There should be clear referral pathways for the
midwife to follow when she has cause for concern regarding a woman's obstetric,
social or emotional wellbeing.
S urveillance for symptoms of pre-eclampsia is ongoing throughout pregnancy. I t
has been recommended by N I CE (2008: para 1.9.2.5) that if there is a ‘single diastolic
blood pressure of 110 mmHg or two consecutive readings of 90 mmHg at least 4 hours
apart and/or significant proteinuria (1+)’, there should be an increase in surveillance
(see Chapter 13).
Indicators of fetal wellbeing
These include:
• increasing uterine size compatible with the gestational age of the fetus;
• fetal movements that follow a regular pattern from the time when they are first felt;
• fetal heart rate that is regular and variable with a rate between 110 and 160
beats/minute.
Eliciting information about recent fetal movements reminds the woman of the
importance of noticing this feedback from her baby. W omen should be reminded that
there should be no reduction in fetal movements in the last trimester (RCO G 2011b)
and to contact their midwife if they notice a reduction. Recurrent reduction in fetal
movements is associated with a poor fetal outcome (O 'S ullivan et al 2009). However,
NICE (2008), and subsequently supported by I mdad et al (2011), does not recommend
routine fetal movement counting as there is insufficient evidence that it improves fetal
wellbeing.
Preparation for labour
Perineal massage
W omen should be informed that there is evidence that perineal massage from 35
weeks of pregnancy is effective in reducing the likelihood of perineal damage during
the birth (Beckmann and Garre 2006) (and see Chapter 15). This can be undertaken
by the woman or her partner just once or twice a week with a significant positive
impact on her perineal integrity and postnatal pain (Chapter 23).
Stretch and sweep
N I CE guidelines (2008) recommend that the midwife offers a membrane sweep to
women who have not given birth by 41 weeks. More recently, the A ntenatal Q uality
S tandard (N I CE 2012) recommends at 40 and 41 weeks for a primigravida (see Box
10.2). This procedure has been shown to reduce the number of women who require
induction of labour, and although this can be uncomfortable it is a safe and simple
technique (Boulvain et al 2005) (see Chapter 19).
Birth plans
D uring the la er weeks of pregnancy, expectations and plans for labour and birth will
be a focus of discussion. W omen should know when they should contact a midwife
and how to do so. I f the woman has planned a home birth, she will be visited by her
midwife to make final preparations. Most maternity units provide a list of items that
women will need to bring with them if they are planning to birth away from home. I n
all situations it is important to ensure that women know how to get advice if they have
any concerns.
A birth plan can be instrumental in assisting the woman towards having the birth
experience of her choice and to consider what she might like to do during labour and
what is important to her. Lundgren et al (2003) suggest that birth plans do not
enhance the childbirth experience for all but some women felt that aspects of pain,
fear and concern for their baby were alleviated by having a birth plan. Birth plans are
likely to be most effective if they are wri en with the midwife sharing information to
enable the woman to make plans that are informed by what is available locally and
what is considered current best practice and care.
Flexibility and adaptability should be built into the labour and birth plans to ensure
an individual approach is adopted and the woman's wishes are carefully considered.
Parents' wishes should be revisited when labour commences and discussions recorded
in the labour notes. Each woman should be aware that it may be necessary to adapt
her plans depending on the circumstances at the time, but be reassured that she will
be fully involved in all decisions made.
Home visit and safe sleeping advice
I t is practice in many units to undertake one of the antenatal visits at the woman's
home, in order to discuss arrangements for caring for the baby when it is born. This
may include seeing where the baby will sleep and advising on safe sleeping principles
(see Chapter 34). I t provides another opportunity to discuss keeping a smoke-free
home and ensuring that the woman knows how and when to make contact when
labour starts.
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two schedules of antenatal visits: the antenatal care project. British Medical
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sands.org/Support/Another-pregnancy/Antenatal-care.html; 2012 [(accessed 31
December 2012)] .
Thackray H, Tifft C. Fetal alcohol syndrome. Pediatrics in Review. 2001;22(2):47–55.
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pregnancy on maternal weight and obstetric outcomes: meta-analysis of
randomised evidence. British Medical Journal.
2012;344:e2088 www.bmj.com/content/344/bmj.e2088.
UNICEF (United Nations Children's Fund). UK Baby Friendly Initiative 2012 Guide
to the Baby Friendly Initiative standards. [Available at]
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2012 [(accessed 12 May 2013)] .
Villar J, Hassan B, Piaggio G, et al. WHO antenatal care randomized trial for the
evaluation of a new model of routine antenatal care. The Lancet.
2001;357(9268):1551–1564.
Walfish A, Hallak M. Hypertension. James P, Steer C, Weiner B, et al. High risk
pregnancy. 3rd edn. Elsevier: Philadelphia; 2006:772–797.
Williams D. Renal disorders. James D, Steer P, Weiner B, et al. High risk
pregnancy. 3rd edn. Elsevier: Philadelphia; 2006:1098–1124.
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to determine the effect of iron supplementation on pregnancy outcome in
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Further reading
Downe S, Finlayson K, Walsh D, et al. ‘Weighing up and balancing out’: a meta-
synthesis of barriers to antenatal care for marginalised women in high-income
countries. BJOG: An International Journal of Obstetrics and Gynaecology.
2009;116(4):519–529.
This article examines how care can be improved for disadvantaged pregnant women..
Raine R, Cartwright M, Richens Y, et al. A qualitative study of women's
experiences of communication in antenatal care: identifying areas for action.
Maternal and Child Health Journal. 2010;14:590–599.
An interesting paper highlighting the importance of effective communication as a
hallmark of high quality antenatal care..
Thomson G, Dykes F, Singh, et al. A public health perspective of women's
experiences of antenatal care: an exploration of insights from community
consultation. Midwifery. 2013;29(30):211–216.
A useful read that identifies why inequalities in antenatal care persist for the most
vulnerable in society..
Useful websites
Child and Maternal Health Intelligence Network. www.chimat.org.uk.
Cochrane Library – database of systematic reviews. www.thecochranelibrary.com.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
Royal College of Obstetricians and Gynaecologists – guidance.
www.rcog.org.uk/womens-health.
C H AP T E R 11
Antenatal screening of the mother and
fetus
Lucy Kean, Angie Godfrey, Amanda Sullivan
CHAPTER CONTENTS
Screening principles 204
Limitations of screening 204
Social and psychological impact of screening investigations 204
How screening is set up and the midwife's role and responsibilities 205
Documentation 205
Discussion of options 206
The process of consent 206
Issues to consider when presenting information 207
Explaining risk 207
Individual screening test considerations 208
Fetal screening tests 208
Screening for Down syndrome 208
Screening for haemoglobinopathies 210
Ultrasonography for fetal screening 211
New and emerging technologies 214
Screening for maternal conditions 214
Infectious diseases 214
New screening 215
Mid-stream urine testing 215
Screening for red cell antibodies 216
How the results are presented 216
What parents need to know 216
Management when an antibody is detected 216
On-going surveillance 217
Conclusion 217
References 217
Further reading 219
Useful websites 219
Screening has now become such a routine part of antenatal care that many
women accept this, often with little thought. There is no aspect of the
screening programme that does not, however, have the potential to raise
huge social, emotional and health issues for pregnant women. The role of
the midwife is to guide women through the wealth of tests available, with the
best advice possible. This can only be achieved by excellent training and
regular updates for all midwives and doctors. Screening develops and
moves forward every few months and so vigilance on behalf of us all is
needed to ensure we provide the best care.
The chapter aims to:
• discuss the principles of screening, good counseling techniques and the potential
impact of positive results on women
• describe the currently available screening tests, their aims, and the efficiency of each
test
• define what consent is and how the consent process should be undertaken
• provide information regarding how to deal with positive tests and what negative results
mean.
Screening principles
S creening of a mother and baby is now a major part of care for all pregnancies. The
underlying principles of screening are that the condition being screened for must be
important and well understood (i.e. something that makes a difference to health and
wellbeing and does more good than harm). Treatment should be available and at a
stage where the outcome can be changed. There should be an appropriate and
acceptable test that is available to a defined group, making the screening cost effective
in reducing poorer health outcomes.
The N ational S creening Commi ee of the United Kingdom N ( S C 2013) defines
screening as:
a process of identifying apparently healthy people who may be at an increased
risk of a disease or condition, they can then be offered information, further tests
and appropriate treatment to reduce their risk and/or any complications arising
from the disease or condition.
Broadly speaking, the conditions that form the national programme for screening in
the United Kingdom (UK) meet these criteria. W hen screening for currently
unscreened conditions is considered (e.g. Group B streptococcus), it is weighed against
these important criteria.
S creening in pregnancy can be divided into looking for conditions in the mother
that, if untreated or undetected, could affect her health or the health of the baby or
both, and screening for conditions in the fetus that could impact significantly on the
health of the baby.
Limitations of screening
S creening has important ethical differences from clinical practice as the health service
is targeting apparently healthy people, offering to help individuals to make be er
informed choices about their health. There are risks involved, however, and it is
important that people have realistic expectations of what a screening programme can
deliver.
W hile screening has the potential to save lives or improve life through early
diagnosis of serious conditions, it is not a foolproof process. Equally, some screening
is directed at detecting conditions in the fetus that may lead to significant handicap,
and to provide prospective parents with choices regarding continuation or otherwise
of the pregnancy.
S creening can reduce the risk of developing a condition or its complications but it
cannot offer a guarantee of protection. I n any screening programme there is a
minimum of false-positive results (wrongly reported as having the condition) and
false-negative results (wrongly reported as not having the condition). The UK N S C is
increasingly presenting screening as risk reduction to emphasize this point.
S creening can be an emotive issue. W hile screening for fetal problems is often
considered the most emotionally charged area, it is important to realize that maternal
screening can also raise issues and challenges that all health professionals involved in
the service need to be equipped to help with. I magine the emotional journey a mother
embarks on when faced with a new diagnosis of Human I mmunodeficiency Virus
(HIV) in early pregnancy.
Social and psychological impact of screening
investigations
Pregnancy is a profound and life-changing event. D uring this time the mother has to
adapt physically, socially and psychologically to the forthcoming birth of her child.
Many women feel more emotional than usual (Raphael-Leff 2005) and may have
heightened levels of anxiety (Kleinveld et al 2006; Raynor and England 2010). A s Green
et al (2004) state, the increasing availability of fetal investigations has been shown to
cause women even greater anxiety and stress. A ny feelings of excitement and
anticipation can quickly change when the mother is introduced to the idea that she is
‘at risk’ of having a baby with a particular problem (Fisher 2006).
There is evidence that mothers nearing the end of their reproductive years (with a
higher risk of chromosomal abnormality) experience pregnancy in a way that is
different to younger women. O lder mothers are often more anxious and have fewer
feelings of a achment to the fetus at 20 weeks of pregnancy (Berryman and Windridge
1999). Psychologists, sociologists and health professionals now generally accept the
finding that high-risk women delay a achment to the fetus until they receive
reassuring test results. Rothman (1986) classically termed this the ‘tentative pregnancy’,
in a study of women undergoing amniocentesis.
A nxiety caused by consideration of possible fetal abnormality may be accompanied
by moral or religious dilemmas. Tests that can diagnose chromosomal or genetic
abnormalities also carry a risk of procedure-induced miscarriage. Many parents
agonize about whether to subject a potentially normal fetus to this risk in order to
obtain this information. Parents may then need to consider whether they wish to
terminate or continue with an affected pregnancy. S ome religious authorities only
support prenatal testing so long as the integrity of the mother and fetus are
maintained. There are also opposing views about the legitimacy of terminating a
pregnancy, even when a serious disorder has been diagnosed. S uch dilemmas are an
unfortunate but inevitable cost of the choices associated with some fetal
investigations.
D espite this, there are important advantages to the acquisition of knowledge about
the fetus before birth. First, society greatly values the freedom of individuals to
choose. People are encouraged to accept some responsibility when making decisions
about treatment options, in partnership with healthcare professionals. A second
advantage is that reproductive autonomy may be increased. W omen can choose for
themselves whether they wish to embark upon the lifelong care of a child with special
needs. This may be viewed as empowering and as a means of preventing later
suffering and hardship for child and family alike.
I n summary, prenatal testing is a two-edged sword. I t enables midwives and doctors
to give people choices that were unheard of in previous generations and that may
prevent much suffering. However, in some circumstances they actually increase the
amount of anxiety and psychological trauma experienced in pregnancy. The long-term
effects of such trauma on family dynamics are not currently understood.
How screening is set up and the midwife's role and
responsibilities
A ll midwives need to have a broad understanding of screening investigations because
they are responsible for offering, interpreting and communicating the results. I n the
UK, the Midwives Rules and S tandards N ( MC 2012) state that midwives should work
in partnership with women to provide safe, responsive and compassionate care. This
implies that the midwife as a key public health agent should enable women to make
decisions about their care based on individual needs. S ome midwives specialize in
discussing complex testing issues with parents and become antenatal screening
coordinators.
I n England from 1 A pril 2013, 27 S creening and I mmunisation Teams will have the
responsibility for commissioning and oversight of the UK N ational S creening
Commi ee (N S C) A ntenatal and N ewborn S creening programmes. The UK N S C ha
the overall responsibility for determining these programmes and will ensure the
Quality Assurance aspect via Regional Quality Assurance Teams.
The UK NSC (2011a) recommends that dedicated screening coordinators oversee the
running of screening programmes in every Trust. S creening coordinators also provide
specialist advice and ensure that there is a line of referral for women whose needs are
not met by routine services. S creening for pregnant women and newborn babies is
now such a complex process that the role of screening coordinator has become a full-
time role in most services.
The UK N S C publishes an extremely helpful timeline for antenatal and newborn
screening that will help individuals to see what is required and by when
(http://cpd.screening.nhs.uk/timeline).
Each of the individual screening programmes has a number of key performance
indicators (KPI ) on which the performance of individual N ational Health S ervice
(N HS ) Trusts is measured. The most recent KPI document runs to 45 pages
O verseeing the delivery of the KPI s is the remit of the screening coordinator in each
Trust, but it is the hard work of the professionals on the ground that ensures targets
are met. A s an example, the KPI for screening for hepatitis B states that at least 70% of
pregnant women who are hepatitis B positive should be referred and seen by an
appropriate specialist within an effective timeframe (6 weeks from identification).
The KPI for screening for D own syndrome at between 10 weeks + 0 days and 20
weeks + 0 days states that in 97% of women there must be sufficient information for
the woman to be uniquely identified, and the woman's correct date of birth, maternal
weight, family origin, smoking status and ultrasound dating assessment in
millimetres, with associated gestational date and sonographer I D , must be included
on the request form.
Failsafe procedures are a necessary part of the screening process. I n the UK these
have been implemented to ensure all screening processes are complete. There are
back-up mechanisms in addition to usual care, which ensures if something goes wrong
in the screening pathway, processes are in place firstly to identify what is going wrong
and secondly to determine what action should follow to ensure a safe outcome.
A ll professionals undertaking screening must be appropriately trained and
confident in discussing the risks and benefits of all screening programmes, and in the
UK they must adhere to the NSC recommendations and standards.
Documentation
I n whatever system is practised, good documentation is vital. The midwife should
discuss and offer screening tests, record that the discussion has taken place, that the
offer has been made, that the offer has been either accepted or declined. I t is very
helpful for the whole team engaged in antenatal care to understand from the
documentation why screening is declined, if this is the case. W omen find being
persistently re-offered a screening test that they have declined frustrating and
annoying, and simply documenting the discussion properly, rather than ticking a box
to indicate that screening was declined, is helpful. This can sometimes also lead on to
discussion that can reveal that a woman has not understood the test, the purpose or
the benefits, which can help to improve understanding.
I n the event of decline for infectious diseases screening at the antenatal ‘booking’
appointment, a routine re-offer should be made at about 28 weeks. From a litigation
perspective, it is not uncommon for women who have declined screening but
experienced a poor outcome to suggest that they were not offered screening or did not
understand the purpose of the test on offer. Good documentation and being able to
show that written information was given can help in the comprehension of such cases.
Discussion of options
W hen offering tests, it is necessary for the midwife to present and discuss the options,
so that women can make an informed choice that best suits their circumstances and
preferences. Midwives are required to discuss options for testing in a manner that
enables shared decision-making (Sullivan 2005). This means providing the opportunity
to discuss choices with a trained professional who is impartial and supportive as the
women make decisions along the screening and diagnostic pathway.
There may be mixed feelings about the final decision. S ometimes it is helpful to
consider what the mother's worst-case scenario would be, as that can help to decide
the best way forward. The principles for consent for shared decision-making are
shown in Box 11.1.
Box 11.1
P rinciple s for obt a ining inform e d conse nt
• Purpose of the procedure/test
• All risks and benefits to be reasonably expected
• Details of all possible future treatments that could arise as a consequence
of testing
• Disclosure of all available options (this may include tests that are offered
by private providers where relevant)
• The option of refusing any tests
• The offer to answer any queries
Midwives commonly recommend antenatal tests such as infectious disease
screening, full blood count or cardiotocograph for reduced fetal movements. However,
tests for fetal anomaly require a non-directive approach that enables the mother to
make an informed choice (Clarke 1994). Consent must be obtained prior to all tests
and this must be documented. S tandardized processes allow systems to serve women
uniformly and allow good quality of care to be offered to all. I n the UK, theNSC
(2011a) has published Consent S tandards and Guidance for the fetal anomaly
screening process which can be used as a model in any healthcare system.
• Standard 1: All hospital trusts must have a care pathway to provide evidence that the
UK National Screening Committee (UK NSC) and NHS Fetal Anomaly Screening
Programme (FASP) information booklet and leaflets are being used.
• Standard 2: All pregnant women must be offered, at least 24 hours before decisions
are made, up-to-date information on fetal anomaly screening based on the current
available evidence. The NHS FASP recommends the use of the UK NSC (2012) leaflet
entitled Screening tests for you and your baby, available on the NHS FASP website:
www.fetalanomaly.screening.nhs.uk. This is available in many different languages
and, where needed, resources are available as audio and easy reading.
• Standard 3: All eligible pregnant women must be offered ‘testing’ and this offer
must be recorded in the woman's notes and/or hospital electronic records at the
antenatal ‘booking’ appointment.
• Standard 4: All decisions about the test itself must be recorded in the woman's hand-
held notes and/or in the hospital records.
I t is important all documentation is dated and signed by the health professional
involved.
The UKN S C (2011a) guidance is very complete and it is a useful document for all
midwives to read. Key aspects are shown in Box 11.2.
Box 11.2
K e y a spe ct s of t he U K N S C ( 2 0 1 1 ) guida nce on
a nt e na t a l scre e ning
• The pregnant woman must understand the condition being screened for.
• The midwife should explain about the nature, purpose, risks, benefits,
timing, limitations and potential consequences of screening.
• The woman should understand that screening is optional, and
understand the risks and benefits of not undergoing screening.
• In the UK there is the choice of continuing or terminating a pregnancy for
serious fetal abnormalities.
Local knowledge should be shared: how, where and when the
test is done:
• What the test results mean and potential significant clinical and
emotional consequences.
• The decisions that might need to be made at each point along the
pathway and their consequences.
• How and when the results will be given.
• How women progress through the pathway, including those who opt out
of screening.
• The possibility that screening can provide information about other
conditions.
• The fact that screening may not provide a definitive diagnosis.
• What further tests might be needed, e.g. chorionic villus sampling (CVS)
and amniocentesis.
• That confirmatory/repeat testing may occasionally be required.
• Balanced and accurate information about the various conditions being
screened should be provided.
A ssumptions must never be made regarding knowledge about the conditions being
screened for. Common misunderstandings are that D own syndrome cannot occur if it
has not previously occurred in a family or that a woman is too young to have an
affected baby. Many women (and their partners) do not understand that syphilis is a
sexually transmitted infection, but that the initial result can show positive if there have
been similar non-sexually transmitted infections (such as Yaws).
W omen who decline first trimester screening should know that they can take up
second trimester screening for D own's syndrome if they change their mind and that
they can undergo second trimester screening for fetal anomaly at 18+0 to 20+6 weeks.
W omen who decline initial screening for infections can and should be offered
screening later in the pregnancy.
I mportantly, only the woman has the right to consent to or decline the screening
tests. A partner or family member has no right to consent or decline on her behalf.
W omen can withdraw consent for testing at any time. This decision should be
recorded.
The process of consent
Consent is a complex process not a single entity, and requires adequate time. I t is
important to ensure that the woman has had the time she needs to consider the
information and come to a decision. That there has been enough time to ask questions,
that she feels comfortable and has involved those she would wish to in reaching a
decision. The extent to which women want to involve others is very variable.
The amount of information needed will vary between women. W omen who do not
understand English will require interpreting services and other services might be
needed for some women. N ot all women will have the capacity to consent. W here
capacity is in doubt there are usually local guidelines as to how this should progress
forward that are beyond the scope of this chapter.
Issues to consider when presenting information
W hen discussing tests, it is important to understand the motivations and thought
processes of pregnant women. The motivation for testing is often different for mother
and practitioner. For the fetal anomaly screening programme, the UK N S C rationale
for testing is to identify fetal anomalies; however mothers commonly accept these
tests in order to gain reassurance that their fetus is normal (Hunt et al 2005). Mothers
often think that fetal anomaly tests such as ultrasound scans are an integral or
mandatory part of their antenatal care. They may also be unaware of the reasons for
performing the test and this can compound the shock of finding problems or
abnormalities (Health Technology Assessment 2000).
W hen women are anxious or under stress, they are less able to remember the
information provided (I ngram and Malcarne 1995). Parents may feel vulnerable and
less able to ask questions. This may lead to dissatisfaction with the quality of
communications with health carers. S ince an unborn fetus is something of an enigma
to parents, this may increase anxiety and sensitivity to real or imaginary cues. For
example, professionals practising non-directive counselling may be perceived as
evasive and as concealing bad news. One particular aspect of counselling that has been
criticized by parents is the portrayal of risk estimates (Al-Jader et al 2000).
There is much evidence that people do not make consistent decisions about
undertaking tests in pregnancy on the basis of the risk information received. For
instance, a mother with a risk of D own syndrome of 1 : 150 may perceive herself to be
at a very high risk and may request amniocentesis. However, others may view that
same risk as very low. The phenomenon of how parents interpret risk information is
not fully understood, although it is clear that personal circumstances, preferences and
beliefs are an integral part of this process. For this reason, it is vital that, with any
screening, the midwife begins a consultation by investigating how much the mother
knows about the condition being tested for, and what she already knows about the test
risks, benefits and the consequences of results.
There are also common biases in the way people interpret risk information. The
midwife should be aware of these in order to help parents choose the most
appropriate course of action. For example, people tend to view an event as more likely
if they can easily imagine or recall instances of it. This means that a mother whose
friend or neighbour has a baby with D own syndrome may be sensitized to this
possibility and overestimate the chances of it happening to her. Mothers who work
with infirm people, or those with a disability, are most likely to seek prenatal
diagnosis (Sjögren 1996). Perhaps these mothers are easily able to imagine the lifelong
commitment of caring for a child with special needs. This common bias in risk
perception is important because it means that some mothers may not easily be
reassured by reiteration of the fact that the risk of a problem may be comparatively
rare.
Explaining risk
The way in which the midwife tells a mother about risk will also greatly influence how
that risk is perceived. For example, a mother who is told that her risk of a particular
condition is 1 in 10 may be more alarmed than if she had been informed that there was
a 90% chance of normality. or 9 out of 10 babies will not be affected by the condition.
This is known as the ‘framing’ effect (Kessler and Levine 1987).
People vary considerably in the ways that they consider and understand risk, so it is
important that this information is presented in a variety of ways using appropriate
language. The UKN S C (2011a) recommend the use of the word ‘chance’ rather than
‘risk’ and that the chance of the outcome (which for antenatal screening now mainly
relates to screening for D own syndrome) be given as a percentage as well as a ratio 1
in x. A s such, a midwife discussing a 1 in 100 chance of a disorder should also point
out the fact that 99% or 99 out of 100 similar people will not experience that disorder.
This may help people cope when considering tests or when anxiously awaiting results.
There are other general considerations to take into account when providing
information (Hunter 1994), as delineated in Box 11.3.
Box 11.3
G e ne ra l principle s whe n providing inform a t ion
1. Be clear: explain everything in terms that are not medical jargon or
complex terminology.
2. Be aware that people can remember only a limited amount of
information at one time – be simple, concise and to the point.
3. Give important information first. This will then be remembered best.
4. Group pieces of information into logical categories, such as treatment,
prognosis and ways to cope.
5. Information may be recalled more easily if it has been presented in
several forms. For example, leaflets can be helpful.
6. Offer to answer any queries. Give contact numbers, in case people
think of questions at a later date.
7. Do not make assumptions about information requirements on the
basis of social class, profession, age or ethnic group.
8. Summarize, check understanding and repeat the information. Ask
whether there is anything that remains unclear.
Source: Hunter 1994
I f a test is undertaken in pregnancy, it is good practice to ensure that the woman is
clear about how, when and from whom she will be able to obtain the result. I f
possible, there should be some options available.
The UKNSC (2011a) is clear that the person ordering the test has the responsibility
to ensure that the test is properly completed and that the woman is informed of the
result. The N ational I nstitute for Health and Clinical Excellence NICE
( 2008) antenatal
care guidelines state that every woman should have the results of all of their screening
tests recorded in their hand-held notes within 14 days or at the 16 week antenatal
appointment. I t therefore requires each midwifery team to have a process for the
management of tracking tests performed and the results, a means to inform women, a
process of fail-safe so that when, as will inevitably happen, a test is not performed or
sample not processed because in some way the process failed, this is recognized in a
timely enough fashion for the test to be repeated, and that the results are recorded in
the woman's hand-held notes.
O n a logistical front, this is no mean task. Failings in the screening system are
identified as serious incidents and there is a formal process in the UK that must be
undertaken when failings are identified. I n practice, the majority of women who fall
between stools are those whose pregnancies do not follow the routine process, for
instance those who move or whose pregnancy does not continue. These women, as
much as anyone else, still should be informed of results that are important to them,
such as the results of infection screening.
Individual screening test considerations
A ntenatal screening tests are broadly divided into those that are looking for a problem
in the mother that could affect the fetus, such as an infection, the presence of a red-cell
antibody, or a particular haemoglobin variant, which if passed on by both parents
could cause an issue, or those looking directly for a problem in the fetus.
Fetal screening tests
Population screening of the fetus (i.e. that offered to everyone) is now directed at two
areas: defining the risk of a baby having D own syndrome (trisomy 21), and the
detection of specific abnormalities.
Screening for Down syndrome
D own syndrome is the most common cause of severe learning difficulty in children. I n
the absence of antenatal screening, around 1 in 700 births would be affected (Kennard
et al 1995). W hile some children with D own syndrome learn literacy skills and lead
semi-independent lives, others remain completely dependent. A round one in three of
these babies are born with a serious heart defect. The average life expectancy is about
60 years, although most people develop pathological changes in the brain (associated
with Alzheimer's disease) after the age of 40 (Kingston 2002).
S creening for D own syndrome has been driven by both health economics and
maternal choice. That is not to say, however, that all mothers wish to be screened, or
would act to end a pregnancy if they knew they were carrying an affected fetus. Uptake
rates for screening vary depending on the population being screened. S ome mothers
will chose screening despite knowing that they would not act on a result that gave
them a high chance. I nterestingly, the single largest factor in deciding whether to take
further tests after a high chance result is the degree of magnitude of the change in
risk. I n other words, a mother who has a pre-test chance (based on age alone) of 1 in
100 (1%), who has a screening result of 1 in 120 (0.83%) will be less likely to wish to
proceed to further testing than a woman who has a pre-test chance of 1 in 1000, who
then receives a result of 1 in 120 chance, even though both are at equal risk of giving
birth to a baby with Down syndrome.
The national screening programme for D own syndrome in the UK comprises the
offer of one of two tests. The gestational age window for a combined test starts from
10+0 weeks to 14+1 weeks in pregnancy.
The combined test comprises measurement of the crown–rump length (CRL) (Fig.
11.1) to estimate fetal gestational age (dating scan), measurement of the nuchal
translucency (N T) space at the back of the fetal neck (Fig. 11.2) and maternal blood to
measure the serum markers of pregnancy-associated plasma protein A (PA PP-A) and
human chorionic gonadotrophin hormone (hCG).
FIG. 11.1 Crown–rump length.
FIG. 11.2 Translucency measurement.
Using this test, 90% of fetuses affected with D own syndrome would be expected to
fall into the high-chance category (a chance of 1 in 150 or more) (the detection rate)
with 2% of women carrying unaffected babies having a chance of 1 in 150 or higher (a
screen positive rate of 2%).
The quadruple test window starts from 14+2 weeks to 20+0 weeks. A maternal blood
sample is required for the analysis of hCG, alpha-fetoprotein (aFP), unconjugated
oestriol (uE3) and inhibin-A.
A s stated in the UKN S C (2011b), Model of Best Practice 2011–2014, this test has a
lesser detection rate of 75% and a screen positive rate of less than 3%, but has been
retained because there will always be women who book too late in pregnancy for
combined testing (about 15% of the pregnant population) and wish to have screening.
W omen presenting after 20 weeks are offered ultrasound for abnormality screening,
which will occasionally detect an abnormality that increases the chance that the baby
has Down syndrome, but there is no population screening available at this gestation.
W omen need to decide as early in their pregnancy as possible if they wish to
undertake screening for D own syndrome as earlier testing is superior, and ease of
access is important in facilitating testing.
I n counselling, women need to be clear that neither screening test gives a guarantee
of normality. With combined screening 10% of affected babies will be missed and with
quadruple testing 25% of D own babies will be missed. This is termed the false-negative
rate.
Diagnostic testing for Down syndrome
I n the UK, women who receive a result of 1 in 150 or higher from either first or second
trimester screening or those women who have previously had a chromosomal
abnormality or who carry a genetic disorder will be offered diagnostic testing, i.e. CVS
or amniocentesis. The N HS no longer provides diagnostic testing for maternal age
alone or following a low chance screening test result, although privately available
services are usually easy to access.
CVS can be performed from 11 weeks of pregnancy. Usually the procedure is carried
out transabdominally (Fig. 11.3), though occasionally a transcervical (TC) route is
needed. The miscarriage rate is often quoted as 2–3% but in most fetal medicine units
the procedure-related loss rate is closer to 1% (though TC sampling risks are higher).
A provisional result is usually issued on a direct preparation at 1–2 days. I f this result
shows no evidence of an extra chromosome 21 it can be taken as 99.9% certain that the
fetus does not have trisomy 21. However, as confined placental mosaicism can rarely
occur, which gives a false-negative result, at this stage definite confirmation cannot be
made until the culture result is available at 14–21 days.
FIG. 11.3 Transabdominal CVS.
A mniocentesis can be performed after 15 weeks (Fig. 11.4). The procedure-related
loss rate is usually no higher than 1% and in many units is closer to 0.5%. Rapid
testing using polymerase chain reaction or fluorescent in situ hybridization can
usually mean that a result for trisomy 21 (and usually 13 and 18) is available in 2–3
working days.
FIG. 11.4 Amniocentesis.
A diagnosis of Down syndrome can be accurately made using CVS or amniocentesis,
but it cannot give certainty as to the severity of the disorder or the quality of life of a
particular individual. Responses to a diagnosis will vary, according to cultural, social,
moral and religious beliefs.
Screening for haemoglobinopathies
The N HS N S C antenatal and newborn screening programmes include antenata
screening for fetal haemoglobinopathies. This should be linked with the newborn
bloodspot screening programme, which tests for sickle cell disease. Linking results of
parents and babies increases health professionals access to families with genetic
disorders, allowing the results to be available throughout the individual's life,
reducing repeat screening. Haemoglobinopathies are inherited disorders of
haemoglobin and are more prevalent in certain racial groups. A ntenatal screening
identifies about 22,000 carriers of sickle cell disease and thalassaemia in the UK every
year (NHS Sickle Cell and Thalassaemia Programme 2011).
Currently, in the UK, antenatal screening for haemoglobinopathy is based on
population prevalence. High prevalence areas have universal screening (offer all
pregnant women electrophoresis screening for haemoglobin variants and
thalassaemia trait). Low prevalence areas use the national Family O rigin
Q uestionnaire (FO Q ) to determine genetic ancestry for the last two generations (or
more if possible). A ll areas collect information on the FO Q in their maternity
population. This information is needed by laboratories to help interpret screening
results.
I n low-prevalence areas, women with genetic ancestry that includes high-risk racial
groups are offered electrophoresis testing. I f the mother is found to be a
haemoglobinopathy carrier, partner testing is then recommended and should be
offered soon after the result is available. Genetic ancestry is also important when
interpreting screening results. I t is important to establish maternal iron levels when
carrier status for thalassaemia is suspected, since iron deficiency can give rise to
similar red cell appearances.(e.g. alpha thalassaemia). Most haemoglobinopathies are
recessively inherited, so the fetus would have a 1 in 4 chance of inheriting the disorder
and a 1 in 2 chance of being a carrier.
Pre-test information for antenatal haemoglobinopathy screening
• In early pregnancy, information should be supplied. In the UK this means that all
women should receive the NSC (2012) information booklet Screening tests for you and
your baby as early in pregnancy as possible.
• The information should be provided in an appropriate language or format.
• Testing should be performed as early in pregnancy as possible, ideally at 8–10 weeks'
gestation, as screening decisions are often gestation-dependent.
• Women who book late in pregnancy should be offered haemoglobinopathy screening
in the same way at the first point of contact. Options for ending an affected
pregnancy may be limited.
W here both parents are identified as carriers, they need urgent counselling. I n the
UK parents are referred urgently to the PEGA S US (Professional Education for Genet
A ssessment and S creening) trained midwife for specialist counselling or to the
combined obstetric/haematology clinic at the booking hospital. D iagnostic testing by
CVS or amniocentesis should be offered.
W here paternity is unknown, the father of the baby is unavailable or declines
testing, the woman should be offered a counselling appointment to calculate the
possibility of the baby having an inherited haemoglobin disorder and an offer of
diagnostic testing made if the risks warrant this. A ll women will be offered neonatal
blood spot screening at 5 days, which will detect sickle cell disease (but not other
haemoglobinopathies).
Ultrasonography for fetal screening
I n the UK, theN S C (2011a) standards are that all pregnant women should be offered
two routine ultrasound scans. These include an early pregnancy scan (usually timed to
be able to perform the N T measurement if requested) and an 18–20 week fetal
anomaly screening scan. Ultrasound works by transmi ing sound at a very high
frequency, via a probe, in a narrow beam. W hen the sound waves enter the body and
encounter a structure, some of that sound is reflected back. The amount of sound
reflected varies according to the type of tissue encountered; for example, fluid does
not reflect sound and appears as a black image. Conversely, bone reflects a
considerable amount of sound and appears as white or echogenic. Many structures
appear as different shades of grey. Generally, pictures are transmi ed in ‘real time’,
which enables fetal movements to be seen.
Safety aspects of ultrasound
Ultrasound has been used as a diagnostic imaging tool since the 1950s, so we are now
into the third generation of scanned babies. I t seems reasonable to assume that any
major adverse effects of this technology would have become apparent before now.
However, modern machines have higher resolutions and indications for ultrasound
scanning have greatly increased. This means that levels of exposure to ultrasound have
increased in pregnancy. A lthough the technology is considered safe, it should be used
with respect and only when there is good indication, and care should be taken to limit
exposure time and the thermal indices should be controlled (European Commi ee of
Medical Ultrasound S afety 2008). Ultrasound is a diagnostic tool, but diagnosis can
only be as reliable as the expertise of the operator and the quality of the machine. A s
W ood (2000) states, abnormalities may be missed or incorrectly diagnosed if the
operator is inexperienced or inadequately trained.
Women's experiences of ultrasound
I n general, women experience ultrasound as a pleasurable opportunity to have visual
access to their unborn baby (S andelowski 1994). I ndeed, ultrasound scans have been
shown to increase psychological a achment to the fetus (S edgman et al 2006). Parents
have a profound curiosity about their baby and a scan can turn something nebulous
into something that seems much more real as a living individual (Furness 1990). This
can be particularly important for a woman's partner and family, who do not have the
immediate physical experience of the pregnancy. W omen tend to regard their scan as
providing a general view of fetal well-being: the fact that the fetus is alive, growing and
developing. However, this reassurance is temporary and begins to wear off after a few
weeks (Clement et al 1998). Mothers may then seek other forms of reassurance (e.g.
monitoring fetal movements, auscultation of the fetal heartbeat). This initial
reassurance may also create an enthusiasm for scans when there is no clinical
indication.
S cans may also cause considerable anxiety, however, particularly if there is a
suspected or actual problem with the fetus. There is evidence to suggest that women
who miscarry after visualization of the fetus on scan may feel a heightened sense of
anguish because the fetus seemed more real. This may also be the case for parents
considering termination of pregnancy on the grounds of fetal abnormality. However,
others may view their scan as a treasured memory of the baby they lost (Black 1992).
The identification of fetal abnormality in the antenatal period has differing
psychological effects for parents when the pregnancy is to continue. S ome parents
have reported feeling grateful that they were able to prepare for the birth of a child
with a disability (Chi y et al 1996). However, others have reported feelings of wishing
they had not known about their child's problems before birth because this created a
powerful image of the fetus as a ‘monster’. S ome parents reported this to be far worse
than the reality of caring for the baby after birth (Turner 1994). I t is necessary for
midwives to be mindful of the powerful psychological effects ultrasound scans have
on pregnant women and their families, if sensitive and appropriate care is to be given
at this potentially distressing time.
The midwife's role concerning ultrasound scans
As for all procedures, mothers should be fully informed about the purpose of the scan.
I nformation should be given about which conditions are being checked for and which
problems the scan would be unable to detect. Because of the pleasurable aspect of
seeing the fetus, ultrasound scans have traditionally been tests that mothers
undertake willingly, without prior discussion and consideration of potential
consequences. Ultrasound screening for fetal abnormality is a screening test and as
such women should be counselled as to the purpose, choices and pitfalls of screening
so that they can decide whether or not they wish to undergo a procedure that may
bring unwelcome news. W omen should be aware that ultrasound scans are optional
and not an inevitable part of their care.
W omen should also understand that a normal ‘scan’ does not guarantee normality
in the baby. Box 11.4 shows the detection rates for the commonly assessed
abnormalities, which should be shared with women.
Box 11.4
D e t e ct ion ra t e s for com m only a sse sse d fe t a l
a bnorm a lit ie s
Anencephaly 98%
Open spina bifida 90%
Cleft lip 75%
Diaphragmatic hernia 60%
Gastroschisis 98%
Exomphalos 80%
Serious cardiac abnormalities 50%
Bilateral renal agenesis 84%
Lethal skeletal dysplasia 60%
Edwards' syndrome (trisomy 18) 95%
Patau's syndrome (trisomy 13) 95%
Source: UK NSC 2010 NHS Fetal Anomaly Screening Programme: 18+ 0 to 20+ 6 Weeks Fetal Anomaly
Scan National Standards and Guidance for England: Appendix 9
There is evidence that, although some mothers may find this information
disturbing, most feel that this is outweighed by the positive aspects of seeing the baby
and gaining reassurance (O liver et al 1996). I ndeed, extra information about the
purpose of the scan has been shown to increase women's understanding and
satisfaction with the amount of information received, while the proportion of women
accepting a scan (99%) appears to remain unchanged (Thornton et al 1995).
The Royal College of O bstetricians and Gynaecologists RCO ( G 2000) recommends
that, wherever scans are performed, a midwife or counsellor with a particular interest
or expertise in the area should be available to discuss difficult news. A ll women with a
suspected or confirmed fetal anomaly should be seen by an obstetric ultrasound
specialist within three working days of the referral being made or seen by a fetal
medicine unit within five working days of the referral being made (N S C 2011a:
S tandard 4). Effective multidisciplinary team working and communication are
therefore essential. I t is also good practice for the midwife to liaise with the primary
healthcare team, who would normally carry out the majority of antenatal care. With
the increasing use of client-held records, mothers may have more opportunity to
scrutinize the wri en results of their scan. Midwives may increasingly be called upon
to explain and discuss these findings, both in hospital and in the community setting.
First trimester pregnancy scans
All women should be offered a first trimester scan. The purpose of this is to establish:
• that the pregnancy is viable and intrauterine (not ectopic);
• to measure the NT if the gestation is appropriate and screening for Down syndrome
is accepted;
• to accurately define the gestational age;
• to determine fetal number (and chorionicity or amnionicity in multiple pregnancies);
• to detect gross fetal abnormalities, such as anencephaly (absence of the cranial
vault).
Early ultrasound scanning is beneficial, in reducing the need to induce labour for
post-maturity (W hitworth et al 2010). A gestation sac can usually be visualized from 5
weeks' gestation and a small embryo from 6 weeks. Until 13 weeks, gestational age can
be accurately assessed by CRL measurement (the length of the fetus from the top of
the head to the end of the sacrum). Care must be taken to ensure that the fetus is not
flexed at the time of measurement. Mothers are asked to a end with a full bladder,
since this aids visualization of the uterus at an early gestation.
Dealing with increased nuchal translucency
A nuchal translucency of >3.5 mm occurs in about 1% of pregnancies (see Fig. 11.2). I t
is considered to be the threshold definition of an increased N T above which the risk of
other (non-chromosomal) abnormalities increases. I ncreased N T is associated with a
risk of chromosomal abnormalities and also with other structural (mainly cardiac)
abnormalities (>10% risk), genetic syndromes and an increased fetal loss rate. W here
an increased N T is seen regardless of whether screening for D own syndrome was
declined, the potential for problems to be present must be discussed and ideally
referral to specialist scanning and counselling arranged. I n the presence of a normal
karyotype, if no structural abnormalities are found the UK NSC (2011a) states that the
incidence of adverse outcome is not increased, but also acknowledges that the chance
of developmental delay is 2–4%.
W here diagnostic testing and 18–20 weeks ultrasound is normal it is reasonable to
be optimistic regarding outcome, but it is worth recognizing that parents will carry the
anxiety of uncertainty with them through and even beyond the end of the pregnancy
and will often require a lot of support.
Second trimester ultrasound scans
A fter 13+6 weeks of pregnancy, gestational age is primarily assessed using the head
circumference (HC).
The detailed fetal anomaly screening scan
This scan is usually performed at 18–20+6 weeks of pregnancy. The purpose of this scan
is to reassure the mother that the fetus has no obvious structural anomalies that fall
into the following categories:
• anomalies that are incompatible with life;
• anomalies that are associated with significant morbidity and long-term disability;
• anomalies that may benefit from intrauterine therapy;
• anomalies that may require postnatal treatment or investigation.
D etection rates should be in line with those outlined earlier. Technical difficulties,
such as fetal position, multiple pregnancy, fibroids or maternal obesity may mean that
a second scan before 23 weeks is offered. S ome structural problems do not have
sonographic signs that would be visible at this gestation or even at all. A nal atresia
does not have a clear appearance on ultrasound; hydrocephalus and other bowel
obstructions may not appear until later in pregnancy. D iagnosis may therefore not be
possible. The UK N S C has defined which structures should be examined Box ( 11.5)
and which images should be stored as part of the woman's record.
Box 11.5
1 8 + 0 t o 2 0 +6 we e ks fe t a l a nom a ly ult ra sound sca n ba se
m e nu
• Spine, vertebrae and skin covering in transverse and longitudinal
sections.
• Head and neck: Head shape and internal structures (cavum pellucidum,
cerebellum, ventricular size at atrium). Nuchal fold. Face and lips.
• Thorax: Four-chamber view of heart, cardiac outflow tracts, lungs.
• Abdominal shape and content – at level of the stomach with small portion
of intrahepatic vein, abdominal wall, renal pelves, bladder.
• Limbs: Arms – three bones and hand (metacarpals). Legs – three bones
and foot (metatarsals).
• Placental location and amniotic fluid.
Source: UK NSC 2010 NHS Fetal Anomaly Screening Programme: 18+ 0 to 20+ 6 Weeks Fetal Anomaly
Scan National Standards and Guidance for England: Appendix 1
S ome features on ultrasound may be seen that increase the risk of another problem
such as D own syndrome. A n increased skin fold measurement of >6 mm at the level of
the nuchal fold (a different entity to the nuchal translucency) should be noted as there
is an associated increase in the risk for D own syndrome of at least 10-fold. Mild
cerebral ventriculomegaly should be noted as there is again an increased risk of
chromosomal abnormalities of about 10%. Echogenic bowel can be seen in cases of
cystic fibrosis, fetal infection, and if associated with growth restriction and mild renal
pelvis dilatation (>7 mm) can progress to significant hydronephrosis.
W hat used to be termed ‘soft markers’ are no longer considered to have any
significant impact on the risk of chromosomal abnormality in isolation or
combination, and are termed ‘normal variants’ and are therefore not usually reported
(choroid plexus cysts, two-vessel cord, dilated cisterna magna, echogenic cardiac
focus).
Advantages and disadvantages of fetal anomaly scans
Provided the sonographer has sufficient expertise, many lethal or severely disabling
conditions can be detected during the 18–20 week scan. There is also an increase in
first trimester diagnosis. A lthough this means that parents may be faced with difficult
and unexpected decisions, it allows parents the choices that would be denied without
this knowledge. Furthermore, many parents are offered reassurance that no obvious
abnormalities were seen. For neonates requiring early surgical or paediatric
interventions, prior knowledge of the abnormality allows a plan of care to be evolved
in advance of the birth. The mother can then give birth in a unit with appropriate
facilities. This has been shown to reduce morbidity in cases of gastroschisis (an
abdominal wall defect, adjacent to the umbilicus, allowing the intestines and other
abdominal organs to protrude outside the body), cardiac abnormalities and intestinal
obstruction (Romero et al 1989). For parents who choose to continue the pregnancy
knowing that the baby has a life-limiting condition, careful planning regarding place
of birth, care of the baby after birth and multidisciplinary support can be provided.
I n summary, the 18–20 week scan appears to confer psychological and health
improvement benefits in some cases, but also has the capacity to cause great anxiety
and distress. Care must be taken to ensure that parents are fully informed of the
purpose, benefits and limitations of ultrasound scans before they consent to this
procedure.
New and emerging technologies
Fetal imaging techniques
Ultrasound scans in pregnancy have been discussed at length in this chapter, since
they are important fetal investigations. W omen generally see two-dimensional (2-D )
images of their unborn baby. However, there is a growing market for three-
dimensional ultrasound imaging (3-D ). A s such, multiple images are stored digitally
and then shaded to produce life-like pictures. This technique can assist the diagnosis
of surface structural anomalies, such as cleft lip and spina bifida, and improvements
are being seen in cardiac and neurological scanning (Sandelowski 1994; S edgman et al
2006).
Magnetic resonance imaging (MRI ) has also been applied in the examination of the
fetus over the last two decades. This technique has not been widely applied because
ultrasound can give similar diagnostic information at a lower cost. However, MRI has a
contribution to make, particularly when examining the brain. There is evidence that
this may provide additional information and change the counselling and management
for a significant number of pregnancies where brain abnormalities are suspected
(Glenn and Barkovich 2006). A further application is that MRI offers an alternative to
postmortem following termination or perinatal death. This can offer information to
parents who decline postmortem because of its invasive nature (Brookes and Hall-
Craggs 1997). MRI imaging has been used to refine the diagnosis of many other
conditions including diaphragmatic hernias and sacrococcygeal teratomas (Kumar and
O'Brien 2004).
Free fetal DNA
Much work is now being done on the technology that identifies free fetal D N A in the
maternal circulation. A lready it is possible to identify with great (though not 100%)
accuracy, fetal sex, blood group and some genetic disorders. Before long RA PI D
(Reliable Accurate Prenatal non-Invasive Diagnosis) study will report the results of the
research into testing for D own syndrome using this technology. A lready a test is
available privately in the United S tates. This will undoubtedly increase the true-
positive rate and decrease the false-negative rate for screening for D own syndrome,
which will become available as a blood test. Confirmatory testing will still be required,
but fewer tests will be needed. Free fetal D N A is now routinely used to determine
fetal blood group (see below).
Screening for maternal conditions
The rationale for screening a mother is to detect conditions that are amenable to
treatment and will have potential health benefits for her and her baby. I n the main, in
pregnancy, screening is focused on those that carry improved outcomes for the baby.
Infectious diseases
I n the UK the N S C programme for screening of infectious diseases in pregnancy
recommends that all pregnant women are screened for:
• HIV
• syphilis
• hepatitis B (HBV)
• rubella.
The infectious diseases screened for meet the screening criteria in that they are
important and intervention can reduce harm. Rubella screening cannot reduce the risk
if a mother develops the illness but allows immunization in the future to reduce risk.
Human immune deficiency virus (HIV)
Knowledge and adequate management of women with HI V can reduce mother to child
transfer to less than 1% and improve maternal health. S creening should be offered at
booking and again later in pregnancy in women at high risk (e.g. women who are paid
for sex, women who have an untested partner from an area of high prevalence,
intravenous drug users). W omen who decline screening should also be re-offered
testing later in pregnancy.
Hepatitis B (HB)
A dequate immunization programmes for infants at risk of vertical transmission of
HBV can reduce infant infection rates by 90% and improvements in maternal health
can be made.
Referral to a specialist is required for women who are found to be hepatitis B
positive. Establishing the neonatal and maternal risk will be determined by testing of
antibody and antigen status and viral D N A levels. O ccasionally hepatitis B can
reactivate in pregnancy and knowledge of status can aid management of the pregnant
mother.
Syphilis
S yphilis used to be a rare infection in the UK, but the incidence is now inexorably
rising. Treatment of syphilis can prevent pregnancy loss plus congenital syphilis, and
prevent long-term problems for the mother. A positive screening result does not
distinguish between syphilis and other treponemal infections, so specialist input is
required if the initial screening test is positive.
I n all three of the above infections, knowledge of infection can prevent unwi ing
infection of sexual partners.
Rubella
S creening for susceptibility to rubella aims to identify the 3% of women who are
susceptible, to counsel about avoidance of potentially infected individuals during
pregnancy and to offer postnatal vaccination.
For the above infections, testing in early pregnancy is recommended. W ri en
information should be provided at least 24 hours prior to decisions being made. I n
order for the woman to make an informed choice, the midwife should discuss the
following points:
• The infections that are screened for, their routes of transmission and the
implications of a positive test.
• The benefits, to both mother and baby, to be gained from the identification and
management of those with positive results.
• The results procedure, including the feedback of results and the possibility of a false-
negative or false-positive result.
• All pregnant women should be advised that if they develop, or are exposed to, a rash
during the pregnancy they should seek professional advice.
That the offer was made and the response to the offer should be documented with
the date. W omen who initially decline should be re-offered testing at a later date;
usually it is best to do this before 28 weeks. I f testing is declined it is good practice to
enquire why and to explore and document the reasons. W omen who book late or who
arrive untested in labour can be urgently screened.
W omen with a positive result for syphilis, HI V or HBV should be seen and
counselled as soon as possible and within 10 days in the UK. A ppropriate referrals
should then be made to ensure that the correct care pathway is inducted.
S creening for infectious diseases in pregnancy can be enormously challenging for
the mother and for the midwife. The cultural and social stigma that is still a ached to
a diagnosis of HI V means that some women will be reluctant to consider testing or
may be devastated when a positive test is confirmed. I ssues such as partner testing
need sensitive exploration and should be undertaken by the wider multidisciplinary
team that will care for these women. The midwife needs to have enough knowledge to
understand the disease, the process following a positive test and the ability to answer
questions or direct women to the answers.
New screening
I n the UK screening does not exist on a population basis yet for Group B S treptococcus
(GBS ). GBS is carried in the genital tract and gut of many healthy people (between 10
and 40%). I t is estimated that about 25% of pregnant women in the UK carry GBS . I n
the UK GBS is either detected opportunistically or by screening for high-risk
situations, such as after premature or prolonged rupture of the membranes. Using this
strategy 0.5/1000 babies are affected by early onset GBS disease, a disease that can
cause severe problems for these babies, including meningitis and death. N ew work on
why only some babies are affected has focused on the ability of the mother to pass on
GBS antibodies, but this has not been able to identify a very high-risk group that could
be effectively targeted.
I n the United S tates screening is offered by vaginal swabs at 35–37 weeks. However,
the risk of GBS in the United S tates is considerably higher, again for reasons that are
not entirely understood.
The N S C (UK) is consulting on whether to include GBS screening within th
programme for the future. I mportant considerations are the effect of antibiotics on as
many as 25% of the pregnant population, weighed against the harm to about 340
babies per year.
Mid-stream urine testing
S creening for asymptomatic bacteriuria is recommended as in pregnancy progression
to pyelonephritis can occur in up to 25% of women. Pyelonephritis can be life-
threatening and can lead to miscarriage and premature labour. Treatment is simple
and effective with appropriately targeted antibiotics.
Screening for anaemia
A naemia is one of the commonest complications of pregnancy. The most common
reason for iron deficiency anaemia in pregnancy is the increased demands of the fetus
for iron. Risk factors for the development of iron deficiency in pregnancy include iron
deficiency prior to pregnancy, hyperemesis, vegetarian or vegan diet, multiple
pregnancies, pregnancy recurring after a short interval and blood loss.
Pregnant women should be offered screening for anaemia in early in pregnancy and
at 28 weeks. This allows enough time for treatment if anaemia is detected.
Haemoglobin levels outside the normal UK range for pregnancy (that is, 11 g/dl at
first contact and 10.5 g/dl at 28 weeks) should be investigated. Provided there are no
unusual features to suggest another cause for the anaemia, treatment with iron can be
started and a blood test for serum ferritin sent at the same time to confirm iron stores
are low. The woman should be asked if she is known to have a haemoglobinopathy.
These women should be directly referred to an O bstetric Haematology clinic for
assessment.
Screening for red cell antibodies
A ll pregnant women should be offered antenatal testing to assess A BO and rhesus
status and to look for red cell antibodies. There will usually be relevant national
guidelines, which will specify the intervals at which this should take place. This will
vary depending on the woman's Rhesus (Rh) type and whether any red cell antibodies
are detected.
Red cell antibodies are antibodies against red cell antigens, and the relevance to
pregnancy will vary depending on the type and level of the circulating antibody. S ome
antibodies occur naturally, without any sensitising event, but most of the important
ones require a sensitising event such as a previous pregnancy or transfusion.
Antibodies to the ABO system tend to be naturally occurring, as does anti-E.
O nce an antibody has been identified it will be relevant to understand the issues for
both the mother and baby.
For the mother with any red-cell antibody the major issue is related to increased
difficulty in crossmatching blood. W omen with antibodies will not be able to undergo
rapid electronic crossmatching and therefore for women at any increased risk in
labour of haemorrhage, crossmatching in the early stages or before planned birth may
be prudent.
For the fetus, red-cell antibodies are of significance as I gG antibodies can cross the
placenta. I f the fetal red blood cells carry the antigen the antibody is directed against
they will be destroyed. This can lead to fetal anaemia and in severe cases cause fetal
hydrops. J aundice and kernicterus (brain damage caused by very high unconjugated
bilirubin levels) in the neonatal period are the major neonatal risks.
Routine antibody testing in pregnancy aims to:
• identify Rhesus-negative women who will be eligible for anti-D immunoglobulin
prophylaxis
• identify women who are difficult to crossmatch so that steps can be taken to
minimize risk
• identify women with antibodies that put the fetus at risk of haemolytic disease of the
newborn (HDN).
The UK recommends that all women should be tested at booking and again at 28
weeks' gestation (NICE 2008).
There are many red cell antibodies and it is useful to understand which ones are
important causes of HDN.
• Antibodies to the Rhesus antigens are the most common to cause problems.
• Rhesus D antibodies are the principle cause of severe HDN.
• Rhesus c can cause HDN, especially if antibodies to Rhesus E are also present
• Rarely antibodies to Rhesus E, e, C and CW can cause HDN.
A ntibodies to non-Rhesus antigens can also cause HN D . A nti-K (Kell) antibodies
are an important cause of severe HD N . These antibodies not only destroy the fetal red
cells, but inhibit production in the bone marrow, exacerbating any developing
anaemia.
O ther antibodies known to cause HD N less commonly include anti Fya (D uffy), anti
Jka (Kidd) and anti S.
A ntibodies to the A BO system may be detected on routine testing. I n general these
occur in Group O women and are naturally occurring anti-A and anti-B antibodies.
Because these antibodies are I gM antibodies they do not cross the placenta and do not
harm the fetus. O ccasionally some group O women produce I gG antibodies when
carrying group A or B infants. These I gG antibodies can cross the placenta and cause
HDN, but this tends to be mild.
How the results are presented
A ntibody levels are either given as the actual measured amount or as the dilution
achieved before there is insufficient antibody to cause red cell clumping.
Rh-D and Rh-c are always measured and the result will be given in iu/ml; hence the
higher the result the worse the effects are likely to be.
O ther antibody levels are expressed as titres. A titre of 1 : 2 means that after a single
dilution there was no clumping of the red cells. This would be a low level of antibody.
A titre of 1 : 16 states that there were four dilutions before the antibody was too weak
to clump cells, implying a much higher level of antibody. I t is useful to understand
that a jump from 1 : 2 to 1 : 4 is a single dilution, as is a jump from 1 : 16 to 1 : 32.
What parents need to know
Parents need to understand the purpose of blood group and red cell antibody
screening, what is being tested for and what the test involves. This will involve
discussion about the nature and effects of red cell antibodies, how and when test
results will be available and the meaning of the results.
Management when an antibody is detected
W hen an antibody is detected it is important that the relevance of this is discussed
with the mother. The discussion should cover the potential for difficulties in
crossmatching blood and the potential for fetal or neonatal problems. I f significant
antibody titres are found management needs to be discussed, including the need for
surveillance for fetal anaemia and the possibility of intrauterine transfusion – this
would usually be done by the obstetrician managing the pregnancy.
S urveillance will depend on the type of antibody found; for some antibodies, the
titre (level) of the antibody; and the gestation of pregnancy at which it is discovered.
D iscussion with the consultant team is usually needed to define the steps that need
to be taken.
When an antibody is detected that may cause HDN the next steps will usually be:
1. Referral for discussion with an appropriate consultant/haematology team.
2. Partner testing. This is to determine the potential for fetal risk. Only a fetus that is
antigen positive for the antibody found can be at risk. This means that, for instance,
if a woman has anti-D antibodies and a Rh-D-positive partner there will be a 50–
100% risk of producing a baby who is Rh-D-positive, depending on whether the
partner carries one or two Rh-D-positive genes. It is imperative that the woman
understands the importance of partner testing, the need to be honest if there can be
any doubt regarding paternity (and for this to be asked about sensitively, without
the partner being present). Beware with IVF pregnancies also. Remember to ask
whether there has been egg donation, as in these cases it may be the maternal
genetic complement that differs and cases of HDN have occurred where this vital
fact has not been ascertained.
3. Free fetal DNA testing. Where the fetus is potentially at risk because the partner is
positive for the antigen to the detected antibody or where partner testing cannot be
undertaken, typing of the fetal red cell status can be performed on a blood test from
the woman. The test is usually carried out between 12–18 weeks. The results are
accurate in 99% of cases but in some cases a result cannot be given.
4. Confirmatory testing. Invasive testing using CVS or amniocentesis is usually
undertaken only where there is a need to establish fetal karyotype for other reasons.
In cases where ultrasound suggests developing anaemia a fetal blood sample prior
to intrauterine transfusion will be tested for fetal blood typing.
On-going surveillance
O nce the risk of a pregnancy being affected has been established the timing and
frequency of repeat testing of antibody titres can be determined. The need for
assessment of the fetus at risk can also be established.
S urveillance for fetal anaemia is now undertaken primarily using ultrasound
measurement of the blood flow velocity within the fetal brain. Measurement of the
maximum velocity in the fetal middle cerebral artery has been found to be as accurate
as the old-fashioned measurement of bilirubin in amniotic fluid, but is without the
attendant risks of serial amniocentesis.
The frequency of surveillance will be determined by the risk of anaemia, which is
dependent on the type and level of antibody and the risk of the fetus being antigen-
positive.
Conclusion
Fetal investigations are an integral aspect of antenatal care. S cientists and clinicians
have developed a range of new diagnostic and imaging technologies. S ome of these
have been incorporated into national screening programmes and standards of care.
The midwife must therefore ensure that women are informed about the benefits and
risks associated with these technologies, so that they can make choices to suit their
requirements. Undoubtedly, testing technologies profoundly influence women's
experiences of pregnancy and their early a achment to their unborn child. Midwives
therefore have a duty to prepare women for tests through sensitive and accurate
communications and then to support parents in their assimilation of information and
decision-making once the results are known.
Maternal investigations also require careful counselling and thought as a
constellation of unintended consequences can arise if women do not think through
their screening choices, or are inadequately counselled.
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spine: an increasingly important tool in prenatal diagnosis, Part 1. American
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Routine care for the healthy pregnant woman, CG 62. NICE: London; 2008.
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screening in pregnancy. Protocol, standards and training. Supplement to ultrasound
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Further reading
Sullivan A, Kean L, Cryer A. Midwife’s guide to antenatal investigations. Elsevier:
London; 2006.
A practical guide for midwives to use when discussing and interpreting antenatal test
results. Covers maternal and fetal investigations..
Useful websites
UK National Screening Committee. www.screening.nhs.uk.
[DIPEx – Patient experiences website] www.dipex.org.
Includes a range of pregnancy and screening experiences from the woman's perspective.
Includes video clips of interviews with women who talk about their experiences..
C H AP T E R 1 2
Common problems associated with early
and advanced pregnancy
Helen Crafter, Jenny Brewster
CHAPTER CONTENTS
The midwife's role 222
Abdominal pain in pregnancy 222
Bleeding before the 24th week of pregnancy 222
Implantation bleed 222
Cervical ectropion 223
Cervical polyps 223
Carcinoma of the cervix 223
Spontaneous miscarriage 224
Recurrent miscarriage 225
Ectopic pregnancy 225
Other problems in early pregnancy 226
Inelastic cervix 226
Gestational trophoblastic disease (GTD) 226
Uterine fibroid degeneration 227
Induced abortion/termination of pregnancy 227
Pregnancy problems associated with assisted conception 228
Nausea, vomiting and hyperemesis gravidarum 228
Pelvic girdle pain (PGP) 229
Bleeding after the 24th week of pregnancy 229
Antepartum haemorrhage 229
Placenta praevia 230
Placental abruption 233
Blood coagulation failure 234
Hepatic disorders and jaundice 235
Obstetric cholestasis 235
Gall bladder disease 236
Viral hepatitis 236
Skin disorders 236
Abnormalities of the amniotic fluid 236
Hydramnios 236
Oligohydramnios 238
Preterm prelabour rupture of the membranes (PPROM) 239
Conclusion 240
References 240
Further reading 242
Useful websites 242
Problems of pregnancy range from the mildly irritating to life-threatening
conditions. Fortunately in the developed world, the life-threatening ones are
rare because of improvements in the general health of the population,
improved social circumstances and lower parity. However, as women delay
childbearing, they become more at risk of disorders associated with
increasing age, such as miscarriage and placenta praevia.
Regular antenatal examinations beginning early in pregnancy are
undoubtedly valuable. They help to prevent many complications and their
ensuing problems, contribute to timely diagnosis and treatment, and enable
women to form relationships with midwives, obstetricians and other health
professionals who become involved with them in striving to achieve the best
possible pregnancy outcomes.
The chapter aims to:
• provide an overview of problems of pregnancy
• describe the role of the midwife in relation to the identification, assessment and
management of the more common disorders of pregnancy
• consider the needs of both parents for continuing support when a disorder has been
diagnosed.
The midwife's role
The midwife's role in relation to the problems associated with pregnancy is clear. At
initial and subsequent encounters with the pregnant woman, it is essential that an
accurate health history is obtained. General and specific physical examinations must
be carried out and the results meticulously recorded. The examination and recordings
enable effective referral and management. Where the midwife detects a deviation from
the norm which is outside her sphere of practice, she must refer the woman to a
suitable qualified health professional to assist her (N MC [N ursing and Midwifery
Council] 2012a). The midwife will continue to offer the woman care and support
throughout her pregnancy and beyond. The woman who develops problems during
her pregnancy is no less in need of the midwife's skilled a ention; indeed, her
condition and psychological state may be considerably improved by the midwife's
continued presence and support. I t is also the midwife's role in such a situation to
ensure that the woman and her family understand the situation; are enabled to take
part in decision-making; and are protected from unnecessary fear. A s the primary care
manager, the midwife must ensure that all the a ention the woman receives from
different health professionals is balanced and integrated – in short, the woman's needs
remain paramount throughout.
Abdominal pain in pregnancy
A bdominal pain is a common complaint in pregnancy. I t is probably suffered by all
women at some stage, and therefore presents a problem for the midwife of how to
distinguish between the physiologically normal (e.g. mild indigestion or muscle
stretching), the pathological but not dangerous (e.g. degeneration of a fibroid) and the
dangerously pathological requiring immediate referral to the appropriate medical
practitioner for urgent treatment (e.g. ectopic pregnancy or appendicitis).
The midwife should take a detailed history and perform a physical examination in
order to reach a decision about whether to refer the woman. Treatment will depend on
the cause (see Box 12.1) and the maternal and fetal conditions.
Box 12.1
C a use s of a bdom ina l pa in in pre gna ncy
Pregnancy-specific causes
Physiological
Heartburn, soreness from vomiting, constipation
Braxton Hicks contractions
Pressure effects from growing/vigorous/malpresenting fetus
Round ligament pain
Severe uterine torsion (can become pathological)
Pathological
Spontaneous miscarriage
Uterine leiomyoma
Ectopic pregnancy
Hyperemesis gravidarum (vomiting with straining)
Preterm labour
Chorioamnionitis
Ovarian pathology
Placental abruption
Spontaneous uterine rupture
Abdominal pregnancy
Trauma to abdomen (consider undisclosed domestic abuse)
Severe pre-eclampsia
Acute fatty liver of pregnancy
Incidental causes
More common pathology
Appendicitis
Acute cholestasis/cholelithiasis
Gastro-oesophageal reflux/peptic ulcer disease
Acute pancreatitis
Urinary tract pathology/pyelonephritis
Inflammatory bowel disease
Intestinal obstruction
Miscellaneous
Rectus haematoma
Sickle cell crisis
Porphyria
Malaria
Arteriovenous haematoma
Tuberculosis
Malignant disease
Psychological causes
Source: Adapted from Cahill et al 2011; Mahomed 2011a
Many of the pregnancy-specific causes of abdominal pain in pregnancy listed in Box
12.1 are dealt with in this and other chapters. For most of these conditions, abdominal
pain is one of many symptoms and not necessarily the overriding one. However, an
observant midwife's skills may be crucial in procuring a safe pregnancy outcome for a
woman presenting with abdominal pain.
Bleeding before the 24th week of pregnancy
Any vaginal bleeding in early pregnancy is abnormal and of concern to the woman and
her partner, especially if there is a history of previous pregnancy loss. The midwife can
come into contact with women at this time either through the booking clinic or
through phone contact. I f bleeding in early pregnancy occurs a woman may contact
the midwife, the birthing unit or a triage line for advice and support. The midwife
should be aware of the local policies pertaining to her employment and how to guide
the woman. I n some areas of the United Kingdom (UK) women are reviewed within
the maternity department from early pregnancy, whereas in others, they will be seen
by the gynaecology team until 20 weeks' gestation, possibly in an early pregnancy
clinic. However, women are often advised to contact their General Practitioner (GP) in
the first instance, and many will visit an accident and emergency department.
I n all cases, a history should be obtained to establish the amount and colour of the
bleeding, when it occurred and whether there was any associated pain. Fetal well-
being may be assessed either by ultrasound scan or, in the second trimester, using a
hand-held D oppler device to hear the fetal heart sounds. Maternal reporting of fetal
movements may also be useful in determining the viability of a pregnancy.
There are many causes of vaginal bleeding in early pregnancy, some of which can
occasionally lead to life-threatening situations and others of less consequence for the
continuance of pregnancy. The midwife should be aware of the different causes of
vaginal bleeding in order to advise and support the woman and her family
accordingly.
Implantation bleed
A small vaginal bleed can occur when the blastocyst embeds in the endometrium. This
usually occurs 5–7 days after fertilization, and if the timing coincides with the expected
menstruation this may cause confusion over the dating of the pregnancy if the
menstrual cycle is used to estimate the date of birth.
Cervical ectropion
More commonly known as cervical erosion. The changes seen in cases of cervical
ectropion are as a physical response to hormonal changes that occur in pregnancy. The
number of columnar epithelial cells in the cervical canal increase significantly under
the influence of oestrogen during pregnancy to such an extent that they extend beyond
to the vaginal surface of the cervical os, giving it a dark red appearance. A s this area is
vascular, and the cells form only a single layer, bleeding may occur either
spontaneously or following sexual intercourse. N ormally, no treatment is required,
and the ectropion reverts back to normal cervical cells during the puerperium.
Cervical polyps
These are small, vascular, pedunculated growths on the cervix, which consist of
squamous or columnar epithelial cells over a core of connective tissue rich with blood
vessels. D uring pregnancy, the polyps may be a cause of bleeding, but require no
treatment unless the bleeding is severe or a smear test indicates malignancy.
Carcinoma of the cervix
Carcinoma of the cervix is the most common gynaecological malignant disease
occurring in pregnancy with an estimated incidence of 1 in 2200 pregnancies
(Copeland and Landon 2011). The condition presents with vaginal bleeding and
increased vaginal discharge. O n speculum examination the appearance of the cervix
may lead to a suspicion of carcinoma, which is diagnosed following colposcopy or a
cervical biopsy.
The precursor to cervical cancer is cervical intraepithelial neoplasia (CIN), which can
be diagnosed from an abnormal Papanicolaou (Pap) smear. W here this is diagnosed at
an early stage, treatment can usually be postponed for the duration of the pregnancy.
The Pap smear is not routinely carried out during pregnancy, but the midwife should
ensure that pregnant women know about the N ational Health S ervice Cervical
S creening Programme (2013), recommending a smear 6 weeks postnatally if one has
not been carried out in the previous 3 years.
Treatment for cervical carcinoma in pregnancy will depend on the gestation of the
pregnancy and the stage of the disease, and full explanations of treatments and their
possible outcomes should be given to the woman and her family. For carcinoma in the
early stages, treatment may be delayed until the end of the pregnancy, or a cone
biopsy may be performed under general anaesthetic to remove the affected tissue.
However, there is a risk of haemorrhage due to the increased vascularity of the cervix
in pregnancy, as well as a risk of miscarriage. Where the disease is more advanced, and
the diagnosis made in early pregnancy, the woman may be offered a termination of
pregnancy in order to receive treatment, as the effects of chemotherapy and
radiotherapy on the fetus cannot be accurately predicted at the present time. D uring
the late second and third trimester the obstetric and oncology teams will consider the
optimal time for birth in order to achieve the best outcomes for both mother and baby.
Spontaneous miscarriage
The term miscarriage is used to describe a spontaneous pregnancy loss in preference to
the term of abortion which is associated with the deliberate ending of a pregnancy. A
miscarriage is seen as the loss of the products of conception prior to the completion of
24 weeks of gestation, with an early pregnancy loss being one that occurs before the
12th completed week of pregnancy (RCO G [Royal College of O bstetricians and
Gynaecologists] 2006).
I t is estimated that 10–20% of clinically recognized pregnancies will end in a
miscarriage, resulting in 50 000 hospital admissions annually. A pproximately 1–2% of
second trimester pregnancies will result in a miscarriage (RCO G 2011a). Methods of
managing pregnancy loss are currently evolving, with more emphasis being placed on
medical intervention and/or management.
I n all cases of miscarriage, the woman and her family will need guidance and
support from those caring for her. I n all areas of communication, the language used
should be appropriate, avoiding medical terms, and be respectful of the pregnancy
loss. Following the miscarriage, the parents may wish to see and hold their baby, and
will need to be supported in doing this by those caring for them. Even where there is
no recognizable baby, some parents are comforted by being given this opportunity
(S A N D S [S tillbirth and N eonatal D eath S ociety 2007
]). I t is also important to create
memories for the parents in the form of photographs, and, for pregnancy losses in the
second and third trimesters, footprints and handprints may be taken (see Chapter 26).
For a pregnancy loss prior to 24 weeks' gestation, there is no legal requirement for a
baby's birth to be registered or for a burial or cremation to take place. However, many
N ational Health S ervice (N HS ) facilities now make provision for a service for these
babies, or parents may choose to make their own arrangements. I n the case of
cremation, the parents should be advised that there are very few or no ashes.
Following a miscarriage, blood tests may be carried out on the woman, and
depending on gestational age, the parents may be offered a post mortem examination
of the fetal remains in an effort to try to establish a reason for the pregnancy loss.
However, in many cases there is no identifiable cause. S hould this be the case, the
outlook for future pregnancies is generally good. Many early pregnancy losses are due
to chromosomal malformations, resulting in a fetus that does not develop. S hould a
reason for the miscarriage be identified, it may be of some comfort to the woman
allowing for medical management to be put in place to enable a subsequent pregnancy
to be more successful.
A spontaneous miscarriage may present in a number of ways, all associated with a
history of bleeding and/or lower abdominal pain.
A threatened miscarriage occurs where there is vaginal bleeding in early pregnancy,
which may or may not be accompanied by abdominal pain. The cervical os remains
closed, and in about 80% of women presenting with these symptoms a viable
pregnancy will continue.
W here the abdominal pain persists and the bleeding increases, the cervix opens and
the products of conception will pass into the vagina in an inevitable miscarriage. S hould
some of the products be retained, this is termed an incomplete miscarriage. I nfection is
a risk with incomplete miscarriage and therapeutic termination of pregnancy. The
signs and symptoms of miscarriage are present, accompanied by uterine tenderness,
offensive vaginal discharge and pyrexia. I n some cases this may progress to
overwhelming sepsis, with the accompanying symptoms of hypotension, renal failure
and disseminated intravascular coagulation (D I C). The remaining products may be
passed spontaneously to become a complete miscarriage.
W here there is a missed or silent miscarriage a pregnancy sac with identifiable fetal
parts is seen on ultrasound examination, but there is no fetal heart beat. There may be
some abdominal pain and bleeding but the products of the pregnancy are not always
passed spontaneously.
The first priority with any woman presenting with vaginal bleeding is to ensure that
she is haemodynamically stable. Profuse bleeding may occur where the products of
conception are partially expelled through the cervix.
Human chorionic gonadotrophic hormone (hCG) is present in the maternal blood
from 9–10 days following conception, and assessing hCG levels may be used as an
indication of the pregnancy's viability. W here a woman has persistent bleeding serial
readings can be taken to assess the progress of a pregnancy or distinguish an ectopic
pregnancy from a complete miscarriage where the uterus is empty on an ultrasound
scan. The levels of hCG double every 48 hours in a normal intrauterine pregnancy
from 4 to 6 weeks of gestation.
A s a pregnancy progresses, transvaginal ultrasound and/or abdominal ultrasound
may be used to confirm the presence or absence of a viable pregnancy sac (RCOG
2006). A gentle vaginal or speculum examination may also be performed to ascertain if
the cervical os is open, and to observe for the presence of any products of conception
within the vagina.
I n the case of threatened miscarriage where viability of the pregnancy has been
confirmed, there is no specific treatment as the likelihood of the pregnancy
progressing is usually good. The practice of bed rest to preserve pregnancy is not
supported by evidence so women should be neither encouraged nor discouraged from
doing this.
For a complete miscarriage, there also is no required treatment if the woman's
condition is stable, apart from the support and guidance she and her family will
require to deal with their loss.
I f there are retained products of conception, an incomplete or missed miscarriage,
the options for treatment will often depend on gestational age and the condition of the
woman. Miscarriages may be managed surgically, medically or expectantly. I n many
cases the appropriate management is to wait for the products of the conception to be
passed spontaneously. However women should be aware that this can take several
weeks (RCO G 2006). W omen adopting this option should be given full information
regarding the probable sequence of events and be provided with contact details for
further advice, with the option of admission to hospital if required. I t is important that
women are educated to actively observe for signs of infection and know what to do if
they suspect this.
The surgical method, where the uterine cavity is evacuated of the retained products
of conception (ERPC) prior to 14 weeks' gestation is suitable for women who do not
want to be managed expectantly and who are not suitable for medical management.
Under either a general or local anaesthetic the cervix is dilated and a suction cure age
is used to empty the uterus. The use of prostaglandins prior to surgery makes the
cervix easier to dilate, thus reducing the risk of cervical damage. Between 1 and 2% of
surgical evacuations result in serious morbidity for the woman with the main
complications being perforation of the uterus, tears to the cervix and haemorrhage.
Medical management of miscarriages includes a variety of regimes involving the use
of prostaglandins, such as misoprostol, and may include the use of an anti-
progesterone such as mifepristone for a missed miscarriage, or progesterone alone for
an incomplete miscarriage. The success rates for medically managed miscarriages vary
from 13 to 96% (RCO G 2006) depending on the gestation and size of the gestational
sac. O ften women will spend time at home between the administration of the first
drug and subsequent treatment, so it should be ensured that they have full knowledge
of what might happen and a contact number to use at any time. A lthough the
complications include abdominal pain and bleeding, overall the medical management
of miscarriage reduces both the number of hospital admissions and the time women
spend in hospital.
Recurrent miscarriage
Tests may be carried out on the woman and fetus following a miscarriage to try to
establish any underlying cause. This is especially important where there is a history of
recurrent miscarriage. Following a history of three or more miscarriages a referral is
usually made to a specialist recurrent miscarriage clinic (RCO G 2011a), where
appropriate and accurate information and support can be given.
Genetic reasons for the miscarriage may be identified through karyotyping of the
fetal tissue, as well as both parents. This can cause difficult dilemmas to deal with but
more recent genetic engineering is offering hope to some couples. W omen should also
be tested for lupus anticoagulant and anticardiolipin antibodies, with treatment of low
dose aspirin and heparin being initiated if either of these is present. O ther treatments
depend on the cause, or causes, of the miscarriages being identified.
Ectopic pregnancy
A n ectopic pregnancy occurs when a fertilized ovum implants outside the uterine
cavity, often within the fallopian tube. However, implantation can also occur within
the abdominal cavity (for instance on the large intestine or in the Pouch of D ouglas),
the ovary or in the cervical canal. The incidence is 11.1 per 1000 pregnancies (RCOG
2010a), with 6 deaths a ributed to ectopic pregnancy in the 2006–2008 S aving Mother's
Lives report (CEMACE [Centre for Maternal and Child Enquiries] 2011).
The conceptus produces hCG in the same way as for a uterine pregnancy,
maintaining the corpus luteum, which leads to the production of oestrogen and
progesterone and the preparation of the uterus to receive the fertilized ovum.
However, following implantation in an abnormal site the conceptus continues to grow
and in the more common case of an ectopic pregnancy in the fallopian tube, until the
tube ruptures, often accompanied by catastrophic bleeding in the woman, or until the
embryo dies.
Many ectopic pregnancies occur with no identifiable risk factors. However, it is
recognized that damage to the fallopian tube through a previous ectopic pregnancy or
previous tubular surgery increases the risk, as do previous ascending genital tract
infections. Further risk factors include a pregnancy that commences with an
intrauterine contraceptive device (I UCD ) in situ or the woman conceives while taking
the progestogen-only pill.
Ectopic (tubal) pregnancies present with vaginal bleeding and a sudden onset of
lower abdominal pain, which is initially one sided, but spreads as blood enters the
peritoneal cavity. There is referred shoulder tip pain caused by the blood irritating the
diaphragm.
I n 25% of cases, the presentation will be acute, with hypotension and tachycardia.
O n abdominal palpation there is abdominal distension, guarding and tenderness,
which assists in confirming the diagnosis. However, in the majority of cases the
presentation is less acute, so there should be a suspicion of ectopic pregnancy in any
woman who presents with amenorrhea and lower abdominal pain. I n these cases the
presentation may be confused with that of a threatened or incomplete miscarriage,
thus delaying appropriate treatment.
A transvaginal ultrasound of the lower abdomen is a useful diagnostic tool in
confirming the site of the pregnancy. A single blood test for hCG level may be either
positive (where the corpus luteum remains active) or negative, so is of limited
diagnostic value. Serial testing is of greater value.
The basis of treatment in the acute, advanced presentation is surgical removal of the
conceptus and ruptured fallopian tube as these threaten the life of the woman if she is
not stabilized and treated rapidly. I n the majority of cases, surgery is currently by
laparoscopy as opposed to a laparotomy, as this reduces blood loss, as well as
postoperative pain. The ectopic pregnancy may either be removed through an incision
in the tube itself, a salpingotomy, or by removing part of the fallopian tube, i.e. a
salpingectomy. A lthough a salpingotomy will enable a higher chance of a uterine
pregnancy in the future, it is associated with a higher incidence of subsequent tubal
pregnancies (RCOG 2010a).
W here the fetus has died, hCG levels will fall and the ectopic pregnancy may resolve
itself, with the products either being reabsorbed or miscarried. Medical management
is also a choice where the diagnosis of an ectopic pregnancy is made and the woman is
haemodynamically stable. Methotrexate is given in a single dose according to the
woman's body weight (RCO G 2010a), and works by interfering with D N A
(deoxyribonucleic acid) synthesis, thus preventing the continued growth of the fetus
(N HS Choices 2012). S hould this be the treatment choice, the woman should be
informed that further treatment may be needed as well as how to access support at
any time should it be required (RCOG 2010a).
W omen who are Rhesus-negative should be given anti-D immunoglobulin as
recommended by national and local guidelines following any form of pregnancy loss
(RCOG 2011b). (See Box 12.2 for further information.)
Box 12.2
N ot e on a nt i- D im m unoglobulin
For all women who are Rhesus-negative, there is an increased risk of
sensitization occurring during any form of pregnancy loss, and threatened
miscarriage (N I CE 2011). A nti-D immunoglobulin prophylaxis should be
considered for non-sensitized women presenting with a history of bleeding
after 12 weeks' gestation. W here the bleeding persists throughout the
pregnancy, anti-D should be repeated at 6-weekly intervals. A nti-D
immunoglobulin should also be administered to all non-sensitized Rhesus-
negative women following miscarriage, ectopic pregnancy or therapeutic
termination of pregnancy (RCOG 2011b).
Other problems in early pregnancy
Inelastic cervix
Formally known as incompetent cervix, an inelastic cervix will lead to silent, painless
dilatation of the cervix and loss of the products of conception, either as a miscarriage,
or a preterm birth. The incidence is 1 : 100–1 : 2000 pregnancies, the large variation
being due to differences in populations (Ludmir and Owen 2007).
The cervix consists mainly of connective tissue, collagen, elastin, smooth muscle and
blood vessels, and undergoes complex changes during pregnancy. The exact
mechanism for inelastic cervix is unknown, but the risk is increased where there has
been trauma to the cervix during surgical procedures such as a dilatation and
curettage or cone biopsy, or the weakness may be of congenital origin.
The diagnosis of an inelastic cervix is usually made retrospectively on review of
gynaecological and obstetric history. There will have been a painless dilatation of the
cervix typically at around 18–20 weeks of gestation, or on digital vaginal or ultrasound
examination, the length of the cervical canal may be noted to have shortened without
any accompanying pain.
A cervical cerclage may be inserted. However the evidence to support this procedure
is weak, and both the procedure and the implications should be fully discussed with
the woman (N I CE [N ational I nstitute for Health and Clinical Excellence] 2007 ). A
suture is inserted from 14 weeks' gestation at the level of the internal os, and remains
in situ until 38 weeks' gestation, unless there are earlier signs of labour. The associated
risks are that the cervix may dilate with the suture in situ, leading to lacerations of the
cervix, and infection. In 3% of cases, the cervix fails to dilate during labour, resulting in
a caesarean section (Ludmir and Owen 2007).
Gestational trophoblastic disease (GTD)
I n this condition there is abnormal placental development, resulting in either a
complete hydatidiform mole or a partial mole and there is no viable fetus. The grape-like
appearance of the mole is due to the over-proliferation of chorionic villi. Usually this is
a benign condition which becomes apparent in the second trimester, characterized by
vaginal bleeding, a larger than expected uterus, hyperemesis gravidarum and often
symptoms of pre-eclampsia. However if a molar pregnancy does not spontaneously
miscarry, two associated disorders can occur; gestational trophoblastic neoplasia (GTN )
where the mole remains in situ and is diagnosed by continuing raised hCG levels and
ultrasound scanning, and choriocarcinoma, which can arise as a malignant variation of
the disease. I t is thought that 3% of complete hydatidiform moles will progress to
choriocarcinoma.
I n the UK, GTD is a rare event, but women of A sian origin are at higher risk. A ge is
also a risk factor for both teenagers and women over 45 years of age. However, 90% of
molar pregnancies occur in women between the ages of 18 and 40 years (Copeland and
Landon 2011). O ther risk factors include a previous molar pregnancy and those with
blood type Group A . Treatment is by evacuation of the uterus, followed by histology of
the tissue to enable accurate diagnosis of molar pregnancy (RCOG 2010b).
D ue to the risk of carcinoma developing following a molar pregnancy, all cases
should be followed up at a trophoblastic screening centre, with serial blood or urine
hCG levels being monitored. I n the UK, this programme has resulted in 98–100% of
cases being successfully treated and only 5–8% requiring chemotherapy (RCOG
2010b). W here the hCG levels are within normal limits within 56 days of the end of the
pregnancy, follow-up continues for a further 6 months. However, if the hCG levels
remain raised at this point, the woman will continue to be assessed until the levels are
within normal limits. Following subsequent pregnancies, hCG levels should be
monitored for 6–8 weeks to ensure that there is no recurrence of the disease (RCOG
2010b).
Following a hydatidiform mole, those women who are Rhesus-negative should be
administered anti-D immunoglobulin as recommended by national and local
guidelines. (See Box 12.2. for further information.)
Uterine fibroid degeneration
Fibroids (leiomyomas) can degenerate during pregnancy as a result of their
diminishing blood supply, resulting in abdominal pain as the tissue becomes
ischaemic and necrotic. S uitable analgesia and rest are indicated until the pain
subsides, although it can be a recurring problem throughout a pregnancy. N ot all
fibroids degenerate during pregnancy as some may receive an increased blood supply,
causing enlargement with the consequential impact of obstructing labour.
Induced abortion/termination of pregnancy
Under the terms of the A bortion A ct 1967, amended by the Human Fertilisation and
Embryology A ct 1990, provision is made for a pregnancy to be terminated up to 24
weeks of pregnancy for a number of reasons and with the wri en agreement of two
registered medical practitioners The medical practitioners must agree that, in their
opinion, the termination is justified under the terms of the statutory A ct (see Box 12.3)
I n the UK, in 2011, 189 931 terminations of pregnancy were undertaken: the majority of
these occurring before 20 weeks' gestation (D epartment of Health 2012). I t should be
noted that the law in I reland does not allow for pregnancies to be terminated unless it
is to preserve the life of the woman (RCOG 2011c).
Box 12.3
S t a t ut ory grounds for t e rm ina t ion of pre gna ncy
(a) that the pregnancy has not exceeded its twenty-fourth week and that the
continuance of the pregnancy would involve risk, greater than if the
pregnancy were terminated, of injury to the physical or mental health of
the pregnant woman or any existing children of her family; or
(b) that the termination is necessary to prevent grave permanent injury to
the physical or mental health of the pregnant woman; or
(c) that the continuance of the pregnancy would involve risk to the life of
the pregnant woman, greater than if the pregnancy were terminated; or
(d) that there is a substantial risk that if the child were born it would suffer
from such physical or mental abnormalities as to be seriously
handicapped.
Abortion Act 1967; amended by the Human Fertilisation and Embryology Act 1990
The majority of terminations in the UK are carried out under clause (a) of the
A bortion A ct, meaning that continuing the pregnancy would involve a greater mental
or physical risk to the woman or her existing family than if the pregnancy were
terminated. Prior to any termination of pregnancy, the woman should receive
counselling to discuss the options available. W hatever the reason for the termination,
support should be offered before, during and following the procedure. I n many cases
the care and support provided for women experiencing a spontaneous miscarriage will
also apply to those undergoing an induced termination of pregnancy. The reasons for
the termination may include malformations of the fetus that are incompatible with
life, or a condition that adversely affects the health of the women such that
terminating the pregnancy offers the best option to expedite appropriate and timely
treatment.
Before the commencement of the termination, it must be ensured that the HS A 1
form, which is a legal requirement of the A bortion A ct 1967 has been completed and
signed by the two medical personnel agreeing to the termination. I n addition, it is also
a legal requirement that the Chief Medical O fficer is notified of all terminations of
pregnancy that take place, within 14 days of their occurrence (RCO G 2011c), by the
practitioners completing form HS A 4. The data on this form is then used for statistical
purposes and monitoring terminations of pregnancies that take place within the UK.
O nly a medical practitioner can terminate a pregnancy. However, in practice, drugs
that are prescribed to induce the termination may be administered by registered
nurses and midwives working in this area of clinical practice.
The methods used for terminating the pregnancy will depend on the gestational age.
Prior to 14 weeks' gestation, the pregnancy is generally terminated surgically by
gradually dilating the cervix with a series of dilators and evacuating the uterus via
vacuum aspiration or suction cure es. This may be carried out under general or local
anaesthesia.
Terminations in later pregnancy are carried out medically, using a regime of drugs
to prepare and dilate the cervix. The actual regime used may vary across healthcare
providers. The cervix is initially prepared using mifepristone, which is a progesterone
antagonist. This is given orally, and is followed 36–48 hours later by vaginal and/or oral
prostaglandins, such as misoprostol. The woman may return home in between the
administration of the two drugs and should be provided with clear information about
what to expect, the contact details of a named healthcare professional and the
reassurance that admission to hospital can be at any time. D uring the termination,
analgesia appropriate to her needs should be available.
A termination of pregnancy should not result in the live birth of the fetus. To this
effect, should the procedure take place after 21 weeks and 6 days gestation, feticide
may be performed prior to the commencement of the termination process. This
involves an injection of potassium chloride being injected into the fetal heart to
prevent the fetus being born alive (RCOG 2011c).
W here nurses and midwives have a conscientious objection to termination of
pregnancy, they have the right to refuse to be involved in such procedures. However,
they cannot refuse to give life-saving care to a woman, and must always be non-
judgemental in any care and contact that they provide (NMC 2012b).
A s with other pregnancy losses, those women who undergo a termination of
pregnancy and are Rhesus-negative will require anti-D immunoglobulin as
recommended by national and local guidelines. (See Box 12.2 for further information.)
Pregnancy problems associated with assisted conception
There are a number of techniques available to a empt assisted conception for women
and couples who have fertility problems. However, achieving a pregnancy is not
always the end of the difficulties that may occur.
A serious condition that may occur is that of ovarian hyperstimulation syndrome.
W hen fertility drugs have been taken to stimulate the production of follicles, massive
enlargement of the ovaries and multiple cysts can develop (RCOG 2007). Many women
taking fertility drugs will experience a mild form of this syndrome, but in a
considerable percentage (0.5–5%) this develops to include oliguria, renal failure and
hypovolaemic shock (Mahomed 2011b). This risk increases when pregnancy has been
achieved. The condition itself subsides spontaneously, but medical support and
treatment is required for those who are severely unwell.
I n assisted conception, the risk of miscarriage is approximately 14.7%. This rate is
probably associated with the quality and length of freezing of the oocytes or embryos
that are used. However there are no differences in the number of chromosomal
malformations when compared with spontaneous pregnancies (Mahomed 2011b).
The number of multiple pregnancies increases with assisted conception, with rates
of 27% for twins and 3% for triplets (Mahomed 2011b). A ssisted reproductive
technology accounts for 1% of all births, but 18% of all multiple births; consequently
multiple birth in itself is a risk factor for pregnancy (see Chapter 14). With all
pregnancies resulting from assisted techniques, there is an increase in the rate of pre-
term birth, small for gestational age babies, placenta praevia, pregnancy induced
hypertension and gestational diabetes. The reasons for these rates are not known, but
it is considered that they relate to the original factors leading to the infertility
(Mahomed 2011b).
Nausea, vomiting and hyperemesis gravidarum
N ausea and vomiting are common symptoms of pregnancy, affecting approximately
70% of women (Gordon 2007), with the onset from 4–8 weeks' gestation and lasting
until 16–20 weeks (N I CE 2010). Very occasionally the symptoms persist for the whole
of pregnancy. From the woman's point of view, nausea and vomiting is frequently
dismissed by others as being a common symptom of physiological pregnancy so the
impact that it may have on her life and that of her family may be ignored (Tiran 2004).
The cause of these symptoms is thought to be due to the presence of hCG, which is
present during the time that the nausea and vomiting is most prevalent, although
oestrogen and/or progesterone are also thought to have some influence (Tiran 2004;
Gordon 2007). A ccording to N I CE (2010), ginger may be of help in reducing the
symptoms, as is wrist acupuncture, a form of treatment for nausea in pregnancy often
chosen by women as it is drug-free. According to Betts (2006: 25), the wrist area is seen
to ‘harmonise the stomach’, thus working to reduce nausea.
H yperemesis gravidarum is the severest form of nausea and vomiting and occurs in
3.5 per 1000 pregnancies (Gordon 2007). The woman presents with a history of
vomiting that has led to weight loss and dehydration that may also be associated with
postural hypotension, tachycardia, ketosis and electrolyte imbalance (Williamson and
Girling 2011). This requires treatment in hospital, where intravenous fluids are given
to re-hydrate the woman and correct the electrolyte imbalance, with anti-emetics being
administered to control the vomiting. Very often a combination of drugs will be
needed in order to achieve this. I t is important to exclude other conditions, such as a
urinary tract infection, disorders of the gastrointestinal tract, or a molar pregnancy,
where vomiting may also be excessive.
The aim of treatment is not only to stabilize the woman's condition, but also to
prevent further complications. Continual vomiting during the pregnancy may lead to
vitamin deficiencies, and/or hyponatraemia, which can present with confusion and
seizures, leading ultimately to respiratory arrest if left untreated (Williamson and
Girling 2011). For women who are immobilized through the severity of the vomiting,
deep vein thrombosis is also a potential complication due to the combination of
dehydration and immobility. I n cases of hyperemesis gravidarum the fetus may be at
risk of being small for gestational age due to a lack of nutrients.
Pelvic girdle pain (PGP)
During pregnancy the activity of the pregnancy hormones, especially relaxin, can cause
the ligaments supporting the pelvic joints to relax, allowing for slight movement. A s a
consequence, pelvic girdle pain (PGP), or formerly known assymphysis pubis
dysfunction, occurs when this relaxation is excessive, allowing the pelvic bones to move
up and down when the woman is walking. This leads to pain in the pubic area as well
as backache, usually occurring any time from the 28th week of pregnancy.
A pproximately, 1 in 5 pregnant women are affected by PGP (A CPW H [A ssociation of
Chartered Physiotherapists in W omen's Health] 2011), with symptoms varying from
mild pain and discomfort to severe mobility difficulties. S ome women also experience
pain and discomfort when lying down in certain positions and on standing (ACPWH
2011). Very often, PGP occurs without identifiable risk factors, but these may include a
history of lower back or pelvic girdle pain, and/or a job that is physically active.
O n suspecting that a woman has PGP, the midwife should explain the condition and
the possible causes to the woman and organize a referral to an obstetric
physiotherapist. The woman should be advised to rest as much as possible and
undertake activities that do not cause her further pain. Very often it is movement that
involves abducting the hips which increases the pain and discomfort. A
physiotherapist can be helpful in advising on mobility and coping with daily tasks and
in supplying aids such as pelvic girdle support belts and in extreme cases, crutches, so
that the pain may be reduced.
A plan for both pregnancy and care in labour should be developed and recorded, so
that the midwives caring for the woman during the birth are aware of the PGP and any
positions that can be beneficial, such as being upright and kneeling as well as the
woman's analgesia requirements. A s there may be a reduction in hip abduction, the
midwife should take care when performing vaginal examinations, and if the lithotomy
position is required during the birth, not to cause the woman unnecessary discomfort
(ACPWH 2011). Following the birth, the ligaments slowly return to their pre-pregnant
condition, but this may take some time. Extra support may be required and
physiotherapy may need to be continued beyond the postnatal period.
Bleeding after the 24th week of pregnancy
Antepartum haemorrhage (APH)
A ntepartum haemorrhage is bleeding from the genital tract after the 24th week of
pregnancy, and before the onset of labour. As shown in Table 12.1, it is caused by:
• Bleeding from local lesions of the genital tract (incidental causes).
• Placental separation due to placenta praevia or placental abruption.
Table 12.1
Causes of bleeding in late pregnancy
Cause Incidence (%)
Placenta praevia 31.0
Placental abruption 22.0
‘Unclassified bleeding’ 47.0
of which:
Marginal 60.0
Show 20.0
Cervicitis 8.0
Trauma 5.0
Vulvovaginal varicosities 2.0
Genital tumours 0.5
Genital infections 0.5
Haematuria 0.5
Vasa praevia 0.5
Other 0.5
Source: Adapted from Navti and Konje 2011
Effect on the mother
A small amount of bleeding will not physically affect the woman (unless she is already
severely anaemic) but it is likely to cause her anxiety. I n cases of heavier bleeding, this
may be accompanied by medical shock and blood clo ing disorders. The midwife will
be aware that the woman can die or be left with permanent morbidity if bleeding in
pregnancy is not dealt with promptly and effectively.
Effect on the fetus
Fetal mortality and morbidity are increased as a result of severe vaginal bleeding in
pregnancy. S tillbirth or neonatal death may occur. Premature placental separation and
consequent hypoxia may result in severe neurological damage in the baby.
Initial appraisal of a woman with APH
A ntepartum haemorrhage is unpredictable and the woman's condition can deteriorate
at any time. A rapid decision about the urgency of need for a medical or paramedic
presence, or both, must be made, often at the same time as observing and talking to
the woman and her partner.
Assessment of maternal condition
• Take a history from the woman.
• Assess basic observations of temperature, pulse rate, respiratory rate and blood
pressure, including their documentation.
• Observe for any pallor or restlessness.
• Assess the blood loss (consider retaining soiled sheets and clothes in case a second
opinion is required).
• Perform a gentle abdominal examination, while assessing for signs of labour.
• On no account must any vaginal or rectal examination be undertaken, nor should an
enema or suppositories be administered to a woman experiencing an APH as these
could result in torrential haemorrhage.
S ometimes bleeding that the woman had presumed to be from the vagina may be
from haemorrhoids. The midwife should consider this differential diagnosis and
confirm or exclude this as soon as possible by careful questioning and examination.
Assessment of fetal condition
• The woman is asked if the baby has been moving as much as normal
• An attempt should be made to listen to the fetal heart. An ultrasound apparatus may
be used in order to obtain information. However if the woman is at home and the
bleeding is severe this would not be a priority. The midwife will need to ensure the
women is transferred to hospital as soon as her condition is stabilized in order to give
the fetus the best chance of survival. Speed of action is vital.
S upportive treatment for moderate or severe blood loss and/or maternal collapse
would consist of:
• providing ongoing emotional support for the woman and her partner/relatives
• administering rapid fluid replacement (warmed) with a plasma expander, with whole
blood if necessary
• administering appropriate analgesia
• arranging transfer to hospital by the most appropriate means, if the woman is at
home.
Management of antepartum haemorrhage depends on the definite diagnosis (see
Table 12.2).
Table 12.2
Comparison of clinical issues in placental abruption and placenta praevia
Placenta praevia
I n this condition the placenta is partially or wholly implanted in the lower uterine
segment. The lower uterine segment grows and stretches progressively after the 12th
week of pregnancy. I n later weeks this may cause the placenta to separate and severe
bleeding can occur. The amount of bleeding is not usually associated with any
particular type of activity and commonly occurs when the woman is resting. The low
placental location allows all of the lost blood to escape unimpeded and a
retroplacental clot is not formed. For this reason, pain is not a feature of placenta
praevia. S ome women with this condition have a history of a small repeated blood loss
at intervals throughout pregnancy whereas others may have a sudden single episode
of vaginal bleeding after the 20th week. However, severe haemorrhage occurs most
frequently after the 34th week of pregnancy. The degree of placenta praevia does not
necessarily correspond to the amount of bleeding. A type 4 placenta praevia may never
bleed before the onset of spontaneous labour or elective caesarean section in late
pregnancy or, conversely, some women with placenta praevia type 1 may experience
relatively heavy bleeding from early in their pregnancy.
Degrees of placenta praevia
Type 1 placenta praevia
The majority of the placenta is in the upper uterine segment (see Figs 12.1, 12.5). Blood
loss is usually mild and the mother and fetus remain in good condition. Vaginal birth
is possible.
Type 2 placenta praevia
The placenta is partially located in the lower segment near the internal cervical os
(marginal placenta praevia) (see Figs 12.2, 12.6). Blood loss is usually moderate,
although the conditions of the mother and fetus can vary. Fetal hypoxia is more likely
to be present than maternal shock. Vaginal birth is possible, particularly if the
placenta is anterior.
Type 3 placenta praevia
The placenta is located over the internal cervical os but not centrally (see Figs 12.3,
12.7). Bleeding is likely to be severe, particularly when the lower segment stretches
and the cervix begins to efface and dilate in late pregnancy. Vaginal birth is
inappropriate because the placenta precedes the fetus.
Type 4 placenta praevia
The placenta is located centrally over the internal cervical os (see Figs 12.4, 12.8) and
torrential haemorrhage is very likely. Caesarean section is essential to save the lives of
the woman and fetus.
FIG. 12.1 Type 1.
FIG. 12.2 Type 2.
FIG. 12.3 Type 3.
FIG. 12.4 Type 4.
FIGS 12.1–12.4 Types and positions of placenta praevia.
FIG. 12.5 Type 1.
FIG. 12.6 Type 2.
FIG. 12.7 Type 3.
FIG. 12.8 Type 4.
FIGS 12.5–12.8 Relation of placenta praevia to cervical os.
Incidence
Placenta praevia affects 2.8 per 1000 of singleton pregnancies and 3.9 per 1000 of twin
pregnancies (N avti and Konje 2011). There is a higher incidence of placenta praevia
among women with increasing age and parity, in women who smoke and those who
have had a previous caesarean section. Furthermore, it is known that there is also an
increased risk of recurrence where there has been a placenta praevia in a previous
pregnancy.
Management
I mmediate re-localization of the placenta using ultrasonic scanning is a definitive aid
to diagnosis, and as well as confirming the existence of placenta praevia it will
establish its degree. Relying on an early pregnancy scan at 20 weeks of pregnancy is
not very useful when vaginal bleeding starts in later pregnancy, as the placenta tends
to migrate up the uterine wall as the uterus grows in a developing pregnancy.
Further management decisions will depend on:
• the amount of bleeding
• the condition of the woman and fetus
• the location of the placenta
• the stage of the pregnancy.
Conservative management
This is appropriate if bleeding is slight and the woman and fetus are well. The woman
will be kept in hospital at rest until bleeding has stopped. A speculum examination
will have ruled out incidental causes. Further bleeding is almost inevitable if the
placenta encroaches into the lower segment; therefore it is usual for the woman to
remain in, or close to hospital for the rest of her pregnancy. A visit to the special care
baby unit/neonatal intensive care unit and contact with the neonatal team may also
help to prepare the woman and her family for the possibility of pre-term birth.
A decision will be made with the woman about how and when the birth will be
managed. I f there is no further severe bleeding, vaginal birth is highly likely if the
placental location allows. The midwife should be aware that, even if vaginal birth is
achieved, there remains a danger of postpartum haemorrhage because the placenta
has been situated in the lower segment where there are fewer oblique muscle fibres
and the action of the living ligatures is less effective.
Immediate management of life-threatening bleeding
S evere vaginal bleeding will necessitate immediate birth of the baby by caesarean
section regardless of the location of the placenta. This should take place in a maternity
unit with facilities for the appropriate care of the newborn, especially if the baby is
preterm. D uring the assessment and preparation for theatre the woman will be
extremely anxious and the midwife must comfort and encourage her, sharing
information with her as much as possible. The partner will also need to be supported,
whether he is in the operating theatre or waits outside.
I f the placenta is situated anteriorly in the uterus, this may complicate the surgical
approach as it underlies the site of the normal incision. I n major degrees of placenta
praevia (types 3 and 4) caesarean section is required even if the fetus has died in utero.
S uch management aims to prevent torrential haemorrhage and possible maternal
death.
Complications
Complication include:
• Maternal shock, resulting from blood loss and hypovolaemia.
• Anaesthetic and surgical complications, which are more common in women with
major degrees of placenta praevia, and in those for whom preparation for surgery has
been suboptimal.
• Placenta accreta, in up to 15% of women with placenta praevia.
• Air embolism, an occasional occurrence when the sinuses in the placental bed have
been broken.
• Postpartum haemorrhage: occasionally uncontrolled haemorrhage will continue,
despite the administration of uterotonic drugs at the birth, even following the best
efforts to control it, and a ligation of the internal iliac artery. A caesarean
hysterectomy may be required to save the woman's life.
• Maternal death is rare in the developed world.
• Fetal hypoxia and its sequelae due to placental separation.
• Fetal death, depending on gestation and amount of blood loss.
Placental abruption
Premature separation of a normally situated placenta occurring after the 24th week of
pregnancy is referred to as a placental abruption. The aetiology of this type of
haemorrhage is not always clear, but it may be associated with:
• hypertension
• a sudden reduction in uterine size, for instance when the membranes rupture or
after the birth of a first twin
• trauma, for instance external cephalic version of a fetus presenting by the breech, a
road traffic accident or domestic violence, as these may partially dislodge the
placenta
• high parity
• previous caesarean section
• cigarette smoking.
Incidence
Placental abruption occurs in 0.49–1.8% of all pregnancies with 30% of cases being
classed as concealed and 70% being revealed (N avti and Konje 2011), although there is
probably a combination of both in many situations (mixed haemorrhage). I n any of
these situations the blood loss may be mild, moderate or severe, ranging from a few
spots to continually soaking clothes and bed linen.
I n revealed haemorrhage, as blood escapes from the placental site it separates the
membranes from the uterine wall and drains through the vagina. However in concealed
haemorrhage blood is retained behind the placenta where it is forced back into the
myometrium, infiltrating the space between the muscle fibres of the uterus. This
extravasation (seepage outside the normal vascular channels) can cause marked
damage and, if observed at operation, the uterus will appear bruised, oedematous and
enlarged. This is termed Couvelaire uterus or uterine apoplexy. I n a completely
concealed abruption with no vaginal bleeding, the woman will have all the signs and
symptoms of hypovolaemic shock and if the blood loss is moderate or severe she will
experience extreme pain. I n practice the midwife cannot rely on visible blood loss as a
guide to the severity of the haemorrhage; on the contrary, the most severe
haemorrhage is often that which is totally concealed.
A s with placenta praevia, the maternal and fetal condition will dictate the
management.
Mild separation of the placenta
Most commonly a woman self-admits to the maternity unit with slight vaginal
bleeding. O n examination the woman and fetus are in a stable condition and there is
no indication of shock. The fetus is alive with normal heart sounds. The consistency of
the uterus is normal and there is no tenderness on palpation. The management would
include the following plan of care:
• An ultrasound scan can determine the placental localization and identify any degree
of concealed bleeding
• The fetal condition should be assessed by frequent or continuous monitoring of the
fetal heart rate while bleeding persists. Subsequently a cardiotocograph (CTG)
should be undertaken once or twice daily
• If the woman is not in labour and the gestation is less than 37 weeks she may be
cared for in the antenatal ward for a few days. She may return home if there is no
further bleeding and the placenta has been found to be in the upper uterine segment.
The woman should be encouraged to return to hospital if there is any further
bleeding.
• Women who have passed the 37th week of pregnancy may be offered induction of
labour, especially if there has been more than one episode of mild bleeding
• Further heavy bleeding or evidence of fetal compromise could indicate that a
caesarean section is necessary.
The midwife should offer the woman comfort and encouragement by a ending to
her emotional needs, including her need for information. Physical domestic abuse
should be considered by the midwife, which the woman may be frightened to reveal. I t
should also be noted that if the woman is already severely anaemic then even an
apparently mild abruption may compromise her wellbeing and that of the fetus.
Moderate separation of the placenta
A bout a quarter of the placenta will have separated and a considerable amount of
blood may be lost, although concealed haemorrhage must also be considered. The
woman will be shocked and in pain, with uterine tenderness and abdominal guarding.
The fetus may be alive, although hypoxic, however intrauterine death is also a
possibility.
The priority is to reduce shock and to replace blood loss:
• Fluid replacement should be monitored with the aid of a central venous pressure
(CVP) line. Meticulous fluid balance records must be maintained.
• The fetal condition should be continuously assessed by CTG if the fetus is alive, in
which case immediate caesarean section would be indicated once the woman's
condition is stabilized.
• If the fetus is in good condition or has died, vaginal birth may be considered as this
enables the uterus to contract and control the bleeding. The spontaneous onset of
labour frequently accompanies moderately severe placental abruption, but if it does
not then amniotomy is usually sufficient to induce labour. Oxytocics may be used
with great care, if necessary. The birth of the baby is often quite sudden after a short
labour. The use of drugs to attempt to stop labour is usually inappropriate.
Severe separation of the placenta
This is an acute obstetric emergency where at least two-thirds of the placenta has
detached and 2000 ml of blood or more are lost from the circulation. Most or all of the
blood may be concealed behind the placenta. The woman will be severely shocked,
perhaps far beyond the degree to which would be expected from the visible blood loss
( s e e Chapter 22). The blood pressure will be lowered but if the haemorrhage
accompanies pre-eclampsia the reading may lie within the normal range owing to a
preceding hypertension. The fetus will almost certainly be dead. The woman will have
very severe abdominal pain with excruciating tenderness and the uterus would have a
board-like consistency.
Features associated with severe antepartum haemorrhage are:
• coagulation defects
• renal failure
• pituitary failure
• postpartum haemorrhage.
Treatment is the same as for moderate haemorrhage:
• Whole blood should be transfused rapidly and subsequent amounts calculated in
accordance with the woman's CVP.
• Labour may begin spontaneously in advance of amniotomy and the midwife should
be alert for signs of uterine contraction causing periodic intensifying of the
abdominal pain.
• If bleeding continues or a compromised fetal heart rate is present, caesarean section
will be required as soon as the woman's condition has been adequately stabilized.
Blood coagulation failure
Normal blood coagulation
Haemostasis refers to the arrest of bleeding, preventing loss of blood from the blood
vessels. I t depends on the mechanism of coagulation. This is counterbalanced by
fibrinolysis which ensures that the blood vessels are reopened in order to maintain the
patency of the circulation.
Blood clotting occurs in three main stages:
1. When tissues are damaged and platelets break down, thromboplastin is released.
2. Thromboplastin leads to the conversion of prothrombin into thrombin: a proteolytic
(protein-splitting) enzyme.
3. Thrombin converts fibrinogen into fibrin to form a network of long, sticky strands
that entrap blood cells to establish a clot. The coagulated material contracts and
exudes serum, which is plasma depleted of its clotting factors. This is the final part
of a complex cascade of coagulation involving a large number of different clotting
factors (simply named Factor I, Factor II etc. in order of their discovery).
I t is equally important for a healthy person to maintain the blood as a fluid in order
that it can circulate freely. The coagulation mechanism is normally held at bay by the
presence of heparin, which is produced in the liver.
Fibrinolysis is the breakdown of fibrin and occurs as a response to the presence of
clo ed blood. Unless fibrinolysis takes place, coagulation will continue. I t is achieved
by the activation of a series of enzymes culminating in the proteolytic enzyme plasmin.
This breaks down the fibrin in the clots and produces fibrin degradation products
(FDPs).
Disseminated intravascular coagulation (DIC)
The cause of disseminated intravascular coagulation (also known as disseminated
intravascular coagulopathy) (D I C) is not fully understood. I t is a complex pathological
reaction to severe tissue trauma which rarely occurs when the fetus is alive and usually
starts to resolve after birth. I nappropriate coagulation occurs within the blood vessels,
which leads to the consumption of clo ing factors. A s a result, clo ing fails to occur at
the bleeding site. D I C is never a primary disease, as it always occurs as a response to
another disease process.
Events that trigger DIC include:
• placental abruption
• intrauterine fetal death, including delayed miscarriage
• amniotic fluid embolism
• intrauterine infection, including septic miscarriage
• pre-eclampsia and eclampsia.
Management
The aims of the management of DIC are summarized in Box 12.4.
Box 12.4
A im s of t he m a na ge m e nt of D I C
• To manage the underlying cause and remove the stimulus provoking DIC
• To ensure maintenance of the circulating blood volume
• To replace the used up clotting factors and destroyed red blood cells
Source: Lindow and Anthony 2011
The midwife should be alert for conditions that affect D I C, as well as the signs that
clo ing is abnormal. The assessment of the nature of the clot should be part of the
midwife's routine observation during the third stage of labour. O ozing from a
venepuncture site or bleeding from the mucous membrane of the woman's mouth and
nose must be noted and reported. Blood tests should include assessing the full blood
count and the blood grouping, clo ing studies and the levels of platelets, fibrinogen
and fibrin degradation products (FDPs).
Treatment involves the replacement of blood cells and clo ing factors in order to
restore equilibrium. This is usually done by the administration of fresh frozen plasma
and platelet concentrates. Banked red cells will be transfused subsequently.
Management is carried out by a team of obstetricians, anaesthetists, haematologists,
midwives and other healthcare professionals who must strive to work together
harmoniously and effectively to achieve the best possible clinical outcomes for the
woman.
Care by the midwife
D I C causes a frightening situation that demands speed both of recognition and of
action. The midwife has to maintain her own calmness and clarity of thinking as well
as assisting the couple to deal with the situation in which they find themselves.
Frequent and accurate observations must be maintained in order to monitor the
woman's condition. Blood pressure, respirations, pulse rate and temperature are
recorded. The general condition is noted. Fluid balance is monitored with vigilance for
any sign of renal failure.
The partner in particular is likely to be confused by a sudden turn in events, when
previously all seemed to be under control. The midwife must make sure that someone
is giving him appropriate a ention, keeping him informed of what is happening. A ll
health professionals need to be aware that the partner may find it impossible to
absorb all that he is told and may require repeated explanations. He may be the best
person to help the woman to understand her condition. The death of the woman from
organ failure as a result of DIC is a real possibility.
Hepatic disorders and jaundice
S ome liver disorders are specific to pregnant women, and some pre-existing or co-
existing disorders may complicate the pregnancy, as shown in Box 12.5.
Box 12.5
H e pa t ic disorde rs of pre gna ncy
Specific to pregnancy
Intrahepatic cholestasis of pregnancy
Acute fatty liver in pregnancy (see Chapter 13)
Pre-eclampsia and eclampsia (see Chapter 13)
Severe hyperemesis gravidarum.
Pre- or co-existing in pregnancy
Gall bladder disease
Hepatitis
Causes of jaundice in pregnancy are listed in Box 12.6.
Box 12.6
C a use s of ja undice in pre gna ncy
Not specific to pregnancy
Viral hepatitis – A, B, C are the most prevalent
Hepatitis secondary to infection, usually cytomegalovirus, Epstein–Barr
virus, toxoplasmosis or herpes simplex
Gall stones
Drug reactions
Alcohol/drug misuse
Budd–Chiari syndrome
Pregnancy-specific causes
Acute fatty liver
HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome
Intrahepatic cholestasis of pregnancy
Hyperemesis gravidarum
Note: Jaundice is not an inevitable symptom of liver disease in pregnancy.
Obstetric cholestasis (OC)
This is an idiopathic condition that usually begins in the third trimester of pregnancy,
but can occasionally present as early as the first trimester. I t affects 0.7% of
pregnancies and resolves spontaneously following birth, but it has up to a 90%
recurrence rate in subsequent pregnancies (Williamson and Girling 2011). I ts cause is
unknown, although genetic, geographical and environmental factors are considered to
be contributory factors. I t is not a life-threatening condition for the woman, but there
is an increased risk of pre-term labour, fetal compromise and meconium staining, and
the stillbirth risk is increased unless there is active management of the pregnancy.
Clinical presentation
The presentation may include:
• pruritus without a rash
• insomnia and fatigue as a result of the pruritus
• fever, abdominal discomfort, nausea and vomiting
• urine may be darker and stools paler than usual
• a few women develop mild jaundice.
Investigations
The following investigations should be done:
• Tests to eliminate differential diagnoses such as other liver disease or pemphigoid
gestationalis (a rare autoimmune disease of late pregnancy that mimics OC) include
hepatic viral studies, an ultrasound scan of the hepatobiliary tract and an
autoantibody screen.
• Blood tests to assess the levels of bile acids, serum alkaline phosphatase, bilirubin
and liver transaminases, which would be raised.
Management
Management consists of:
• Application of local antipruritic agents, such as antihistamines.
• Vitamin K supplements are administered to the woman, 10 mg orally daily, as her
absorption will be poor, leading to prothombinaemia which predisposes her to
obstetric haemorrhage if left untreated.
• Monitor fetal wellbeing possibly by Doppler of the umbilical artery blood flow.
• Consider elective birth when the fetus is mature, or earlier if the fetal condition
appears to be compromised by the intrauterine environment, or the bile acids are
significantly raised, as this is associated with impending intrauterine death.
• Provide sensitive psychological care to the woman.
• Advise the woman that her pruritus should disappear within 3–14 days of the birth.
• If the woman chooses to use oral contraception in the future, she should be advised
that her liver function should be regularly monitored.
Gall bladder disease
Pregnancy appears to increase the likelihood of gallstone formation but not the risk of
developing acute cholecystitis. D iagnosis is made by exploring the woman's previous
history, with an ultrasound scan of the hepatobiliary tract. The treatment for gall
bladder disease is based on providing symptomatic relief of biliary colic by analgesia,
hydration, nasogastric suction and antibiotics. I f at all possible, surgery in pregnancy
should be avoided.
Viral hepatitis
Viral hepatitis is the most commonly diagnosed viral infection of pregnancy (Andrews
2011). S ee Table 12.3 for information about hepatitis A , B and C in pregnancy.
Hepatitis D , E and G have more recently been described in medical literature but their
relevance to pregnancy is not yet known.
Table 12.3
Viral hepatitis in pregnancy
Skin disorders
Many women suffer from physiological pruritus in pregnancy, particularly over the
abdomen as it grows and stretches. The application of calamine lotion is often helpful.
However pruritus can be a symptom of a disease process, such as O C and pemphigoid
gestationalis, an auto-immune disease of pregnancy where blisters develop over the
body as the pregnancy progresses.
W omen with pre-existing skin conditions such as eczema and psoriasis should be
advised about the use of steroid creams and applications containing nut oil
derivatives, which may adversely affect the fetus.
Abnormalities of the amniotic fluid
The amount of liquor present in a pregnancy can be estimated by measuring ‘pools’ of
liquor around the fetus with ultrasound scanning. The single deepest pool is measured
to calculate the amniotic fluid volume (A FV). However, where possible a more accurate
diagnosis may be gained by measuring the liquor in each of four quadrants around the
fetus in order to establish an amniotic fluid index (A FI ). There are two abnormalities of
amniotic fluid: hydramnios (or polyhydramnios) and oligohydramnios.
Hydramnios
Hydramnios is present when there is an excess of amniotic fluid in the amniotic sac.
Causes and predisposing factors include:
• twin to twin transfusion syndrome
• maternal diabetes
• fetal anaemia (maternal alloimmunization, syphilis/parvovirus infection)
• fetal malformation such as oesophageal atresia, open neural tube defect,
anencephaly
• a fetal and placental tumour (rare).
However, in many cases the cause is unknown.
Types
Chronic hydramnios
This is gradual in onset, usually starting from about the 30th week of pregnancy. I t is
the most common type.
Acute hydramnios
This is very rare. I t usually occurs at about 20 weeks and develops very suddenly. The
uterine size reaches the xiphisternum in about 3 or 4 days. A cute hydramnios is
frequently associated with monozygotic twins or severe fetal malformation.
Diagnosis
The woman may complain of breathlessness and discomfort. I f the hydramnios is
acute in onset, she may experience severe abdominal pain. The condition may cause
exacerbation of symptoms associated with pregnancy, such as indigestion, heartburn
and constipation. O edema and varicosities of the vulva and lower limbs may also be
present.
Abdominal examination
O n inspection, the uterus is larger than expected for the period of gestation and is
globular in shape. The abdominal skin appears stretched and shiny, with marked
striae gravidarum and superficial blood vessels.
O n palpation, the uterus feels tense and it is difficult to feel the fetal parts, but the
fetus may be balloted between the two hands. A fluid thrill may be elicited by placing
a hand on one side of the abdomen and tapping the other side with the fingers.
Ultrasonic scanning is used to confirm the diagnosis of hydramnios and may also
reveal a multiple pregnancy or fetal malformation.
Auscultation of the fetal hear may be difficult due to the hydramnios.
Complications
These include:
• maternal ureteric obstruction and urinary tract infection
• unstable lie and malpresentation
• cord presentation and prolapse
• prelabour (and often preterm) rupture of the membranes
• placental abruption when the membranes rupture
• preterm labour
• increased incidence of caesarean section
• postpartum haemorrhage
• increased perinatal mortality rate.
Management
Care will depend on the condition of the woman and fetus, the cause and degree of the
hydramnios and the stage of pregnancy. The presence of fetal malformation will be
taken into consideration in choosing the mode and timing of birth. I f there is a gross
malformation present, labour may be induced. S hould the fetus have an operable
condition, such as oesophageal atresia, transfer will be arranged to a neonatal surgical
unit.
Mild hydramnios is managed expectantly. Regular ultrasound scans will reveal
whether or not the hydramnios is progressive. S ome cases of idiopathic hydramnios
resolve spontaneously as pregnancy progresses.
For a woman with symptomatic hydramnios, an upright position will help to relieve
any dyspnoea and antacids can be taken to relieve heartburn and nausea. I f the
discomfort from the swollen uterus is severe, then therapeutic amniocentesis, or
amnioreduction, may be considered. However, this is not without risk, as infection may
be introduced or the onset of labour provoked. N o more than 500 ml of amniotic fluid
should be withdrawn at any one time. I t is at best a temporary relief as the fluid will
rapidly accumulate again and the procedure may need to be repeated. A cute
hydramnios managed by amnio-reduction has a poor prognosis for the fetus.
Labour may need to be induced in late pregnancy if the woman's symptoms become
worse. The lie must be corrected if it is not longitudinal and the membranes ruptured
cautiously, allowing the amniotic fluid to drain out slowly in order to avoid altering
the lie and to prevent cord prolapse (see Chapter 22). I n addition, placental abruption
is also a risk if the uterus suddenly diminishes in size.
Labour usually progresses physiologically, but the midwife should be prepared for
the possibility of postpartum haemorrhage. The baby should be carefully examined for
malformations at birth and the patency of the oesophagus is ascertained by passing a
nasogastric tube.
Oligohydramnios
O ligohydramnios is an abnormally small amount of amniotic fluid. I t affects 3–5% of
pregnancies (Beall et al 2011). At term there may be 300–500 ml but amounts vary and
they can be even less. W hen diagnosed in the first half of pregnancy, oligohydramnios
is often found to be associated with renal agenesis (absence of kidneys) or Po er's
syndrome, in which the baby also has pulmonary hypoplasia. W hen diagnosed at any
time in pregnancy before 37 weeks, oligohydramnios may be due to fetal malformation
or to preterm prelabour rupture of the membranes where the amniotic fluid fails to re-
accumulate. The lack of amniotic fluid reduces the intrauterine space and over time
will cause compression malformations. The baby has a squashed-looking face,
fla ening of the nose, micrognathia (a malformation of the jaw) and talipes. The skin
is dry and leathery in appearance.
O ligohydramnios can accompany maternal dehydration, and sometimes occurs in
post-term pregnancies.
Diagnosis
On inspection, the uterus may appear smaller than expected for the period of gestation.
The woman may have noticed a reduction in fetal movements if she is a multigravida
and has experienced childbirth previously.
On palpation, the uterus is small and compact and fetal parts are easily felt.
Ultrasonic scanning will enable differentiation of oligohydramnios from
intrauterine growth restriction (I UGR). Renal malformation may be visible on the
scan.
Auscultation of the fetal heart should be heard without any undue difficulty.
Management
This will depend on the gestational age, the severity and the cause of the
oligohydramnios. I n the first trimester the pregnancy is likely to miscarry. The
condition causes the greatest dilemmas in the second trimester but is often associated
at this time with fetal death and congenital malformations. I f the pregnancy remains
viable the woman may wish to consider a termination of pregnancy. I n the third
trimester the condition is more likely associated with preterm prelabour rupture of the
membranes (PPROM) and birth is usually indicated (Beall et al 2011).
Liquor volume will be estimated by ultrasound scan and the woman should be
questioned about the possibility of pre-term rupture of the membranes. D oppler
ultrasound of the uterine artery may be performed to assess placental function,
although N eilson (2012), in a recent Cochrane review, suggests this is of limited
clinical value. I f the woman is dehydrated she should be encouraged to drink plenty of
water, or offered intravenous hypotonic fluid.
W here fetal anomaly is not considered to be lethal, or the cause of the
oligohydramnios is not known, prophylactic amnioinfusion may be performed in
order to prevent compression malformations and hypoplastic lung disease, and
prolong the pregnancy. Li le evidence is available to determine the benefits and
hazards of this intervention in mid-pregnancy. I f the oligohydramnios is due to
preterm prelabour rupture of the membranes and labour does not ensue, the woman
should be observed for uterine infection (chorioamnionitis), and treated accordingly if
it develops.
I n cases of near-term and term pregnancy, induction of labour is likely to be
advocated. A lternatively, fetal surveillance by cardiotocography, amniotic fluid
measurement with ultrasound and D oppler assessment of fetal and uteroplacental
arteries may be offered to the woman who prefers to await the onset of spontaneous
labour. Regardless of whether labour commences spontaneously or is induced,
epidural analgesia may be indicated because uterine contractions can be unusually
painful due to the lack of amniotic fluid. Continuous fetal heart rate monitoring is
desirable because of the potential for impairment of placental circulation and cord
compression. Furthermore, if meconium is passed in utero it will be more concentrated
and represent a greater danger to an asphyxiated fetus during birth.
Preterm prelabour rupture of the membranes (PPROM)
Preterm prelabour rupture of the membranes (PPRO M) occurs before 37 completed
weeks' gestation, where the fetal membranes rupture without the onset of
spontaneous uterine activity and the consequential cervical dilatation.
I t affects 2% of pregnancies and placental abruption is evident in 4–7% of women
who present with PPRO M. The condition has a 17–32% recurrence rate in subsequent
pregnancies of affected women (S vigos et al 2011). There is a strong association
between PPRO M and maternal vaginal colonization, with potentially pathogenic
micro-organisms, with a 30% incidence of subclinical chorioa mnionitis (S vigos et al
2011). I nfection may both precede (and cause) or follow PPRO M. I t is also more
common in smokers and recreational drug users, for example cocaine users. Preterm
prelabour rupture of the membranes is associated with 40% of preterm births (RCOG
2010c).
Risks of PPROM
Risks associated with PPROM include:
• imminent labour resulting in a preterm birth
• chorioamnionitis, which may be followed by fetal and maternal systemic infection if
not treated promptly
• oligohydramnios if prolonged PPROM occurs
• cord prolapse
• malpresentation associated with prematurity
• antepartum haemorrhage
• neonatal sepsis
• psychosocial problems resulting from uncertain fetal and neonatal outcome and
long-term hospitalization; increased incidence of impaired mother and baby bonding
after birth
Management
I f PPRO M is suspected, the woman will be admi ed to the maternity unit. A careful
history is taken and rupture of the membranes confirmed by a sterile speculum
examination of any pooling of liquor in the posterior fornix of the vagina. S aturated
sanitary towels over a 6-hour period will also offer a reasonably conclusive diagnosis if
urine leakage has been excluded. A N itrazine test may be useful to confirm this. A
fetal fibronectin immunoenzyme test is useful in confirming rupture of the
membranes, and ultrasound scanning also has some value.
D igital vaginal examination should be avoided to reduce the risk of introducing
infection. O bservations are made of the fetal condition from the fetal heart rate, as an
infected fetus may have a tachycardia, and also a maternal infection screen,
temperature and pulse, uterine tenderness and any purulent or offensively smelling
vaginal discharge. A decision on future management will then be made.
I f the pregnancy is less than 32 weeks, the fetus appears to be uncompromised and
APH and labour have been excluded, it will be managed expectantly.
• The woman is admitted to hospital.
• Frequent ultrasound scans are undertaken to assess the growth of the fetus and the
extent and complications of any oligohydramnios.
• Corticosteroids are administered to mature the fetal lungs as soon as PPROM is
confirmed, should the baby be born early.
• If labour intervenes the administration of a tocolytic drug (such as atosiban acetate)
should be considered to prolong the pregnancy. In practice these are usually
discontinued after the corticosteroids have had time to take effect.
• Known vaginal infections are treated with antibiotics. Prophylactic antibiotics may
also be offered to women without symptoms of infection.
• If membranes rupture before 24 weeks of gestation the outlook is poor and the
woman may be offered termination of the pregnancy.
• If the woman is more than 32 weeks pregnant, the fetus appears to be compromised
and APH or intervening labour is suspected or confirmed, active management will
ensue. The mode of birth will need to be decided and induction of labour or
caesarean section performed.
Hindwater leakage of amniotic fluid, and resealing of the amniotic sac are currently
poorly understood phenomena.
Conclusion
Midwives have an important role to play when women experience pathological
problems in their pregnancy. The woman is likely to report symptoms firstly to a
midwife, who will then make basic observations that confirm or exclude the likelihood
of a deviation from normal. W hile explaining her findings to the woman and her
partner, the midwife must make a decision about possible diagnoses, whether to
transfer her to a high-risk obstetric unit and if this warrants transportation by
ambulance. The midwife may be required to start managing the woman's condition
prior to admission to hospital. I n hospital the midwife is required to ensure the
woman's care is coordinated with other healthcare professionals, who must be
supplied with appropriate background information, that the woman and her partner
receive psychological support and that contemporaneous records are kept (NMC
2012a). The midwife must report any deterioration in a woman's condition
immediately to an appropriate healthcare professional. The midwife is responsible for
maintaining continual updating of her professional knowledge and skills in all areas of
practice to ensure that every woman receives optimal maternity care throughout her
pregnancy.
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corp/GTG17recurrentmiscarriage.pdf.
RCOG (Royal College of Obstetricians and Gynaecologists). The use of anti-D
immunoglobulin for rhesus D prophylaxis. [Green-top Guideline No. 22] RCOG:
London; 2011 www.rcog.org.uk/files/rcog-corp/GTG22AntiD.pdf.
RCOG (Royal College of Obstetricians and Gynaecologists). The care of women
requesting induced abortion. [Evidence-Based Clinical Guideline No. 7] RCOG:
London; 2011 www.rcog.org.uk/files/rcog-
corp/Abortion%20guideline_web_1.pdf.
SANDS (Stillbirth and Neonatal Death Society). Pregnancy loss and the death of a
baby: guidelines for professionals. SANDS: London; 2007.
Svigos JM, Dodd JM, Robinson JS. Prelabour rupture of the membranes. James
D. High risk pregnancy management options. Saunders Elsevier: Philadelphia;
2011:1091–1100.
Tiran D. Nausea and vomiting in pregnancy. Churchill Livingstone: Edinburgh;
2004.
Williamson C, Girling J. Hepatic and gastrointestinal disease. James D. High risk
pregnancy management options. Saunders Elsevier: Philadelphia; 2011:1032–1060.
Further reading
Bothamley J, Boyle M. Medical conditions affecting pregnancy and childbirth. Milton
Keynes: Radcliffe; 2009.
A midwifery textbook written for midwifery students with useful sections on
hyperemesis gravidarum and obstetric cholestasis..
Boyle M. Emergencies around childbirth. Milton Keynes: Radcliffe; 2011.
This book has useful sections on antepartum haemorrhage and maternal collapse,
written with student and newly qualified midwives in mind..
Monga A, Dobbs S. Gynaecology by ten teachers. Hodder: London; 2011.
A general gynaecology text book which will provide students and midwives with useful
background information about early pregnancy and pregnancy-related gynaecology
conditions..
Raynor MD, Marshall JE, Jackson K. Midwifery practice: critical illness,
complications and emergencies casebook. McGraw–Hill/Open University Press:
Maidenhead; 2012.
Provides a useful case study approach with questions and answers for the reader to
enhance their knowledge and understanding in recognizing the critically ill woman,
and conditions such as APH, DIC and obstetric cholestasis..
World Health Organization (WHO). Facts on induced abortion worldwide. WHO:
Geneva; 2012 www.guttmacher.org/pubs/fb_IAW.html.
Useful fact sheet looking at the incidence and trends of abortion worldwide..
World Health Organization. Safe and unsafe induced abortion: global and regional
levels in 2008, and trends during 1995–2008. WHO: Geneva;
2012 http://apps.who.int/iris/bitstream/10665/75174/1/WHO_RHR_12.02_eng.pdf
Useful information sheet examining global trends on both safe and unsafe abortion..
Useful websites
Antenatal Results and Choices. www.arc-uk.org.
This charity website aims to offer information and support to parents and families
following the diagnosis of a fetal abnormality, which may then lead to difficult
decisions having to be made. Information, leaflets and training are also available for
professionals..
Ectopic Pregnancy Trust. www.ectopic.org.uk.
Website for professionals and women related to ectopic pregnancy..
ICP Support. www.icpsupport.org.
Website offering support and information for women and professionals regarding
intrahepatic cholestasis of pregnancy (obstetric cholestasis)..
Miscarriage Association. www.miscarriageassociation.org.uk.
Offers support and information to parents following the various forms of early
pregnancy loss. Information also available for professionals..
NHS Cervical Screening Programme. www.cancerscreening.nhs.uk/cervical/.
Provides details of the cervical cancer screening programme offered in the UK, as well as
information relevant for the public and professionals..
Pelvic Partnership. www.pelvicpartnership.org.uk.
This website is run by volunteers who all have personal experience of Pelvic Girdle
Pain. The information provided is mainly provided for women, but provides
additional knowledge and guidance for students and midwives alike..
Pregnancy Sickness Support. www.pregnancysicknesssupport.org.uk.
A charity website that offers information and support to both women and professionals
with regards to nausea and vomiting in pregnancy. There is also guidance regarding
hyperemesis gravidarum..
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
RCOG website that provides a wealth of information and guidance through the Green-
top series on best practice relating to gynecological and obstetric-related situations..
SANDS (Stillbirth and Neonatal Death Society). www.uk-sands.org.
This is a comprehensive website offering information and support for parents and
families following the loss of a baby. SANDS also produces guidelines for
professionals to help support those caring for bereaved families..
C H AP T E R 1 3
Medical conditions of significance to
midwifery practice
S Elizabeth Robson, Jayne E Marshall, Rowena Doughty, Moira McLean
CHAPTER CONTENTS
Hypertensive disorders 244
Blood pressure – regulation and measurement 244
Hypertensive conditions of pregnancy 245
Secondary hypertension 248
Pre-eclampsia 249
Eclampsia 251
Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome 253
Acute fatty liver disease 253
Metabolic disorders 253
Obesity 253
Obstetric cholestasis 257
Endocrine disorders 257
Diabetes mellitus 257
Thyroid disease 262
Prolactinoma 264
Cardiac disease 265
Diagnosis of cardiac disease 265
Care of women with cardiac disease 266
Congenital heart disease 268
Acquired heart disease 268
Respiratory disorders 269
Asthma 269
Thromboembolic disease 270
Thromboprophylaxis in pregnancy 270
Deep vein thrombosis 271
Pulmonary embolism 273
Disseminated intravascular coagulation (DIC) 273
Haematological disorders 273
Anaemia 273
Folic acid deficiency 274
Haemoglobinopathies 275
Neurological disorders 277
Epilepsy 277
Infection/sepsis 279
Genital tract sepsis 279
Candida albicans 279
Chlamydia trachomatis 279
Cytomegalovirus 280
Gonorrhoea 280
Hepatitis A, B and C 280
Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome
(AIDS) 280
Human papillomavirus 281
Streptococcus A and B 281
Syphilis 281
Urinary tract infection 281
References 282
Further reading 285
Useful websites 286
Medical disorders are of increasing significance in midwifery practice. A few
years ago a student midwife would have learnt about a few of them during
education and training, but this situation is changing. Increasing maternal
age and advances in medical treatment have resulted in women who might
have previously died, or been advised against pregnancy, now presenting
for maternity care and bringing considerable challenges along with them
(CMACE 2011). In addition to using this chapter as a resource, a midwife
caring for such women may need to seek additional sources for advancing
her knowledge as not every medical condition or infection could be fully
explored within this chapter.
The chapter aims to:
• provide an account of the most common medical conditions and their effect on
childbearing women
• provide an overview of the less common medical conditions and their significance to
the health and wellbeing of the woman and her family
• explain the importance of midwives having an in-depth knowledge of medical conditions
in order to recognize women with such conditions and care for them effectively.
Hypertensive disorders
Blood pressure – regulation and measurement
Blood pressure (BP) is the force exerted by blood volume on the blood vessel walls,
known as peripheral resistance. This force is generated by contraction of the ventricles
of the heart, and in the case of young, healthy adults blood enters the aorta at
120 mmHg at systole (contraction) and falls to 80 mmHg at diastole (relaxation)
(Tortora and D errickson 2010). A s the blood is dispersed through the arterial system
the pressure gradually lowers to 16 mmHg by the time it reaches the capillaries. Blood
pressure is never zero unless there is a cardiac arrest (Webster et al 2013).
W hen cardiac output rises due to increased stroke volume or heart rate the BP rises,
providing peripheral resistance remains constant, and BP lowers with a decrease in
cardiac output. Haemorrhage lowers blood volume and cardiac output so the blood
pressure will fall; conversely it will rise due to fluid retention increasing blood volume
(Tortora and Derrickson 2010). S ystolic pressure is relatively labile, and can be affected
by emotional mood and body posture. BP rises with age as the arteries become thicker
and harder and is exacerbated by conditions such as atherosclerosis.
Regulation of blood pressure
Blood pressure is regulated by neural, chemical and hormonal controls of which the
midwife needs a basic knowledge because drugs to control BP often act on these
pathways.
Baroreceptors are specialized nerve endings in the left ventricle, carotid sinus, aortic
arch and pulmonary veins that act as stretch receptors. I ncreased pressure in these
vessels stimulates the baroreceptors to relay this information to the cardiovascular
centre of medulla oblongata in the brain. The cardiovascular centre responds by
pu ing out parasympathetic impulses via the motor (efferent) fibres of the vagus nerve
supplying the heart, causing fewer sympathetic impulses reaching the heart. This
causes a lowered heart rate, lowered cardiac output and vasodilatation of arterioles
giving rise to a fall in BP (Tortora and D errickson 2010). Conversely, if pressure on the
baroreceptors decreases, the feedback to the cardiovascular centre results in increased
sympathetic impulses causing accelerated heart rate, increased force of contraction
and vasodilatation. BP then rises.
Chemoreceptors monitor blood chemicals, in particular hydrogen ions, oxygen and
carbon dioxide, and are situated close to the baroreceptors. They also relay
information to the cardiovascular centre of the medulla oblongata (Tortora and
D errickson 2010). I f there is a deficiency of oxygen (hypoxia) the carbon dioxide level
rises and hydrogen ion concentration increases causing acidity, such that the
chemoreceptors are stimulated and send responses to the medulla oblongata. I n
response the cardiovascular centre increases sympathetic nerve stimulation causing
vasoconstriction of arterioles and veins, and BP rises.
Certain hormones influence blood pressure as follows (Tortora and Derrickson 2010):
• Epinephrine and norepinephrine from the adrenal medulla increase heart rate and
raise BP.
• Antidiuretic hormone (ADH) released from the posterior pituitary gland causes
vasoconstriction especially if there is hypovolaemia due to haemorrhage. Alcohol
inhibits release of ADH leading to vasodilatation, which lowers BP.
• Angiotensin II causes vasoconstriction and stimulates secretion of aldosterone
resulting in greater reabsorption of water by the kidneys, both resulting in raised BP.
• Atrial natriuretic peptide (ANP) from cells in the heart's atria causes vasodilatation,
and lowers BP.
• Histamine released by mast cells in an inflammatory response is a vasodilator,
decreasing BP.
• Progesterone of pregnancy causes vasodilatation and lowers BP (see below).
Blood pressure adaptation in pregnancy
I n pregnancy blood plasma volume increases from approximately 2600 ml to 3800 ml
by 32 weeks' gestation and red cell mass from 1400 to 1800 ml; consequently cardiac
output increases by 40%, with the majority of the extra output directed to the uterus
and kidneys (Greer et al 2007). This should result in raised BP, however the increasing
release of progesterone throughout pregnancy causes vasodilatation, and systolic and
diastolic pressures actually fall in the first and second trimesters by about 10 mmHg
(Burrow et al 2004), which can predispose the pregnant woman to fainting due to
hypotension (see Chapter 9). S ystolic and diastolic measurements rise slowly to the
pre-pregnancy levels in the third trimester (Redman et al 2010).
Measuring blood pressure
A ccurate measurement of BP is essential in order to confirm wellness or to diagnose
hypotension or hypertension at the earliest possibility. Traditionally blood pressure
was measured using a mercury sphygmomanometer and stethoscope, but human
errors in these readings resulted in greater use of manual (usually anaeroid) and
digital devices (Waugh and S mith 2012), as well as health and safety concerns about
mercury devices. D iastolic BP is now determined at Korotkoff Phase V (disappearance
of sound) rather than Korotkoff Phase I V (muffling sound) when using manual
devices. Box 13.1 outlines recommendations for measuring BP pressure.
Box 13.1
B lood pre ssure m e a sure m e nt
• Patient/woman should be seated for at least 5 minutes, relaxed and not
moving or speaking.
• The arm must be supported at the level of the heart.
• Ensure no tight clothing constricts the arm.
• Place the cuff neatly, with the centre of its bladder over the brachial
artery. This bladder should encircle at least 80% of the arm, but not more
than 100%.
Digital devices
• Some monitors allow manual blood pressure setting selection, where you
choose the appropriate setting.
• Other monitors will automatically inflate and re-inflate to the next setting
if required.
• Repeat three times and record measurement as displayed.
• Initially test blood pressure in both arms and use the arm with the
highest reading for subsequent measurement.
Manual devices
• Estimate the systolic beforehand:
(a) Palpate the brachial artery
(b) Inflate cuff until pulsation disappears
(c) Deflate cuff
(d) Estimate systolic pressure.
• Then inflate to 30 mmHg above the estimated systolic level needed to
occlude the pulse.
• Place the stethoscope diaphragm over the brachial artery and deflate at a
rate of 2–3 mm/sec until you hear regular tapping sounds.
• Measure systolic (first sound) and diastolic (disappearance) to nearest
2 mmHg.
Source: NICE 2011
The size of cuff is an important consideration as a cuff, and the bladder inside it,
that are too small will undercuff the woman with risk of overestimating the blood
pressure. A bout 25% of antenatal women could fall into this category, so both
standard and large size cuffs should be available in all maternity clinics and wards
(Waugh and Smith 2012).
A difference in systolic BP readings between left and right arms of >10 mmHg can
be observed in general populations, including healthy women in the antenatal period,
and is considered normal (Clarke et al 2012). I f hypertension is suspected, the
N ational I nstitute for Health and Clinical Excellence (N I CE) (2011)recommends
measuring BP in both arms and if the difference is >20 mmHg the measurements
should be repeated. I f the >20 mmHg difference remains, all subsequent readings
should be measured in the arm with the higher reading and the midwife should bring
this difference to the attention of a doctor (Nursing and Midwifery Council 2012).
Defining hypertension
Hypertension is systolic or diastolic BP that is raised from normal values. N ew
guidelines recommend that a diagnosis of hypertension should be confirmed using 24-
hour ambulatory blood pressure monitoring (A BPM) as gold standard rather than be
based solely on measurements of BP taken in clinical situations (N I CE 2011).
Definitions applied to the general, non-pregnant, population are outlined in Box 13.2.
Box 13.2
D e finit ions of hype rt e nsion in t he ge ne ra l, non-
pre gna nt popula t ion
Stage 1 hypertension
Blood pressure of 140/90 mmHg or higher and subsequent ambulatory
blood pressure monitoring (A BPM) daytime average or home blood
pressure monitoring (HBPM) average of 135/85 mmHg or higher
Stage 2 hypertension
Blood pressure of 160/100 mmHg or higher and subsequent ambulatory
blood pressure monitoring (A BPM) daytime average or home blood
pressure monitoring (HBPM) average of 150/95 mmHg or higher
Severe hypertension
Systolic blood pressure is 180 mmHg or higher, or clinical diastolic pressure
is 110 mmHg or higher.
Source: NICE 2011
Hypertension in pregnant women should be taken seriously; lower parameters of BP
measurement apply and the definitions in Box 13.3 are used in midwifery and obstetric
practice.
Box 13.3
D e finit ions of hype rt e nsion in pre gna ncy
Mild hypertension
D iastolic blood pressure 90–99 mmHg, systolic blood pressure 140–
149 mmHg.
Moderate hypertension
D iastolic blood pressure 100–109 mmHg, systolic blood pressure 150–
159 mmHg.
Severe hypertension
D iastolic blood pressure 110 mmHg or greater, systolic blood pressure
160 mmHg or greater.
N ote the lower measurements for this definition when compared with severe
hypertension in the general population.
Chronic hypertension
This is hypertension that is present at the initial visit (booking) or before 20
weeks, or if the woman is already taking antihypertensive medication when
referred to maternity services. It can be primary or secondary in aetiology.
Gestational hypertension
This is new hypertension presenting after 20 weeks without significant
proteinuria.
Pre-eclampsia
This is new hypertension presenting after 20 weeks with significant
proteinuria.
Severe pre-eclampsia
This is pre-eclampsia with severe hypertension and/or with symptoms,
and/or biochemical and/or haematological impairment.
Source: NICE 2010a
Hypertensive conditions of pregnancy
O ver the years there have many classifications of hypertension in pregnancy and in
particular the competing definitions of pregnancy-induced hypertension (PI H) have
caused confusion. The midwife is therefore advised to use the definitions in Box 13.3.
The following will a empt to clarify how the conditions present and develop into the
next stage, with inherent complications.
Chronic hypertension
Chronic hypertension encompasses hypertension >140/90 mmHg that existed before
pregnancy (N I CE 2010a). This was previously known as benign or essential
hypertension. The earlier that hypertension is diagnosed in pregnancy the more likely
it is to be pre-existing chronic hypertension (Webster et al 2013). Lack of illness
symptoms implies the woman is unlikely to have had her BP measured pre-pregnancy
and potentially it is diagnosed for the first time once she is pregnant.
Chronic hypertension has many associated factors, especially: obesity, black race,
family history of hypertension and lifestyle factors such as lack of exercise, alcohol
consumption and poor diet with high salt or fat intake. The risk of developing chronic
hypertension increases with age and it can be primary or secondary in aetiology (NICE
2010a). If this condition is known pre-pregnancy, the women should be directed to pre-
conception care. This is to ascertain the extent of the hypertension, treat the causes
and assess co-morbidities such as renal impairment or diabetes mellitus where the BP
may be lower than with hypertension alone, as the risk of cardiovascular disease is
greater (Webster et al 2013). Current medication should be reviewed as angiotensin-
converting enzyme (A CE) inhibitors, diuretics and angiotensin receptor blockers
(A RB) increase the risk of congenital malformations (W augh and S mith 2012) and
safer alternatives might need to be prescribed (see Box 13.4).
Box 13.4
A nt ihype rt e nsive drugs use d in pre gna ncy
Beta-blockers
• Inhibit action of catecholamines on the adrenoreceptors
• Beta-1 affects heart rate and contractility
• Beta-2 affects vascular and smooth muscle
• Associated with neonatal hypoglycaemia and IUGR
Labetalol (first line treatment)
• Combined alpha- and beta-blocker that can be given orally or IV
• Licensed for use in pregnancy. Used IV for the acute treatment of severe
hypertension
• Avoid use with asthmatic women as it causes bronchospasm
• Compatible with breastfeeding
Methyldopa
• Acts centrally to produce a decrease in vascular resistance
• Has a maximum effect 48 hours after commencement of treatment
• Small amounts are secreted into breastmilk, but it is classified as
compatible with breastfeeding
Nifedipine
• Calcium channel-blocker that inhibits transport of calcium across cell
membranes
• Causes vasodilatation, which reduces blood pressure
• Not licensed for pregnancy use before 20 weeks' gestation
• Probably compatible with breastfeeding
Hydralazine
• Direct-acting vasodilator
• No adverse fetal effects, but many maternal side effects, including acute
hypotension, tachycardia and palpitations
• Initially 25 mg twice/day given orally in the third trimester only
• Compatible with breastfeeding
Diuretics
• Relieve oedema by inhibiting sodium re-absorption in the kidney and
increasing urine production, thus lowering blood volume and in turn
blood pressure
• Act within 1–2 hours of oral administration and last for 12–24 hours
• Usually administered in the morning so that diuresis does not interfere
with sleep
• Loss of potassium (hypokalaemia) is a complication and potassium
supplements may be given for long-term treatment of hypertension
• Use in pregnancy is restricted to treating complex disorders, e.g. heart
disease or renal disease in combination with other drugs
Source: NICE 2010a; Webster et al 2013
Gestational hypertension
Gestational hypertension is hypertension >140/90 mmHg that presents after the 20th
week of pregnancy and without significant proteinuria. The BP should return to
normal values postnatally. I t can be difficult to differentiate between the presentation
of chronic hypertension and gestational hypertension, because the physiological fall in
BP in the first trimester of pregnancy occurs with both normotensive and hypertensive
women, and can mask the existence of chronic hypertension unless pre-pregnancy
values are known (Webster et al 2013). The diagnosis of gestational versus chronic
hypertension might be resolved only in retrospect when the six-week postnatal BP
readings are performed.
Complications
A ccording to Waugh and S mith (2012) and Webster et al (2013), the complications of
gestational hypertension and chronic hypertension are the same:
• intrauterine fetal growth restriction (IUGR)
• placental abruption
• superimposed pre-eclampsia
• worsening hypertension leading to severe hypertension and risks of stroke (cerebral
vascular accident [CVA] and organ damage).
Management
• The woman with known chronic hypertension should be booked at a consultant unit,
and re-referred to any clinics treating her hypertension and co-existing conditions. If
she is taking ACE inhibitors or ARB these are discontinued and alternative
hypertensive therapy prescribed (see Box 13.4).
• The physiological fall of BP in early pregnancy might entail reducing or even ceasing
antihypertensives in the first trimester, and then increasing doses gradually towards
term based on BP readings.
• The woman who has a raised BP without proteinuria presenting during pregnancy is
likely to have gestational hypertension and should be referred to a maternal medicine
clinic and booked for labour and birth in a consultant-led unit.
Thereafter management of both chronic and gestational hypertension is the same
and requires involvement of both doctor and midwife as follows:
• Schedule antenatal appointments, as for nulliparae, to see a doctor and midwife at
16, 25, 28, 31, 34, 36, 38 weeks (NICE 2010a).
• Additional appointments should be arranged for maternal medicine or hypertension
clinics if indicated.
• At each appointment record BP, urinalysis with emphasis on proteinuria, and assess
fetal growth by symphysis–fundal height (SFH). Be alert for signs of pre-eclampsia.
• Review BP readings; adjust drug dosages accordingly, aiming to keep BP
<150/100 mmHg in uncomplicated cases (NICE 2010a).
• The doctor should prescribe low-dose aspirin (75 mg once daily).
• Arrange ultrasound fetal growth and amniotic fluid volume assessment and
umbilical artery Doppler velocimetry between 28 and 30 weeks and between 32 and
34 weeks. If results are normal, these are not repeated unless there is a clinical
indication (NICE 2010a).
• Assess and manage co-existing conditions such as obesity or diabetes mellitus.
• Advise the woman to keep her dietary intake of sodium low (NICE 2010a).
• Hospital admission is unlikely with both chronic and gestational hypertension
unless the hypertension becomes severe.
• Labour should be induced at 37 weeks or earlier if BP is uncontrolled, or fetal or
antenatal complications develop.
• Labour will require hourly BP monitoring and administration of hypertensive drugs
with dosages adjusted if BP fluctuates.
• An epidural may be advantageous in labour as this lowers BP.
• Continuous fetal monitoring is required in labour (NICE 2007).
• A normal birth by the midwife can be anticipated, and caesarean section should be
performed for obstetric reasons only.
• The length of the second stage of labour should be shortened only if severe
hypertension develops.
• Ergometrine and syntometrine should be avoided for the third stage of labour as
these are acute vasoconstrictors. Use oxytocin in preference.
• Breastfeeding should be encouraged.
• The midwife should record BP daily in the postpartum period for the first 3 days and
then on the 5th day.
• Postpartum BP should be maintained below 140/90 mmHg and, if necessary,
medication adjusted (Waugh and Smith 2012).
• Prior to transfer home from hospital the woman should be seen by an obstetrician
who is likely to stop methyldopa within two days of birth and restart the
antihypertensive treatment the woman was taking before she planned the pregnancy.
• If BP falls below 130/80 mmHg the obstetrician should reduce the hypertensive
treatment (NICE 2010a).
• The midwife should reinforce advice on lifestyle factors such as diet and exercise.
• The combined oral contraceptive pill might be contraindicated, so referral to a doctor
or family planning clinic for specialist advice is essential.
• The midwife should not discharge the woman from her care if BP levels give concern
and other members of the multidisciplinary team may need to be involved.
• A 2-week postnatal review with the general practitioner (GP) should be arranged
where the continued use of antenatal hypertensive treatment should be reviewed.
• A medical review in combination with the 6-week postnatal review should also be
arranged (NICE 2010a).
Superimposed pre-eclampsia
W omen with chronic hypertension may develop pre-eclampsia as well, and the signs
and symptoms are the same as for pre-eclampsia (see below). I n these women the
blood pressure profile may be more difficult to interpret as the baseline BP is likely to
be higher and exacerbated by the effects of treatment with antihypertensives (Webster
et al 2013). D evelopment of significant proteinuria (see Box 13.3) is indicative of pre-
eclampsia and often accompanied by fetal growth restriction (Webster et al 2013).
Management and treatment are as for pre-eclampsia.
Secondary hypertension
W omen may develop secondary hypertension as a complication of either underlying
physiology or disease, most commonly caused by:
• Renal disease, which results in sodium retention by the kidney leading to water
retention, an increased blood volume and thereafter hypertension. This may be
classified as renal hypertension. Depending upon the nature of the renal disease the
early birth of the baby may become necessary to prevent long-term kidney damage
(Webster et al 2013).
• Phaeochromocytoma, an adrenal gland tumour secreting the hormones dopamine,
adrenaline and noradrenaline (see section on regulation of blood pressure).
• Congenital heart disease, especially if there is constriction of the aorta.
• Conn's syndrome: an excess of aldosterone hormone causes sodium retention and
associated hypokalaemia.
• Cushing's syndrome: an excess of glucocorticoid hormones.
Management
The management is to address the underlying cause. However, substantive treatment
might have to wait until the woman has given birth and then treat the condition as for
chronic hypertension.
Pre-eclampsia
Pre-eclampsia (formerly known as PET: pre-eclamptic toxaemia) is anidiopathic (=
cause unknown) condition of pregnancy characterized by proteinuria and
hypertension presenting after 20 weeks of pregnancy in a woman who previously had
normal blood pressure. The severity can be mild, moderate or severe, and may be pre-
eclampsia or eclampsia (see below).
Pre-eclampsia occurs in 3% of all pregnancies (Hutcheon et al 2011) and >10% of
women will develop this in their first pregnancy (Waugh and S mith 2012) (Box 13.5).
W hilst most of these women will have a successful outcome to their pregnancy, some
will proceed to multisystem complications. I n the latest Centre for Maternal and Child
Enquiries triennial report into maternal deaths (CMACE 2011), there were a total of 19
women in the United Kingdom (UK) who died as a result of pre-eclampsia or
eclampsia (N eilson 2011), with an estimated 500–600 babies dying each year, mainly
due to premature birth rather than the condition itself. The probability of a woman
developing it in future pregnancies is 16%, rising to 25% in cases of severe pre-
eclampsia and, where the woman's baby was born before 28 weeks, this probability
rises to 55% (NICE 2011).
Box 13.5
A ssocia t e d fa ct ors for de ve loping pre - e cla m psia
Maternal factors
• Primipaternity (first pregnancy with a new partner)
• Extremes of maternal age (<20 and >40 years)
• Family history of pre-eclampsia
• Pre-eclampsia in a previous pregnancy
• Pregnancy after assisted reproductive technology
• Obesity
• Pre-existing diabetes mellitus type 1
• Pre-existing hypertensive disease
• Pre-existing medical conditions, e.g. renal disease, systemic lupus
erythematosus (SLE), rheumatoid arthritis
Pregnancy related factors
• First pregnancy
• Multiple pregnancy
• Developing a medical disorder during pregnancy, e.g. venous
thromboembolic disease (VTE), such as antiphospholipid (Hughes)
syndrome (APS), gestational diabetes, gestational hypertension
• Developing infection with inflammatory response
• Hydropic degeneration of the placenta
Source: NICE 2010a; James et al 2011
Pre-eclampsia is commonly known as a disease of theories and the pathophysiology is
not fully understood. I t is thought that the condition arises from the influence of
placental tissue as it can arise in molar pregnancies (gestational trophoblastic disease)
where there is placental tissue but no fetal tissue (Waugh and Smith 2012).
Management in pregnancy
W omen at risk of pre-eclampsia should be investigated for underlying medical
problems and will normally be commenced on aspirin from 12 weeks of pregnancy
until the baby is born (see Table 13.1) (Webster et al 2013). W omen at high risk have
one of the following:
• hypertensive disease during a previous pregnancy
• chronic hypertension
• chronic kidney disease
• autoimmune disease, especially antiphospholipid syndrome (APS) or systemic lupus
erythematosus (SLE) (NICE 2010a).
Table 13.1
Management of pregnancy with pre-eclampsia
Early recognition of pre-eclampsia is paramount as the midwife is likely to be the
first health professional to notice the clinical signs at an antenatal appointment, and
prompt referral to an obstetrician is necessary for investigations, albeit the ultimate
responsibility for the diagnosis lies with the doctor. Pre-eclampsia can be recognized
by:
• blood pressure: systolic >140 mmHg or diastolic >90 mmHg (see Chronic
hypertension)
• proteinuria (see Box 13.6 for principles of assessing proteinuria)
Box 13.6
D e t e rm ining prot e inuria in pre gna ncy
• If using a dipstix to test the urine, ensure the reagent strips are in date
and read according to the stipulated times along the exterior label.
• A mid-stream specimen of urine (MSSU) may be necessary to exclude
urinary tract infection (UTI) as a cause of proteinuria.
• If an automated reagent-strip reading device is used to detect proteinuria
and a result of 1+ or more is obtained, use a spot urinary protein :
creatinine ratio or 24-hour urine collection to quantify proteinuria.
• Significant proteinuria is diagnosed when the urinary protein : creatinine
ratio is >30 mg/mmol, or if a 24-hour urine collection result shows >
300 mg protein.
• Ensure 24 hour urine collections are complete before sending to the
laboratory for analysis.
Source: NICE 2010a
• oedema – may be detectable on examination. Ankle oedema is a common
phenomenon in pregnancy and tends to diminish overnight. More generalized
oedema that pits on pressure on the pre-tibial surface, face, hands, abdomen and
sacrum, especially if sudden in onset, warrants further investigation. The severity of
the oedema increases with the severity of the pre-eclampsia.
The midwife should appreciate that the woman may be feeling well and will need
convincing that she requires a hospital referral. Referral should be to a consultant-led
unit for investigations that, according to Williams and Craft (2012), are likely to
include:
• Urine sample or 24 hour urine collection to quantify the proteinuria (>300 mg) and
determine the ratio of protein to creatinine (>30 mg/mmol).
• Full blood count to observe for platelet consumption and haemolysis. In pre-
eclampsia the haemoglobin concentration may be raised (>120 g/l) due to
haemoconcentration.
• Urea and electrolytes to assess renal dysfunction (raised serum creatinine
>90 µmol/l).
• Liver enzymes to assess liver function and observe for transaminitis.
• Assessment of fetal wellbeing by ultrasound to monitor growth and volume of
amniotic fluid and Doppler velocimetry of the umbilical arteries.
O nce pre-eclampsia is diagnosed the woman should be offered hospital admission
with an integrated package of care including investigations, assessment of fetal
wellbeing and drug therapy, that will alter depending upon the severity of the pre-
eclampsia as outlined in Table 13.1. Labetalol is the first-line treatment (unless the
woman has asthma) and other antihypertensives such as methyldopa and nifedipine
(see Box 13.4) might be offered after considering the side-effect profiles for woman
and fetus (N I CE 2010a). Popular theories about vitamins being natural remedies for
pre-eclampsia have no sound research base (Talaulikar and Manyonda 2011) and a
meta-analysis by Basaran et al (2010) actually found vitamins C and E supplementation
to be associated with an increased risk of gestational hypertension.
W hilst drugs will treat the hypertension, the solution for pre-eclampsia is to
expedite the birth of the baby and placenta. I nduction of labour will be determined by
the obstetrician, and is likely to be at 37 weeks for mild pre-eclampsia 34–36 weeks for
moderate pre-eclampsia and at 34 weeks for severe hypertension, following a course of
corticosteroids to assist with fetal lung maturity (N I CE 2010a; Vijgen et al 2010). Birth
should be earlier in the event of uncontrolled blood pressure or fetal or antenatal
complications, with caesarean section being undertaken for urgent clinical situations
or if the fetus is very preterm (Webster et al 2013), ensuring close liaison with neonatal
intensive care and anaesthetist teams (NICE 2010a).
Management in labour
Vigilant care by the midwife is paramount in labour, and whilst this is a high-risk
labour the midwife may facilitate the birth of the baby in the absence of obstetric
complications. I ntrapartum care is similar to that provided to a woman with chronic
hypertension and in particular there should be continuous fetal monitoring. A n
epidural anaesthetic is encouraged after review of the platelet count and continuation
of antenatal antihypertensive drugs and blood tests according to previous results and
the clinical picture are also warranted (Webster et al 2013). O xytocin is used to control
haemorrhage during the third stage of labour in preference to syntometrine or
ergometrine. Blood pressure should be measured hourly, with the midwife being alert
for signs of fulminant eclampsia.
Postnatal management
A s with chronic hypertension, there should be regular measurement of blood pressure
until hypertensive treatment has ceased. Blood pressure should be measured four
times a day whilst in hospital, then recorded daily at home until the third day and
once between days 3 to 5. O n each occasion the midwife should ask the woman about
severe headache and epigastric pain (NICE 2010a). Methyldopa is usually discontinued
or replaced by another antihypertensive drug. I f the BP is>150/100 mmHg the midwife
should refer the woman for medical care, where the dosage of antihypertensives is
likely to be increased.
The midwife should arrange for the woman to take drugs home before transfer from
hospital as she is likely to continue with the antenatal drug regimen until her BP
lowers to 130/80 mmHg when the dosage can be adjusted by the medical team. The
woman should not be discharged from the midwife's care until the BP becomes stable
and the maternal condition no longer gives any cause for concern. There should be a
review of hypertensive treatment by the GP at 2 weeks and an obstetric with specialist
review offered between 6 and 8 weeks to assess the hypertension (NICE 2010a).
Severe pre-eclampsia and eclampsia
S evere pre-eclampsia encompasses high blood pressure of systole >160 mmHg or
diastole >110 mmHg on two occasions and significant proteinuria. Modern definitions
also include women with moderate hypertension who have at least two of the features
below:
• low blood platelet count <100 ×106/l
• abnormal liver function
• liver tenderness
• Haemolysis Elevated Liver enzymes and Low Platelet count (HELLP) syndrome
• clonus (intermittent muscular contractions and relaxations)
• papilloedema
• epigastric pain
• vomiting
• severe headache
• visual disturbance (flashing light similar to migraine)
This condition, unless treated effectively, can lead to eclampsia with risk of mortality
and morbidity. The woman must be admi ed to a high-risk obstetric ward for medical
treatment to bring her blood pressure under control, reduce the risk of fluid overload
and prevent seizures. O ral labetalol or nifedipine may be used but if the BP is
>170/110 mmHg, intravenous (I V) labetalol or hydrallazine are given in bolus doses to
lower the BP and then as a continuous I V infusion (I VI ). I ntravenous magnesium
sulphate may also be administered as this drug can reduce the chance of an eclamptic
seizure by 50%. Fluid restriction and a low salt diet should be initiated and monitored
with a fluid balance chart, including regular urinalysis to assess proteinuria. The
midwife should also be aware that magnesium toxicity may present with a reduced
urine output of <10 ml per hour. The effects on the fetus are as for pre-eclampsia, but
there is an 80-fold increased risk of iatrogenic pre-term birth before 33 weeks, I UGR
and consequent admission to neonatal intensive care (Hutcheon et al 2011).
Fulminant eclampsia
This is the acute worsening of symptoms, especially headache, epigastric pain and
vomiting accompanied by high blood pressure, indicating that severe eclampsia is
developing into eclampsia and that a convulsion is imminent. Consequently,
emergency intervention is required.
Eclampsia
Eclampsia is a neurological condition associated with pre-eclampsia, manifesting with
tonic-clonic convulsions in pregnancy that cannot be a ributed to other conditions
such as epilepsy (N I CE 2010a; Hutcheon et al 2011). A national study undertaken
throughout the UK through the United Kingdom (UK) O bstetric S urveillance S ystem
(UKO S S ) between February 2005 and February 2006 identified 214 cases, indicating an
estimated incidence of 27.5 cases per 100 000 births (Knight 2007) compared with a rate
of 82 cases per 100 000 births in the United S tates of A merica (US A) Hutcheon
( et al
2011). Rates of eclampsia have actually decreased in the developed world, due to
improved antenatal care, timing of birth and use of magnesium sulphate (Knight 2007;
Hutcheon et al 2011). However, as Neilson (2011) reports, when combining the UKO S S
data and that of the latest CMA CE triennial report into maternal deaths CMACE (
2011) the case fatality rate from eclampsia is estimated to be 3.1%.
Eclampsia can develop any time from 20 weeks' gestation up to 6 weeks postpartum
and indeed 44% of cases occur postnatally (S hennan and Waugh 2003). The UKO S S
data revealed that 63% of women in the UK who had eclampsia did not have
established pre-eclampsia and over 20% of women had their first convulsion at home
(Knight 2007) and were initially admitted to accident and emergency departments.
W hen a woman has an eclamptic seizure the midwife must summon medical aid
immediately, initiate A irway, Breathing, Circulation (A BC) principles and then assist
the doctor with treatment as outlined in Box 13.7.
Box 13.7
M a na ge m e nt of a n e cla m pt ic se iz ure
• Do not leave the convulsing woman alone.
• Summon medical and senior midwifery aid to gather equipment to site an
IVI, administer emergency drugs and set up bed rails.
• In the community, ambulance and paramedic team are required.
• Try to reassure the woman and her relatives.
• Prevent any subsequent injury to the mother with bed rails and by
applying padding.
A: Airway. Protect from aspiration by placing woman in left lateral
position, assisted by a wedge if still pregnant. Use suction for oral
secretions.
B: Breathing. Anaesthetist should be called for possible intubation.
Consider an oral airway. Administer supplementary oxygen by face mask.
C: Circulation. Observe the pulse, and if cardiac arrest occurs commence
continuous chest compressions (cardiac massage).
• The doctor should site an IVI and take blood samples for: full blood
count, group and save, clotting factors, uric acid, liver function tests,
serum calcium, and urea and electrolytes.
• Accurate records of all fluid given should be maintained.
• A Foley's catheter should be inserted in the bladder to ensure accurate
recording of the urinary output and regular urine testing for proteinuria.
D: Drugs. Administration of the anticonvulsant magnesium sulphate is
given as 4 g by a slow IVI for 5 minutes. If recurrent seizures occur the IV
rate is increased or a further bolus dose of 2–4 g is given. An
electrocardiogram (ECG) should be conducted during the loading dose
and for one hour afterwards. The maximum IV dose of magnesium
sulphate is 9 g over the first hour. If the convulsions do not stop the
medical team may consider administering 5 mg diazepam or 1 mg
lorazepam.
D: Documents. All observations and treatment to be documented in the
woman's case notes.
E: Environment. Ensure the woman keeps safe.
F: Fundus. If the woman is still pregnant, the uterus should be displaced by
assisting her into the left lateral position, assisted by a wedge.
Source: Hull and Rucklidge 2009
The birth
I f eclampsia arises during the antenatal or intrapartum period, the woman is likely to
require an emergency caesarean section, so the midwife should prepare her for this
type of birth and a potentially preterm baby. A n epidural or spinal anaesthesia is
preferred to reduce the consequences associated with general anaesthesia. I f the
woman gives birth vaginally, syntometrine and ergometrine should be avoided to
manage the third stage of labour and oxytocin used instead.
Subsequent care
O nce the woman's condition is stabilized she should have one-to-one care in either the
I ntensive Care Unit (I CU) or the High D ependency Care Unit (HD CU) a ached to th
labour ward. The aim of the care is to a ain a BP of <150/80 mmHg. The woman will
require an electrocardiogram (ECG) for one hour after the loading dose of magnesium
sulphate, and this drug is continued by I VI for at least 24 hours. A blood sample to
measure serum magnesium should be taken as this drug can reach a toxic level. I f the
urinary output reduces to <100 ml over 4 hours the magnesium sulphate may be
reduced by 50% by the doctor, hence accurate fluid balance recording is essential.
Continuous monitoring of the woman's BP is warranted along with hourly
monitoring of pulse, respiration, oxygen saturation, urine output and reflexes.
O ngoing antihypertensive therapy should be continued and adjusted as determined
by the woman's blood pressure readings (Hull and Rucklidge 2009). This monitoring
usually continues for 24–48 hours, after which, providing the woman's condition
improves, she can be transferred to the postnatal ward for a few more days until the
medical team considers her condition is satisfactory for transfer home.
The baby is likely to be initially cared for on the neonatal unit and the woman
should be taken to see her baby as soon as her condition permits. Breastfeeding is to
be encouraged and psychological support given by the midwife and neonatal staff.
Haemolysis, Elevated Liver enzymes and Low Platelets
(HELLP) syndrome
This is a multisystem disorder that can occur on its own or in association with pre-
eclampsia. There is activation of the coagulation system causing increased deposits of
protein fibrin throughout the body resulting in fragmentation of erythrocytes
(Webster et al 2013). Fibrin deposits on blood vessel walls initiate clumping of
platelets resulting in blood clots and lowering of the platelet count. These deposits
decrease the diameter of the blood vessels, raising blood pressure and reducing the
blood flow to organs (Webster et al 2013). The liver is especially affected, with
destruction of liver cells leading to abnormal liver function and a distended liver with
symptoms of epigastric discomfort.
HELLP syndrome presents antenatally in 70% of cases, most usually in the third
trimester, and in the postnatal period it occurs in 30% of cases. I f HELLP syndrome
occurs before 26 weeks it is usually associated with antiphospholipid syndrome (A PS )
(Pawelec et al 2012). I t also complicates 20% of severe pre-eclampsia cases resulting in
high maternal and perinatal morbidity and mortality rates (Greer et al 2007). O f the 19
maternal deaths reported by N eilson (2011) in the latest CMA CE triennial report,
there was evidence of HELLP syndrome in eight of these women.
The woman will present with non-specific symptoms, often malaise, including
nausea, vomiting and epigastric pain. I n some cases there may be haematuria or
jaundice. I f there is pre-eclampsia there will be raised blood pressure and proteinuria.
These symptoms are similar to acute fa y liver disease (A FLD ) and the blood tests
define the diagnosis. Complications can include:
• progressive disseminated intravascular coagulation (DIC)
• liver haematoma and rupture
• placental abruption
• pulmonary oedema and adult respiratory distress
• pleural effusions
• renal failure.
The main treatment is to expedite the birth of the baby with the management and
midwifery care being similar to that for severe pre-eclampsia, with emphasis on the
administration of magnesium sulphate to prevent convulsions. The condition usually
resolves, however, 2 weeks after the baby's birth.
Acute fatty liver disease
A cute fa y liver disease of pregnancy is a rare and serious condition with uncertain
aetiology, and current theory implies it is part of the pre-eclampsia spectrum
(D oughty and Waugh 2013). W omen with a raised body mass index (BMI ),
primigravidae and women with a multiple pregnancy appear to be at risk.
Five out of the following symptoms denote diagnosis, which usually present after 30
weeks of pregnancy: nausea, vomiting, polyuria, polydipsia, fever, headache,
encephalopathy, pruritus, abdominal pain, tiredness, confusion, jaundice, anorexia,
ascites, coagulopathy, hypertension, proteinuria, liver failure and hepatic
encephalopathy (James et al 2011).
The condition of the woman can deteriorate rapidly, especially liver function,
affecting both maternal and fetal morbidity and mortality. The woman must be
referred to a specialist hepatologist for further investigation and to exclude alternative
diagnoses such as HELLP. Management is to hasten the birth of the baby such that the
midwife may need to prepare the woman for a preterm birth. Careful fluid balance is
required in labour and vigilant observation, as D I C is a significant risk. Following the
birth the woman is likely to be transferred to an I CU/HD CU where her condition
should begin to improve after 48 hours (Doughty and Waugh 2013).
Metabolic disorders
Obesity
O besity is considered to be one of the most significant health concerns affecting
society, with significant impact on the maternity services ( Modder and Fi simons
2010). I ndividual risk of serious morbidity or mortality is related to increasing weight
through the development of disease pathways directly a ributable to obesity, e.g.
cardiovascular disease, certain cancers and type 2 diabetes mellitus. However, these
pathways are unclear as individuals of normal body weight may also develop these
conditions.
The increasing prevalence of obesity is commonly called an epidemic (W orld Health
O rganization [W HO ] 2000), although obesity does not resemble an infectious disease;
rather, it is used to describe a trend. Using BMIclassification, statistics demonstrate
25% of adults over 16 years are obese (BMI ≥30 kg/m2) of which 18.5% are women of
childbearing age (Modder and Fi simons 2010). These figures rise to almost 60%
when those in the overweight category are included with a further 5% of the
population having a BMI ≥40 kg/m2 (Heslehurst et al 2010). I n 2007, it was estimated
that if this trend continues to rise, by 2050 more than 50% of women will be classed as
obese (Foresight 2007). Currently only around 40% of women have a normal BMI.
Classifying size using body mass index (BMI)
O besity is diagnosed using the BMI classification, implemented over 50 years ago as a
measure of fatness, being considered a more robust way of assessing a person's level of
body fat than measuring solely height and weight (Gard and W right 2005). O besity is
defined as a BMI ≥30 kg/m2 and can be subdivided into classes I , I I and I I I (seeBox
13.8). A s a screening tool for fatness, the BMI is considered accurate in 75% of cases at
best, failing to account for variations in body fat distributions, muscle and bone
density, ethnic variations, gender specifics or age effect.
Box 13.8
W H O int e rna t iona l body m a ss inde x ( B M I )
cla ssifica t ions ( kg/m 2 )
• Under-weight = <18.5
• Normal range = 18.5–24.9
• Pre-obese = 25.0–29.9
• Obese = ≥30.0
– Obese Class I = 30.0–34.9
– Obese Class II = 35.0–39.9
– Obese Class III = ≥40.0
Distribution of body fat and disease
D istribution of body fat is considered a significant indicator of future ill-health, being
suggestive of a disordered glucose tolerance (W HO 2000), which often contributes to
medical complications such as type 2 diabetes mellitus. I n such conditions, visceral fat
(fat retained abdominally) is metabolically more active, contributing to metabolic
syndrome which is directly associated with cardiovascular disease and type 2 diabetes
(Gluckman and Hanson 2012).
Obesity as a concept
Being obese is not in itself a disease, although, as the level of obesity increases so does
the individual risk of developing chronic disease (Gluckman and Hanson 2012). S ocial
scientists would agree that obesity is not a disease, but is a social construct defined as
a disease, because it is considered abnormal in current Western culture (de Vries
2007). O bese individuals are consequently subject to significant stigma and
discrimination directly a ributed to their size and shape, even by healthcare
professionals (N yman et al 2010). This negative a itude probably reflects deeper
cultural prejudices that exist towards obesity, reflected in the prevailing ideology of it
being caused by the individual. However, the cause of obesity is multifactorial: it is
considered a complex interplay of genetics, biology and behaviour on a background of
cultural, environmental and social factors, where the individual plays a passive role
within an obesogenic society (Foresight 2007).
Obesity demographics
A high incidence of obesity is associated with socioeconomic inequalities. Sellstrom
et al (2009) identified increased rates of obesity in poorer societal groups, especially
younger age groups. Children born into lower social class families are likely to become
obese, although this trend is seen more in women than in men, probably because of
the complexity of the role of women in society (Khlat et al 2009).
Pathophysiology of obesity
The main effect obesity has on an individual's health is increasing their risk of
developing metabolic syndrome. O besity, especially central obesity, causes metabolic
dysfunction involving primarily lipids and glucose, which eventually results in organ
dysfunction within many of the body systems, especially the cardiovascular system.
O ther risk factors for metabolic syndrome include family history, poor diet and a
sedentary lifestyle.
Metabolic syndrome is thought to be caused by visceral adipose tissue causing the
release of pro-inflammatory cytokines, known as adipokines, which promote insulin
resistance. This causes a systemic inflammatory response, which over time results in
microvascular and endothelial dysfunction in all of the body systems. The individual
will have atherogenic dyslipidaemia, identified by low high density lipoprotein (HD L),
raised triglycerides, hypertension and raised fasting blood glucose levels. A s well as
insulin resistance, such individuals develop a prothrombotic state with raised fibrinogen
and plasminogen-activator-inhibitor levels (Miller and Mitchell 2006).
Nutritional needs in pregnancy
Weight gain is usual at certain times in a female's life, e.g. during infancy, between the
ages of 5 and 7 years, adolescence, pregnancy and the menopause (Webb 2008).
Maternal overnutrition has permanent effects on a fetus, that is, a higher birth weight
tends to result in a higher BMI as an adult (S mith et al 2008). Physiological changes in
pregnancy predispose to weight gain, essentially to provide energy for labour and
lactation, and this storage is facilitated by the effect that increases in oestrogen,
progesterone and human placental lactogen (HPL) have on glucose metabolism (Webb
2008). W omen with a raised BMI should be advised and encouraged to lose weight pre-
conceptually to optimize pregnancy outcomes (Modder and Fitzsimons 2010).
A woman's basal metabolic rate (BMR) increases during pregnancy due to the
increased metabolic activity of the maternal and fetal tissues. The increased body
weight and the increased maternal cardiovascular, renal and respiratory load also
influence a rise in the basal metabolic rate (BMR), but in part this is counterbalanced
by a general decrease in activity. The resulting increase in required calorie intake is
therefore relatively small; an extra 200 kcal per day are required during the third
trimester for most women (N I CE 2010b). Weight gain in pregnancy is dependent on
factors such as diet, activity and maternal wellbeing (Gardner et al 2011).
Antenatal care
The BMI is routinely calculated at the initial visit with the midwife (booking) and a
discussion about the implications of a raised BMI should consequently take place
between the midwife and the woman. D epending on local guidelines, women with a
raised BMI are often referred to a multiprofessional antenatal clinic, which involves
specialist midwives, obstetricians and dieticians (Modder and Fi simons 2010).
O teng-N tim et al (2011) undertook a systematic review, consisting of 1228 women, and
found that where lifestyle interventions were introduced for obese and overweight
women during pregnancy, the gestational weight gain was reduced, along with a
reduction in the prevalence of gestational diabetes. However, the quality of the
published studies was mainly poor, so these results must be taken with caution.
O besity is a significant risk factor for maternal mortality (CMA CE 2011 ), with 16 of
the women who died in the triennium 2006–2008 having a BMI ranging from>25 kg/m2
to >40 kg/m2.. The subsequent risk of morbidity associated with childbearing of women
who have a raised BMI is outlined inBox 13.9 (S mith et al 2008; Modder and
Fi simons 2010). However, it is important to note that obesity alone is not associated
with poor perinatal outcomes, but that it does increase the risk, which subsequently
increases as the BMI increases (S co -Pillai et al 2013). W omen with obesity might find
some minor disorders of pregnancy, such as back pain and fatigue, are exacerbated (see
Chapter 9).
Box 13.9
R isks a ssocia t e d wit h obe sit y in pre gna ncy
Maternal
• Miscarriage and stillbirth
• Gestational diabetes: offered a glucose tolerance test (GTT) at 24–28
weeks if BMI ≥30
• Hypertension: ensure correct size cuff and increase surveillance if BMI
≥35; increase antenatal appointments to screen for PET to every 3 weeks
between 24 and 32 weeks and refer to specialist care if one or more
additional risk factors are present, e.g. first baby, raised BP at booking
• Venous thromboembolism: assess risk at every visit; prophylaxis is
recommended if two or more risk factors are present
• Prolonged pregnancy: risks associated with induction of labour
• Presence of pre-existing medical conditions, e.g. ischaemic heart disease
• Poorer mental health, e.g. depression
Fetal
• Neural tube defects (NTDs): all women should take 5 mg folic acid daily
• Macrosomia
• Preterm labour
• Lower Apgar scores
• Late stillbirth
• Neonatal mortality
Maternity services
• Increased hospital admissions
• Increased costs associated with managing complications
• Increased length of hospital stay
• Increased neonatal care requirements
Source: Smith et al 2008; Modder and Fitzsimons 2010
D uring pregnancy, women who are obese may report a range of psycho-social issues
related to their increased BMI . For instance, they may feel disappointed at not being
recognized as pregnant until later in pregnancy (N ash 2012a) and worry about their
weight gain in pregnancy (Nash 2012b). They may also experience a variety of feelings
towards their body image, but generally feel less stigma and discrimination, as weight
gain is more socially acceptable while pregnant (Johnson et al 2004).
The maternity services need to ensure suitable equipment and staffing levels are
available, e.g. suitable beds and chairs, large BP cuffs, sufficient operating department
staff in respect of caring for women with obesity (Modder and Fi simons 2010). Risk
assessments for labour should be undertaken antenatally for each woman, considering
moving and handling issues in order to ensure suitable aids are available to assist with
movement (Modder and Fi simons 2010; Marshall and Brydon 2012). Furthermore,
CMA CE/Royal College of O bstetricians and GynaecologistsModder ( and Fi simons
2010) endorse that all maternity units should have documented environmental risk
assessments regarding the availability of facilities for pregnant women presenting
with a BMI of >30 kg/m2 at the initial visit.
Intrapartum care
O besity is a significant risk factor during labour, as detailed in Box 13.10. For women
who have a BMI ≥35 kg/m2 it is recommended that the birth should occur in a
consultant-led environment (Kerrigan and Kingdon 2010). However, these women will
benefit from good-quality midwifery-led care to promote optimal outcomes, e.g.
encouraging mobility and an upright position. I t could also be argued that these
women might benefit from birthing in a midwife-led unit/birth centre alongside an
obstetric unit. I t is recommended by N I CE (2007) that individual discussions with
women whose BMI is between 30 and 34 kg/m2 should take place regarding the local
birth place options available.
Box 13.10
I nt ra pa rt um risks a ssocia t e d wit h obe sit y
• Prolonged pregnancy and induction of labour
• Prolonged labour: labour is slower and there is often a delay between 4–
7 cm with syntocinon use being higher. There should be close observation
of progress in labour with one-to-one care for women with a BMI ≥40
• Complications, e.g. shoulder dystocia
• Emergency caesarean birth: if a woman has a BMI >40 the incidence is
almost 50%. There is an increased risk of malpresentation, e.g. occipito-
posterior (OP) position and vaginal birth after caesarean (VBAC) is less
successful
• Primary postpartum haemorrhage (PPH): venous access and active
management of the third stage of labour is recommended for women with
a BMI ≥40
Source: Kerrigan and Kingdon 2010; Modder and Fitzsimons 2010
I t is worth noting that there may be difficulties in assessing maternal and fetal
wellbeing during labour, e.g. ensuring a good quality cardiotocograph (CTG)
recording, undertaking vaginal examinations and performing manoeuvres in an
emergency such as shoulder dystocia (D oughty and Waugh 2013). I n addition, there
may be difficulties in managing intraoperative complications such as controlling
haemorrhage.
Postnatal care
O besity has a direct influence on short- and long-term health and wellbeing for the
mother and the baby following birth, as indicated in Box 13.11.
Box 13.11
R isks a ssocia t e d wit h obe sit y in t he post na t a l pe riod
Maternal
• Venous thromboembolism: early mobilization following birth
encouraged. Prophylaxis considered even following vaginal birth
• Longer postoperative recovery
• Increased postoperative complications, e.g. wound dehiscence and
infection
• Tendency to retain pregnancy weight gain
• Lowered rates of breastfeeding duration
• Reduced contraception choices: depending on presence of co-morbidities
Neonatal
• Increased risk of congenital abnormality, e.g. heart defects
• Macrosomia: increased risk of trauma from birth; practical difficulties
associated with undertaking the neonatal examination
• Low birth weight: associated with the presence of antenatal maternal co-
morbidity, with increased risk of possible long-term effects on health, e.g.
increased rates of cardiovascular disease and diabetes mellitus in middle
age
Source: Smith et al 2008; Modder and Fitzsimons 2010
Breastfeeding has been shown to reduce the weight a woman has gained in
pregnancy more effectively than in those women who choose to artificially feed their
babies (Baker et al 2008). O bese women are as likely to initiate breastfeeding as
women of a normal weight, but tend to breastfeed for a shorter time (A mir and
Donath 2007). I t is known that obese women have delayed lactogenesis and a lowered
response of prolactin to suckling, leading to reduced milk production and premature
cessation of breastfeeding. However, the response to prolactin is reduced over time so
extended support from midwives skilled at supporting the continuance of
breastfeeding is especially important in this group of women (Jevitt et al 2007).
Weight gained in pregnancy is difficult to lose postnatally due to a number of
factors such as the demands of caring for a new baby, eating irregular meals and an
inability to exercise as frequently. This may result in higher rates of obesity in later life
(Gardner et al 2011). W omen who were obese during pregnancy also exhibit a
tendency to retain fat centrally following the baby's birth, which may result in
increased morbidity and mortality later in life (Villamor and Cna ingius 2006).
However, interpregnancy weight reduction has been shown to improve outcomes in
any subsequent pregnancy (Modder and Fi simons 2010). D iscussions around weight,
activity and healthy lifestyle modification behaviours by healthcare professionals
during the 6–8 weeks postnatal examination are recommended by N I CE (2010b)and
the RCO G (2006). I f co-morbidities such as gestational diabetes have been diagnosed
during pregnancy a glucose tolerance test (GTT) should be undertaken at the postnatal
examination and the woman should continue to have annual cardiometabolic
screening (Modder and Fi simons 2010). The Royal College of Midwives (RCM) has
collaborated with S limming W orld© to develop strategies to positively influence and
improve the health of childbearing women (Avery et al 2010; Pallister et al 2010).
Obstetric cholestasis
O bstetric cholestasis (O C) is also known asintrahepatic cholestasis of pregnancy and is a
condition specific to pregnancy that denotes a disruption and reduction of bile
products by the liver. I t is diagnosed by the presence of raised serum bile acids and
usually appears after the 28th week gestation, resolving a couple of weeks following
the birth of the baby. O bstetric cholestasis manifests as intense itching (pruritus) that
mainly affects the soles of the feet, hands and body, becoming worse at night, albeit
there is no visible rash. The woman often complains of loss of sleep. Urinary tract
infections (UTI ) are common and jaundice may occur, with the woman stating that her
faecal stools are pale.
Treatment is based on the use of topical creams, but medications such as
ursodeoxycholic acid and chlorampheniramine may be prescribed. O bstetric
cholestasis causes severe liver impairment and increases perinatal morbidity and
mortality (S aleh and A bdo 2007). Timing of the birth depends on gestational age and
fetal wellbeing, which is monitored through fetal growth and biophysical profiles, fetal
movements and CTG. Birth before 38 weeks is usually advocated R ( CO G 2011a). There
is also an increased risk of postpartum haemorrhage (PPH) due to coagulation
disruption. O ral vitamin K 10 mg is often prescribed to lessen the risk and active
management of the third stage of labour is advised. Postnatal care is based on
ensuring liver function tests (LFTs) return to normal. Recurrence in a subsequent
pregnancy is high, at around 90%.
Endocrine disorders
Insulin is a polypeptide hormone produced in the pancreas by the beta cells of the
islets of Langerhans. I t has a pivotal role in the metabolism of carbohydrate, fat and
protein and lowers the level of blood glucose. Conversely, the alpha cells produce the
hormone glucagon which increases the blood glucose. I n healthy individuals, the blood
glucose level regulates the secretion of insulin and glucagon on a negative-feedback
principal. Hence if the blood glucose level is high (hyperglycaemia) more insulin is
released, whereas if the blood glucose level is low (hypoglycaemia) insulin is inhibited
and glucagon is released (Tortora and D errickson 2010). Excess glucose is stored in the
liver where it can be released depending upon metabolic demands. I n the longer term,
excess glucose is stored as body fat and this is an important issue when considering
obesity and also macrosomic babies of mothers with diabetes.
Diabetes mellitus
Diabetes mellitus is a metabolic disorder due to deficiency or diminished effectiveness
of endogenous insulin affecting 5.5% of the adult population in the UK and is the most
common pre-existing medical disorder complicating pregnancy in the UK (N I CE 2008;
J ames et al 2011). I t is characterized by hyperglycaemia, deranged metabolism and
complications mainly affecting blood vessels.
The classic presentation, especially in type 1 diabetes, is of weight loss and the
occurrence of the three polys: polydipsia (excess thirst), polyuria (excessive, dilute urine
production) and polyphagia (excessive hunger) (Tortora and D errickson 2010). There
may also be lethargy, prolonged infection, boils and pruritis vulvae. Conversely, with
type 2 diabetes, individuals are often obese with few or no presenting symptoms.
A random blood glucose result >11.1 mmol/l is highly suggestive of diabetes and the
diagnosis is confirmed by a fasting blood glucose test. A GTT entails taking a fasting
blood sample, giving a 75 g glucose drink and a taking a further blood test 2 hours
later to determine the plasma glucose levels. I f the plasma level is >7.0 mmol/l
following the fasting test, or >7.8 mmol/l following the 2-hour test, a diagnoses of
diabetes is made by the physician.
There are several types of diabetes mellitus, as follows.
Type 1 diabetes (formally insulin-dependent or juvenile onset
diabetes)
Type 1 diabetes develops as a result of progressive autoimmune destruction of the
pancreatic beta cells, most probably initiated by infection, with the result that no, or
an inadequate amount of, insulin is produced. Hyperglycaemia occurs leading to
glycosuria, dehydration, lipolysis and proteolysis with the classic symptoms listed
above. Metabolism of type 1 diabetes mimics starvation. I n the absence of insulin the
body cells use fa y acids to produce adenosine triphosphate (ATP). By-products of
this process produce organic acids called ketones. A s ketones accumulate they lower
the pH of the blood making it acidic, known as ketoacidosis (Tortora and D errickson
2010). This can be detected by the presence of ketones in the urine and the breath
smelling of pear drop sweets. If untreated, the ketoacidosis will lead to coma and death.
I n 85% of cases there is no first-degree family history of the condition; however, if
one parent has type 1 diabetes, there is a 2–9% chance of an individual developing it,
and if both parents have the condition the risk rises to 30%. D iagnosis is confirmed by
raised blood glucose results. Complications include nephropathy, neuropathy,
retinopathy and cataract formation. Microvascular complications arise if there is
chronic hyperglycaemia, leading to secondary complications such as atherosclerosis
and gangrene of the feet due to sensory neuropathy and ischaemia. For this reason
individuals with diabetes are discouraged from walking barefooted and may need
referral to a diabetic foot clinic.
Treatment is the lifelong administration of insulin, which has to be given by
subcutaneous injections two to five times a day. This is usually self-administered.
Traditionally animal-derived insulins from beef and pork were used, and from the
1980s human insulin was introduced prior to a genetically modified form known as
human analogue. All of these can be short- and long-lasting, as shown in Table 13.2.
Table 13.2
Types of insulin according to origin and length of action
NB: Pre-mixed insulin can be prescribed, but only when two injections a day are required.
Treatment is based upon best practice guidelines and is determined for each
individual person with diabetes and the specialist diabetes team (N I CE 2008; Scottish
I ntercollegiate Guidelines N etwork [S I GN ] 2010
). The blood glucose levels aimed for
are in the range of a person without diabetes, which are: preprandial (fasting/before a
meal) between 3.5 and 5.9 mmol/l, and one hour postprandial <7.8.00 mmol/l. I nsulin
dosage is adjusted according to blood glucose levels and the individual needs to test
their blood sugar at least twice a day using finger prick tests and reagent strips read
against a colour chart, or with a glucose meter (glucometer). I n the home se ing, urine
is also tested for ketones using dipsticks.
Hypoglycaemia is a potential problem when insulin therapy is used, as insulin will
decrease blood glucose levels. W hen the level is low, adrenergic symptoms of
palpitations, perspiration, tremor and hunger alert the individual to take action and
resolve this by eating a meal or taking glycogen sweets or gel (de Valk and Visser
2011). I f the blood glucose decreases further the individual is likely to experience
neuroglycogenic symptoms of altered behaviour and mood swings (de Valk and Visser
2011). I f left untreated, convulsions and loss of consciousness can result, leading to
coma and death.
Severe hypoglycaemia is associated with loss of consciousness and requires the
assistance of another person to administer glucagon intramuscularly as there is a risk
of asphyxiation with oral administration. I ndividuals who have diabetes should always
carry glucagon ready-to-use devices with them for this purpose.
W here diabetes control cannot be achieved by a traditional basal/bolus regime,
individuals with diabetes are increasingly being offered the choice of insulin pump
therapy. Continuous subcutaneous insulin infusion pumps (CS I I ) are in common use
in the US A and the midwife is increasingly likely to encounter them in the UK. The
pump controls the constant administration of insulin as a basal dose, in bursts at 3-
minute intervals with the individual self-administering a bolus dose via the pump
when they consume carbohydrate, or if they need to reduce severely high blood
glucose levels. This is not currently a closed loop system, as each individual has to have a
good understanding of their own personal carbohydrate to insulin ratios in order to
regulate the pump to administer an appropriate bolus dose whenever carbohydrate is
consumed and set the pump up to follow their required basal dose profile. There are
also some pumps that work in conjunction with a continuous glucose monitoring
sensor which is injected into the skin, with a transmi er clipped to the surface. The
transmi er sends readings to the pump once every 5 minutes. The pump can be set up
to sound an alarm if the readings are outside limits defined by the individual and is
particularly useful for diabetics who are susceptible to serious hypoglycaemic
episodes while asleep. However, as the individual remains responsible for defining
appropriate insulin doses based on the information provided by the sensor, they are
still required to perform daily blood glucose and urinary ketones tests which
necessitates the mental capacity to cope with the system and calculations.
A fully closed loop system, also known as the artificial pancreas which mimics normal
pancreatic administration of insulin, has also been developed. A s with the CS I I there
is a pump and a sensor, but there is an additional hand-held control device that
contains an algorithm to calculate the insulin dose required. This information is
transmi ed to the pump and the insulin is administered automatically without any
intervention from the individual. There is also a suspend insulin command to prevent
hypoglycaemic episodes. Results from clinical trials are promising and this treatment
may become mainstream in just a few years, with midwives encountering it soon in a
research context with childbearing women. I slet cell transplants are now available in
the UK for individuals who meet strict criteria, being intended for those unable to
recognize severe hypoglycaemia or those who are otherwise healthy renal transplant
recipients.
Regular attendance at outpatient clinics is necessary to monitor diabetic control. The
glycated or glycosylated haemoglobin (HbA 1c) test is performed every 2–6 months.
This measures the average blood glucose level by analysing the molecule in the
haemoglobin in the red blood cell where glucose binds. The higher the HbA 1c the
poorer is the diabetic control. Treatment aims to keep the HbA 1c at <48 mmol/mol
(6.5%). However, since 2011, HbA 1c has been expressed in mmol/mol to comply with
the International Federation of Clinical Chemistry (IFCC) Units.
Type 2 diabetes (formally non-insulin-dependent or maturity onset
diabetes)
I n type 2 diabetes there is a gradual resistance to the action of insulin in the liver and
muscle. This can also be combined with impaired pancreatic beta cell function leading
to a relative insulin deficiency. Type 2 diabetes accounts for 85% of cases of diabetes
and tends to cluster in families. A ll racial groups are affected but it is six times more
common in people of S outh A sian descent and three times more common among
people of A frican and A frican-Caribbean origin. Traditionally it was associated with
older people but it is increasingly diagnosed in children, young adults and among
those with a raised BMI and sedentary lifestyle (Gregory and Todd 2013).
The initial treatment is by strict diet to reduce weight and increased physical activity
to improve glucose tolerance and control the diabetes. A s the condition progresses
oral diabetic agents such as metformin become necessary, and eventually insulin
treatment might be required. Furthermore, ancillary medication such as A CE
inhibitors and statins may be prescribed to prevent cardiovascular complications.
Diabetic monitoring is the same as for type I diabetes.
Secondary diabetes
This is a type of diabetes that presents secondary to another medical condition such as
pancreatic disease or cystic fibrosis (Dornhorst and Williamson 2012).
Maturity onset diabetes of the young (MODY)
I n this type of diabetes, there is a genetic defect affecting pancreatic beta cell insulin
secretion. O ut of all cases presenting, 95% have a first-degree relative affected.
However, maturity onset diabetes of the young (MO D Y) is not associated with obesity
and it tends to be diagnosed in the second or third decade of life (D ornhorst and
Williamson 2012).
Gestational diabetes mellitus (GDM)
This is a form of diabetes that arises in the second or third trimester of pregnancy,
affecting up to 5% of all pregnancies, and resolves after the birth of the baby. There is
intolerance to glucose which is a ributed to increasing levels of placental hormones,
in particular HPL and increasing maternal insulin resistance, especially after 20 weeks
of gestation (Gregory and Todd 2013). Gestational diabetes is usually asymptomatic
and according to Reece et al (2009) it is associated with:
• increasing maternal age
• family history of type 2 diabetes or GDM
• certain ethnic groups (Asian, African-Caribbean, Latin American, Middle Eastern)
• previous unexplained stillbirth
• previous macrosomia
• obesity (three-fold risk of GDM)
• smoking (two-fold risk of GDM: England et al 2004)
• change in weight between pregnancies: an inter-pregnancy gain of more than three
BMI points doubles the risk of GDM (Villamor and Cnattingius 2006)
Gestational diabetes should resolve shortly after the birth of the baby. The finite
diagnosis is therefore made in retrospect as it is not possible during pregnancy to
differentiate between GD M and types 1 and 2 diabetes that present for the first time in
pregnancy (the la er two of which do not resolve following the baby's birth). I t is
therefore important that observations and outpatient follow-up appointments are
undertaken in the postnatal period. The lifetime risk of developing type 2 diabetes
after gestational diabetes is seven-fold (Bellamy et al 2009). The treatment is referral to
a dietician with adherence to a diet restricting sugar and fat, encouragement of 30
minutes exercise a day, self-monitoring of blood glucose and insulin therapy if
necessary.
Pre-conception care
Pre-conception care is essential for any women with diabetes because of the potential
pregnancy complications and four-fold increased risk overall of congenital
malformations which are associated with hyperglycaemia. I f the HbA 1c is
>58 mmol/mol (7.5%) at the initial visit to the midwife, this risk increases to nine-fold
with a four-fold increase in spontaneous miscarriage (Temple 2011) . Hughes et al
(2010) therefore argue there is a requirement for formalized pre-conception clinics and
midwifery involvement for women who have diabetes as approximately only a third of
these women receive any such care from their GP or from a hospital clinic (Temple
2011). This should involve each woman taking a daily dose of 5 mg of folic acid prior to
conception (N I CE 2008) and having a thorough medical assessment, as existing
complications such as retinopathy and nephropathy can deteriorate during pregnancy
(S canlon and Harcombe 2011; Gregory and Todd 2013). A ny medication should be
reviewed and ACE inhibitors discontinued.
Type 1 diabetes
I nsulin might need to be changed and the regimen intensified to obtain optimal
control. NovoRapid® is the only insulin licensed for use in pregnancy.
Type 2 diabetes
Pre-conception care is important as some anti-diabetic drugs may be teratogenic to
early fetal development. W omen with type 2 diabetes may also be on statins and A CE
inhibitors, which should be discontinued. Consequently, insulin by subcutaneous
injection should be commenced and contraception continued until the woman
achieves optimal diabetic control. The BMI should be calculated and, if indicated,
weight reduction should be encouraged prior to conception.
Pre-conception management
NICE (2008) advocates the following:
• Aim to maintain HbA1c <43 mmol/l (6.1%) to reduce the risk of congenital
malformations.
• Strongly advise women with HbA1c >86 mmol/l (10%) to avoid pregnancy.
• Reinforce self-monitoring of blood glucose.
• Offer HbA1c testing monthly.
• Offer retinal assessment at the first pre-conception appointment and then annually if
no retinopathy is found.
• Assess nephropathy risk including microalbuminuria estimation and serum
creatinine/epidermal growth factor receptor (eGFR). If serum creatinine is
≥120 µmol/l, or the eGFR is <45 ml/min/1.73 m, a referral should be made to a
nephrologist before contraception is discontinued.
• Discontinue statins before pregnancy or as soon as pregnancy is confirmed.
Antenatal management
The midwife will increasingly encounter women with pre-existing diabetes because of
the increased prevalence of diabetes in young people. Furthermore, some
multigravidae might silently develop type 2 diabetes, conceive their fourth or fifth
child and present late for the initial appointment with the midwife due to being
familiar with pregnancy, however they are at risk of developing complications
associated with hyperglycaemia.
Existing medical complications can worsen during pregnancy, or be recognized for
the first time. Furthermore, the midwife will care for women when diabetes presents
during pregnancy: indeed the midwife is likely to be the first health professional to
recognize the altered state of health. I f diabetes is identified in the first trimester, then
this is likely to be pre-existing diabetes diagnosed for the first time in pregnancy
rather than GDM. Complications for the pregnancy encompass:
• pre-eclampsia
• macrosomic baby, due to hyperglycaemia, with risk of shoulder dystocia
• IUGR
• polyhydramnios
• exacerbation of diabetic complications in the woman, in particular retinopathy and
nephropathy
• risk of iatrogenic preterm birth leading to the baby being admitted to the neonatal
unit.
I n addition, the risks to the fetus/baby born to a woman with diabetes are that they
are:
• five times more likely to be stillborn
• three times more likely to die in the first few months of life
• four times more likely to have a major congenital malformation.
These risks, however, are substantially reduced if there is good blood glucose
control before and after pregnancy. The initial visit to the midwife where a detailed
medical history is taken should identify those women with pre-existing diabetes in
order for a referral to be made to a specialist endocrine/obstetric clinic. Regular
appointments at this clinic are usually at fortnightly intervals, where a
multidisciplinary team of obstetrician, physician, dietician and specialist
nurse/midwife will provide care. A s this will be considered to be a high-risk
pregnancy, the woman should not be assigned to low-risk schemes of care. Guidelines
from N I CE (2008) also recommend diabetes screening should be undertaken with
women who present at the first appointment with the following risk factors for
developing GDM:
• BMI >30 kg/m2
• previous macrosomic baby ≥4.5 kg or above
• previous GDM
• first-degree relative with diabetes
• family origin with a high prevalence of diabetes, e.g. South Asian, African-Caribbean
and Middle Eastern origin.
N ewly diagnosed women will require education in monitoring their blood sugar
glucose levels using the necessary equipment and reagent strips, which need
prescribing. They will require education in self-administration of insulin and in
balancing insulin requirements based on their blood glucose readings. D ietary
assessment and advice is essential so that the insulin dose can be adjusted according
to a woman's normal eating habits.
Medical management should achieve a delicate balance between preventing both
hyperglycaemia and hypoglycaemia (de Valk and Visser 2011). Blood glucose target
levels in pregnancy are likely to be a fasting blood glucose of between 3.5 and
5.9 mmol/l and one-hour postprandial blood glucose below 7.8 mmol/l (N I CE 2008),
which may be lower than the woman is used to. Q ualitative research has shown that
pregnant women are happier if their pre- and postprandial blood glucose levels are
between 7 and 10 mmol/l with no hypoglycaemia (Richmond 2009), hence the midwife
should stress to the woman the importance of complying with the prescribed levels
and give advice to her and her family about recognizing the signs and symptoms of
hypoglycaemia. However, the woman should be informed that her blood glucose levels
will change throughout pregnancy due to altered hormone levels and the developing
fetus having its own metabolic demands. Consequently, it is important that the
woman carries glucose tablets/gel and a ready-to-use intramuscular device at all times
in case of hypoglycaemic episodes. I n addition, women should be advised that as most
hypoglycaemia occurring during weeks 8–16 is a ributed to nausea and vomiting of
pregnancy, it is important they seek advice if this becomes a significant problem in
maintaining diabetic control.
Key points to consider relating to the antenatal care of women presenting
with/developing diabetes are detailed below:
• A supplement of 5 mg folic acid should be taken daily for the first 12 weeks of
pregnancy to reduce the risk of congenital malformations in the fetus.
• Urinalysis should be undertaken at each visit to test for glucose, ketones as well as
the protein.
• Women with type 1 diabetes should be offered ketone testing strips and be advised
to test for ketonuria if they have symptoms of hyperglycaemia or become unwell.
• Blood pressure should be recorded at each visit with the midwife being alert for
signs of pre-eclampsia, especially with GDM.
• Women should be discouraged from fasting, especially for long periods (e.g. as with
religious observances).
• Women should test their blood glucose levels on waking and one hour postprandial
after every meal during pregnancy.
• If taking insulin, women should also test their blood glucose level before going to
bed.
• Women with type 2 diabetes are likely to be commenced on insulin: if taking
metformin pre-pregnancy, some centres may decide to continue its use until 32 weeks
due to emerging evidence of its safety (Gregory and Todd 2013).
• An ultrasonic scan is undertaken at 7–9 weeks' gestation to confirm viability and
gestational age, followed by a further scan at 18–20 weeks to assess the four chambers
of the fetal heart for any anomalies, estimate liquor volume and to ascertain fetal
growth.
• Monthly scans are undertaken to assess fetal growth and their results recorded,
observing for signs of macrosomia (dimensions above the 95th centile for the period
of gestation).
• Weekly tests of fetal wellbeing, including CTG or biophysical profiles, should
continue until labour commences or there is an indication to intervene earlier: e.g.
induction at 38 weeks or caesarean section.
Intrapartum management
• If the labour is preterm, steroids are given to the woman to improve fetal lung
maturation and additional insulin may be required.
• If the fetus is macrosomic, the woman should be informed of the risks and benefits
of vaginal birth, induction of labour and caesarean section.
• Blood glucose levels should be monitored hourly through labour and birth, aiming to
maintain them between 4 and 7 mmol/l.
• For women with type I diabetes an IVI of insulin and dextrose should be commenced
from the onset of established labour.
• For women with type 2 and GDM an IVI of insulin and dextrose should be
commenced if blood glucose levels cannot be maintained between 4 and 7 mmol/l.
• The neonatal team should be alerted that the woman is in labour, should their
assistance be required when the baby is born.
Care of the baby at birth
• A paediatrician should be present at the birth if the woman is receiving insulin.
• The midwife should be alert for signs of respiratory distress, hypoglycaemia,
hypothermia, cardiac decompensation and neonatal encephalopathy.
• A baby should be admitted to a neonatal intensive care unit (NICU) only if a
significant complication is apparent.
• The woman should hold her baby as soon as is practical after the birth and prior to
any transfer to the NICU.
• Blood glucose testing of the baby should be carried out after birth and at intervals
according to local protocols.
• The baby should feed within 30 minutes of birth and then every 2–3 hours until pre-
feed blood glucose levels are at least 2 mmol/l. If the blood glucose falls <1.5 mmol/l
the paediatrician must be called and admission to the NICU is a possibility. (NB:
NICUs tend to set a higher baseline for neonatal hypoglycaemia, so local protocols should be
consulted.)
• Blood glucose levels should be assessed in babies who show signs of hypoglycaemia
(abnormal muscle tone, level of consciousness, apnoea or seizures) with referral to
the paediatrician, who is likely to treat with IV dextrose.
• The baby should not be transferred home until at least 24 hours old, is maintaining
blood glucose levels and is feeding well.
Postnatal care of the woman with diabetes
• Type 1 diabetes: insulin should be reduced immediately after birth and blood glucose
levels monitored with insulin adjusted until the appropriate dose is obtained.
• The woman should be observed for signs of hypoglycaemia.
• As placental hormone levels fall, the insulin sensitivity improves, such that the
insulin infusion rate is likely to need reducing in the early postnatal period.
• The woman will usually return to her pre-pregnancy insulin levels, unless she is
breastfeeding, when the insulin requirements are reduced by 30% (Gregory and Todd
2013).
• The woman should be advised that breastfeeding affects glycaemic control and there
is the need for continued blood glucose monitoring and insulin adjustment.
• For Type 2 diabetes: insulin should cease immediately and the doctor should confer
with the pharmacist as to which oral diabetic agents the woman may safely take if
breastfeeding (otherwise she returns to her pre-pregnancy drug therapy).
• For GDM: insulin ceases immediately and blood glucose monitoring can stop.
• A fasting blood glucose test should be undertaken at 6 weeks and if there is a
possibility that would indicate another form of diabetes, a GTT should be performed
immediately.
• The woman should be advised of the risk of developing diabetes in future
pregnancies and the need for pre-pregnancy screening.
• The woman should be informed of the importance of using contraception to prevent
pregnancies in rapid succession and to seek pre-conception care prior to future
pregnancies.
• A healthy lifestyle with regular exercise, smoking cessation and maintaining a BMI
within normal limits should also be emphasized to the woman.
• A follow-up appointment at 6 weeks with the diabetes team or the local GP is also
essential (Gregory and Todd 2013).
Thyroid disease
The thyroid gland is a highly vascular organ that is shaped like a bu erfly and is
situated at the front of the neck. I ts main function is to produce the iodine-rich
hormones tri-iodothyronine (T3) and thyroxine (T4). These hormones are secreted
directly into the blood circulation in response to a negative feedback to the
hypothalamus which secretes thyrotropin releasing hormone (TRH) that stimulate the
anterior pituitary gland to secrete thyroid stimulating hormone (TS H) (T ortora and
D errickson 2010). TS H also initiates the uptake of iodine, which combines with an
amino acid called tyrosine which enables synthesis of the thyroid hormones within the
thyroid follicles (D ornhorst and Williamson 2012). O nce in the blood circulation, 99%
of T3 and T4 are bound to thyroxine-binding globulin (TBG) with the remaining 1%
unbound or free: e.g. fT3 and fT4 (J ames et al 2011). I t is fT3, fT4 and TS H that are
measured in thyroid function tests.
Excess T4 is converted to the more potent T3 by deionization in the peripheral tissue
(D ornhorst and Williamson 2012). Most body tissue has receptors for fT3, and once
bound to the tissue, metabolic activities result. The thyroid hormones regulate the
metabolic rate throughout all body tissue and influence growth and maturity.
I n pregnancy, the circulating level of TBG enables increased levels of T3 and T4, so
only fT3 and fT4 should be measured by laboratory testing (Dornhorst and Williamson
2012). The fetus cannot synthesize T3 and T4 until the 10th week of pregnancy and is
dependent upon maternal thyroid hormones from placental transfer (D ornhorst and
Williamson 2012). N ormal development of the fetal brain is dependent upon
maternally derived T4 which is converted intracellularly to T3 (Girling 2006).
Thyroid disease is the second most common cause of endocrine dysfunction in
pregnancy and is difficult to recognize as the symptoms mimic pregnancy ( Girling
2006; J ames et al 2011) indicated by Table 13.3. The most common thyroid disorders in
pregnancy are hypothyroidism and hyperthyroidism (thyrotoxocosis), being of
considerable significance due to their effect on both the woman and fetus.
Table 13.3
Similarities between clinical symptoms of thyroid disease and pregnancy
Pregnancy Hyperthyroidism Hypothyroidism
Heat intolerance Yes
Increased appetite Yes
Nausea Yes
Palpitations Yes
Tachycardia Yes
Tremor Yes
Sweating Yes
Warm palms Yes
Goitre Yes Yes
Amenorrhea Yes
Weight gain Yes
Carpal tunnel syndrome Yes
Fluid retention Yes
Constipation Yes
Loss of concentration Yes Yes
Tiredness Yes Yes
Reproduced from Girling J C 2006 Thyroid disorders in pregnancy, Current Obstetrics and Gynaecology 16: 47–53, with
permission from Elsevier
Hypothyroidism
This is under-activity of the thyroid gland with absent or low levels of thyroid
hormones T3 and T4 due to malfunctioning thyroid tissue, or secondary to pituitary or
hypothalamic disease. The most common cause in pregnancy is autoimmune
thyroiditis and goitre may or may not be present (Gregory and Todd 2013). Lack of
dietary iodine can also cause goitre. Goitre is enlarged thyroid tissue due to infiltration
of lymphocytes and increase of fibrous tissue; this condition is also known as
Hashimoto's disease.
Hypothyroidism is familial and may be associated with other autoimmune disease
such as type 1 diabetes (Gregory and Todd 2013). S ymptoms include weight gain,
intolerance to cold temperature, constipation, alopecia, dry skin, lethargy, hoarse
voice, ataxia, bradycardia and cognitive impairment. Menstrual irregularities and
infertility are common, because TRH stimulation induces hyperprolactinaemia which
prevents ovulation. N ot all women have symptoms and consequently the disease
might be first recognized during infertility investigations. The most serious
complication of untreated hypothyroidism is myxoedema coma which presents with
hypothermia, hypoventilation and bradycardia, followed by unconsciousness (Gregory
and Todd 2013).
Pregnancy complications of hypothyroidism are hypertension and low birth weight
and psychomotor retardation in the fetus. D ornhorst and Williamson (2012) raise
concern of the low I ntelligence Q uotient (I Q ) of children born to mothers with
untreated hypothyroidism and cretinism may result from severe maternal iodine
deficiency associated with hypothyroidism (J ames et al 2011). Pre-conception care is
therefore very important and fT4 and thyroxine levels should be measured and the
dose of thyroxine adjusted until TSH reaches normal level (Gregory and Todd 2013).
D uring pregnancy the woman should be reviewed by an endocrinologist to measure
fT4 and TS H levels at the outset in order to obtain a baseline measurement G ( regory
and Todd 2013). The TS H level rises in pregnancy causing an increased demand for
thyroxine and so the dose of therapeutic thyroxine is adjusted, usually increasing by
25–50% (Gregory and Todd 2013). I ron supplements should be taken at a different
time to the thyroxine to maximize absorption (J ames et al 2011). A lthough a large
goitre might cause complications for general anaesthesia (J ames et al 2011), there are
otherwise no specific issues for labour and consequently intrapartum care may be
provided by the midwife (Gregory and Todd 2013).
Postnatally, the thyroxine dose is reduced to the pre-pregnancy level and the fT4 and
TS H levels should be measured at the 6-week follow-up or postnatal appointment. I t is
important that the neonatal bloodspot screening test is undertaken as the condition
can be familial and thus the midwife should provide support to the parents, who are
likely to be anxious (Gregory and Todd 2013). I n addition, the woman needs to be
observed for signs of thyroiditis and postnatal depression (James et al 2011).
Hyperthyroidism (thyrotoxicosis)
Hyperthyroidism is an overactivity of the thyroid gland that affects 0.2% of pregnant
women (J ames et al 2011). I t usually manifests as a clinical syndrome called
thyrotoxicosis with signs and symptoms that include weight loss despite having a good
appetite, intolerance to heat, sweating, tachycardia with bouncing pulse, insomnia,
agitation, tremor, exophthalmos (protrusion of the eyeballs due to the tissue behind
the eye becoming oedematous and fibrous), diarrhoea and menstrual irregularities
(Gregory and Todd 2013). N on-pregnancy treatment is with carbimazole and
propylthiouracil, which inhibit thyroid hormone synthesis (D ornhorst and Williamson
2012) . Thyroidectomy is reserved for cases where there is excessively large goitre and
drug therapy is ineffective. I f radioiodine treatment has been used to destroy thyroid
tissue to lower the thyroid levels, the woman should be counselled to delay conception
for at least four months (James et al 2011).
The main complication of hyperthyroidism is the medical emergency of thyroid crisis
(or thyroid storm) where there are exaggerated features of thyrotoxicosis with
additional hyperpyrexia, cardiac dysrhythmias, congestive cardiac failure, altered
mental state and ultimately coma. Goitre may also be present. Hyperthyroidism is
treated with I V fluids, hydrocortisone, propranolol, oral iodine, carbimazole and
propylthiouracil (D ornhorst and Williamson 2012). I f the thyrotoxicosis is autoimmune,
with antibodies to the TS H receptor, it is calledGraves' disease, which accounts for 95%
of hyperthyroidism in pregnancy (J ames et al 2011). A lthough the risk of miscarriage
increases in early pregnancy, the disease otherwise tends to improve in pregnancy and
women may go into remission in the latter half of pregnancy (Gregory and Todd 2013).
Care in pregnancy aims to normalize thyroid function and carbimazole and
propylthiouracil are the drugs of choice with the dose adjusted after monthly
measurements of fT4 and TS H. I f the control is poor the fetus is at risk of fetal
thyrotoxicosis which may necessitate cordocentesis to measure fetal fT4 and TS H
(Gregory and Todd 2013). This is a high-risk pregnancy and the woman should
consequently be referred to a specialist obstetric unit. The midwife should ensure
monthly measurements of fT4 and TS H are undertaken and organize serial fetal
growth ultrasound scans. There should also be regular assessment of the fetal heart
rate to detect fetal tachycardia. A s a result, continuous fetal heart monitoring during
labour is required and the paediatrician should be informed when labour is
established (Gregory and Todd 2013).
Labour can precipitate thyroid crisis/storm (J ames et al 2011) so meticulous
monitoring and recording of maternal observations and wellbeing is vital. A s with
hypothyroidism, should goitre be present and is large, there may be complications if
general anaesthesia is warranted (James et al 2011).
Postnatally, the midwife should be alert for signs of thyrotoxicosis flare in the
woman and extend the period of undertaking observations with emphasis on maternal
pulse. Propylthiouracil is the drug of choice if the woman chooses to breastfeed her
baby. The woman's thyroid hormone levels should also be measured 6 weeks following
the baby's birth and the drug dose revised accordingly.
W hen examining the baby, the midwife should be alert for signs of neonatal goitre
and thyrotoxicosis, referring promptly to the paediatrician if these are suspected. The
baby might require temporary treatment with antithyroid drugs and propanolol
necessitating admission to the NICU (Gregory and Todd 2013).
Prolactinoma
The pituitary gland increases in size by 50–70% in pregnancy due to normal lactotroph
hyperplasia, which in rare cases causes symptoms in pregnancy (D ornhorst and
Williamson 2012). The presence of an adenoma, called a prolactinoma, in the pituitary
gland will further increase its size and cause symptoms. This adenoma, or cyst,
increases the production of prolactin, which is the hormone that initiates lactation
(Gregory and Todd 2013). There are two types of adenoma:
• Microadenoma: accounts for 90% of cases in pregnancy. They are <10 mm in diameter
and rarely grow significantly, with some regressing spontaneously.
• Macroadenoma: accounts for 10% of cases in pregnancy. They are >10 mm in diameter
and are more likely to expand and cause symptoms of headache and visual
disturbance. Occasionally they may progress to pituitary apoplexy or diabetes
insipidus (Dornhorst and Williamson 2012).
With both types of adenoma there is a risk of infertility and treatment is with
dopamine agonists, which cause side-effects of nausea, vomiting, postural
hypotension, constipation, nasal congestion and Raynaud's phenomenon. Pre-
conception care is important and management depends upon the size of the adenoma
which might involve a trial of discontinuing the dopamine agonist or changing to
bromocriptine. I n some cases, surgery might be a empted prior to conception to reduce
the bulk size of the adenoma (Gregory and Todd 2013).
O nce pregnant, the woman should be referred to a specialist unit as this is a high-
risk pregnancy. A ntenatal care, however, can be shared with the community midwife
and medical/obstetric team. At the initial visit the midwife should take particular note
of past surgery and current medication when undertaking the woman's history. At
each subsequent visit the woman should be asked about headache and visual
symptoms. I t is the medical team who will determine the type and dose of dopamine
agonist and perform monthly visual perimetry to detect early signs of compression on
the optic chiasma (Gregory and Todd 2013). I f there are indications of adenoma
expansion, a magnetic resonance imaging (MRI ) scan should be performed urgently
and bromocriptine commenced.
I n most cases the intrapartum care can be facilitated by the midwife, however if the
adenoma is expanding the woman is likely to have a preterm induction of labour. The
obstetric team may advise an elective instrumental birth to avoid a rise in intracranial
pressure during the second stage of labour (Gregory and Todd 2013).
I n the postnatal period the woman is advised to report any symptoms. A n MRI scan
might be ordered by the medical team and prolactin levels measured after 3 weeks, by
which time the values should have returned to their pre-pregnancy levels. Follow-up
appointments should be made with the specialist medical team who will evaluate the
symptoms when determining the re-commencement of pre-pregnancy treatment with
dopamine agonists. The midwife should consult with the doctor and pharmacist for
suitable alternative medication if the woman wishes to breastfeed her baby as
dopamine agonists are usually contraindicated. Furthermore, the woman will require
specialist contraception advice as oestrogen contained within the oral contraceptive
pill might further increase the size of the adenoma and consequently is
contraindicated (Gregory and Todd 2013).
Cardiac disease
The chance of midwives caring for a woman with pre-existing cardiac disease, or
developing cardiac disease in pregnancy, has increased over recent years due to many
factors, including the increased age of childbearing women and the association it has
with co-existing medical conditions such as diabetes, hypertension, as well as obesity,
smoking and previous illicit drug use. Furthermore, improved life expectancy of
women born with congenital cardiac disease and increased immigration revealing an
increase in rheumatic heart disease adds to the prevalence. However, the majority of
pregnancies complicated by maternal cardiac disease are expected to have a favourable
outcome for both the woman and fetus.
Risk for morbidity and mortality depends on the nature of the cardiac lesion, its
affect on the functional capacity of the heart and the development of pregnancy-
related complications such as hypertensive disorders of pregnancy, infection,
thrombosis and haemorrhage. Cardiac disease is the commonest cause of maternal
death in the UK (N elson-Piercy 2011), giving a maternal mortality rate of 2.31 per 100
000 maternities, with 53 women dying from heart disease associated with or
exacerbated by pregnancy in the triennium 2006–2008. O f these, acquired heart disease
was the cause of the majority of deaths with sudden adult death syndrome (S A D S )
and ischaemic heart disease (I MD ) being common causes of death in pregnancy.
Women with congenital heart disease only accounted for one these deaths.
The majority of deaths secondary to cardiac causes occur in women with no previous
history. I t is vital that a midwife undertakes an accurate history from the woman at the
first visit. S hould any history of cardiac disease be revealed, a more detailed account
should be elicited in order to ensure prompt and appropriate referral to an
appropriately skilled and experienced multidisciplinary team, usually in regional
centres. These women require an individualized midwifery approach to care to address
the psychosocial concerns that may often get subsumed within a medical model of
care. The midwife's role involves not only being astute to any deviation that may arise
in the course of the woman's pregnancy, but also being supportive of the woman's
individual needs as she may have the same pregnancy concerns as any other woman.
I n a healthy pregnancy the haemodynamic profile alters in order to meet the
increasing demands of the developing feto-placental unit. Healthy pregnant women
are able to adjust to these physiological changes quite easily; for women with co-
existing cardiac disease, however, the added workload can precipitate complications.
The three sensitive periods of cardiovascular stress (28–32 weeks of pregnancy, during
labour and 12–24 hours postpartum) are the most critical and life threatening for
women with cardiac disease (Roberts and A damson 2013). Understanding the changes
in cardiovascular dynamics during pregnancy can support the midwife's recognition of
key indicators and when limitations to cardiac function are occurring that require
prompt referral (see Chapter 9).
Diagnosis of cardiac disease
A long with the signs and symptoms, physical assessment of functional capacity and
laboratory tests can assist with the diagnosis of cardiac disease and determine the type
of lesion. These may include:
• full cardiovascular examination, including personal history and assessment of
lifestyle risk factors
• blood tests: full blood count, clotting studies and cardiac enzymes (Troponin)
• 12-lead electrocardiogram (ECG)
• echocardiogram: an ultrasound examination to examine cardiac structure and
function
• chest X-ray to assess cardiac size and outline, pulmonary vasculature and lung fields
(always undertaken when clinically indicated, e.g. in women presenting with chest
pain)
• other imaging: computerized tomography (CT) scan or magnetic resonance imaging
(MRI) scan of the chest.
Care of women with cardiac disease
Pre-conception care
W omen with a pre-existing cardiac problem should receive pre-conception counselling
to inform them of any potential risks that a pregnancy may have on their health and
that of their unborn baby in terms of inheriting any congenital malformations. This
will enable them to make informed decisions and plan their pregnancy monitoring
more carefully to reduce any subsequent morbidity and mortality. The risk of
inheriting cardiac disease varies between 3% and 50% depending on the type of
maternal heart disease. Children of parents with a cardiovascular condition inherited
in an autosomal dominant manner (e.g. M arfan syndrome, hypertrophic cardiomyopathy,
o r long Q T syndrome) have an inheritance risk of 50%, regardless of gender of the
affected parent.
For a steadily increasing number of genetic defects, genetic screening by chorionic
villous biopsy (CVS ) can be offered in the 12th week of pregnancy. A ll women with
congenital heart disease should be offered fetal echocardiography between the 19th
and 22nd week of pregnancy. Measurement of nuchal fold thickness around the 12th
to 13th week of pregnancy is an early screening test for D own syndrome in women
over 35 years of age. The sensitivity for the presence of a significant cardiac defect is
40–45%, while the specificity of the method is 99%. The incidence of congenital cardiac
disease with normal nuchal fold thickness is 1/1000 (Eleftheriades et al 2012).
Antenatal care
The symptoms of physiological pregnancy can mimic the signs and symptoms of
cardiac disease, e.g. dyspnoea on exertion, orthopnoea, palpitations, dizziness,
fainting, a bounding pulse, tachycardia, peripheral oedema, distended jugular veins
and alterations in heart sounds. O bservations and investigations of the woman's
health should be undertaken prior to and at the beginning of pregnancy to obtain
baseline referral points. A dapted antenatal records that include triggers such as
shortness of breath, palpitations, pulse rate and rhythm as well as auscultation of the heart
for any murmur and lung fields for signs of pulmonary oedema are useful to prompt the
midwife into early detection of subtle increases of any worsening symptoms. These
observations should be undertaken alongside the usual antenatal examination, but the
midwife also needs to be mindful that women with cardiac disease can also develop
other complications such as pre-eclampsia or gestational diabetes (RCOG 2011b).
There should be frequent assessment of the woman with a multidisciplinary
approach involving midwives, obstetricians, cardiologists and anaesthetists. The aim is
to maintain a steady haemodynamic state and prevent complications, as well as
promote physical and psychological wellbeing. I n addition, the fetal wellbeing is
assessed by the following means:
• ultrasound examination to confirm gestational age and any congenital malformation
• clinical assessment of fetal growth and amniotic fluid volume and by ultrasound
• monitoring of the fetal heart rate by CTG
• measurement of fetal and maternal placental blood flow indices by Doppler
ultrasonography.
A care plan for pregnancy, labour and the early postnatal period should be informed
by the individual woman's situation with a view to optimizing outcomes for her and
her baby. S uch a plan should be shared with the woman with copies being available in
her own hand-held records and those held at a central point.
Potential interventions, such as a ending parent education classes, can help in
allaying the woman's general anxieties about motherhood alongside the antenatal care
received from the midwife. This may involve advice regarding modifying and
adjusting physical activity during pregnancy. S ome women may need to commence
maternity leave earlier than anticipated whereas others may require admission to
hospital for rest and close monitoring. I n addition, guidance about the constituents of
a well-balanced diet with restricted intake of cholesterol, sodium-rich foods and salt
should also be provided. Monitoring of weight gain should be undertaken as excess
weight gain will place additional strain on the heart. Compliance with taking iron and
folic acid supplementation is also important in preventing anaemia.
Antithrombotic therapy
The hypercoagulable state in pregnancy increases the risk of thromboembolic disease
in women who have arrhythmias, mitral valve stenosis or who have had mechanical
cardiac valve replacements. However, the treatment of women requiring
antithrombotic therapy during pregnancy is challenging. Warfarin is commonly used
as an antithrombotic, but as it is teratogenic to the developing embryo/fetus and
associated with a high fetal loss rate, it is not used in pregnancy. Furthermore,
warfarin also predisposes the woman and her fetus to haemorrhage when used in the
third trimester. S ubcutaneous low molecular weight heparins, such as enoxaparin, are
useful for thromboprophylaxis but may not be suitable for women with mechanical
heart valves. A s a consequence, the advice of a haematologist should be sought. Full-
length thromboembolism deterrent (TED ) support stockings should be worn if the
woman is admi ed to hospital for rest and assessment, and should also be worn
during labour and in the immediate postnatal period.
Intrapartum care: the first stage of labour
Many women with cardiac disease have an uncomplicated labour but it is good
practice that there is effective communication among a dedicated multidisciplinary
team of midwife, obstetrician, cardiologist, neonatologist, anaesthetist and the woman
and her family to optimize birth outcome. Vaginal birth is preferred unless there is an
obstetric indication for caesarean section as haemodynamic stability is greater and
there is less chance of postoperative infection and pulmonary complications (RCOG
2011b).
I ntrapartum care involves monitoring the maternal condition using the Modified
Early O bstetric Warning S coring (MEO W S ) system that triggers any deviation in orde
to prompt timely intervention and maximize maternal and fetal wellbeing (McLean
et al 2013). Continuous ECG is recommended in nearly all cases and pulse oximetry
may be utilized to assess arterial haemoglobin saturation, which may be reduced in
women with cardiac disease owing to disruption of normal gas exchange between the
lungs and blood. Fluid balance should be recorded, and use of intravenous fluids may
be limited. Routine antibiotic prophylaxis is not recommended. Continuous electronic
fetal heart rate monitoring is usually recommended (Regitz-Zagrosek et al 2011).
Labour induction
I f induction is indicated and the cervix is favourable (using the Bishop score: Chapter
19), artificial rupture of the membranes (A RM) is undertaken with an I VI of oxytocin
should contractions not establish. A prolonged induction should be avoided. I f the
cervix is unfavourable, synthetic prostaglandin is used to soften/ripen it. W hile there is
no absolute contraindication to misoprostol (prostaglandin E1) or dinoprostone
(prostaglandin E2), there is a theoretical risk of coronary vasospasm and a low risk of
arrhythmias. I n addition, dinoprostone has more profound effects on BP than
misoprostol and is therefore contraindicated in active cardiovascular disease.
Pain relief
The midwife should assist the woman to use the techniques that she has learned for
coping with stress. N itrous oxide and oxygen (Entonox®) and pethidine are usually
considered safe means of intrapartum analgesia for women with cardiac disease, but it
is important to review the labour plan with the multidisciplinary team before
administration. I n some situations, epidural anaesthesia may be the analgesia of
choice for its effectiveness in relieving pain and decreasing cardiac output and heart
rate (RCO G 2011b). I t causes peripheral vasodilatation and decreases venous return,
which alleviates pulmonary congestion. Furthermore, an effectively working epidural
in situ may eliminate the need for emergency general anaesthesia.
Positioning
Cardiac output is influenced by the position of the woman during labour and
consequently those with cardiac disease are particularly sensitive to aortocaval
compression by the gravid uterus if adopting the supine position. I t is recommended
that midwives encourage an upright or left lateral position for women to adopt during
labour and birth wherever possible (McLean et al 2013).
The second stage of labour
This should be short without undue exertion on the part of the woman. Prolonged
pushing with held breath (the Valsalva manoeuvre) should be discouraged as it can
further compromise the health of the woman with cardiac disease. S uch a manoeuvre
raises the intrathoracic pressure, forces the blood out of the thorax and impedes
venous return, resulting in a fall in cardiac output. The midwife should therefore
encourage the woman to breathe as normal and follow her natural desire to bear down
giving several short pushes during each contraction.
A n instrumental birth using forceps or ventouse may be undertaken to shorten the
second stage of labour. Care should be taken, however, when the woman is in the
lithotomy position, where the lower part of the body is higher than the trunk, as this
produces a sudden increase in venous return to the heart, which may result in heart
failure. A wedge should therefore be used to avoid aortocaval compression (McLean
et al 2013).
The third stage of labour
A n active third stage of labour is usually advocated with a slow I VI of 2 U/min
oxytocin administered after the birth of the placenta to avoid systemic hypotension
and prevent haemorrhage (see Chapter 18). Prostaglandin F analogues are useful to
treat PPH, unless an increase in pulmonary artery pressure (PA P) is undesirable.
Ergometrine is contraindicated in women with cardiac disease as it can cause
vasoconstriction and hypertension (Regitz-Zagrosek et al 2011).
Postnatal care
The first 48 hours following the baby's birth are critical for the woman with significant
cardiac disease. The heart must be able to cope with the extra volume of blood
(autotransfusion) from the uterine circulation as well as the increased venous return
following relief of aortocaval compression of the uterus. Conversely, the total blood
volume may be diminished by the amount lost at birth and during the postnatal
period. Furthermore, the heart will need to compensate should the blood flow be
impaired due to PPH. Close monitoring of haemodynamic changes is required at this
time and the midwife should identify early signs of infection, thrombosis or
pulmonary oedema. O bservation of the condition of the woman's legs, the use of
antiembolic stockings and early ambulation are important strategies for the midwife
to adopt in order to reduce the risk of thromboembolism.
Breastfeeding should be encouraged as cardiac output is not affected by lactation,
although drug therapy for specific heart conditions may need to be reviewed for safety
during breastfeeding. The midwife is required to provide the woman with support to
successfully breastfeed her baby, emphasizing the importance of adequate rest and a
dietary intake containing sufficient calories to sustain breastfeeding.
It is important that prior to transfer from hospital, the midwife explores the help and
support available in the home for when the woman returns home with her baby.
Relatives and friends often fulfil this need but community support services should
also be considered if necessary. I n addition, the midwife should offer appropriate
contraceptive advice and the options available to the woman who has cardiac disease,
considering their individual risks need to be balanced against the risk of pregnancy
(RCOG 2011b).
Congenital heart disease
The most common congenital heart diseases (CHD ) found in pregnancy are atrial
septal defect (A S D ), ventricular septal defect (VS D ), patent ductus arteriosus (PD A)
pulmonary stenosis, aortic stenosis and tetralogy of Fallot. The majority of these
lesions should have been surgically corrected in childhood, resulting in a growing
population of women with CHD achieving a pregnancy. Uncorrected lesions may
cause pulmonary hypertension, cyanosis and severe left ventricular failure and are
therefore present a greater risk in achieving successful pregnancy outcome.
Congenital heart disease is also associated with increased fetal complications such as
fetal loss, I UGR, pre-term birth and an increased risk of fetal CHD Regitz-Zagrosek
(
et al 2011). Particularly high-risk cardiac conditions for pregnancy include the
following.
Eisenmenger's syndrome
A large left–right shunt of blood is apparent usually through a VS D , A S D or PD A
which is still patent. This results in an increase in the pulmonary blood flow, which
over time leads to fibrosis and the development of pulmonary hypertension and
cyanosis (Regi -Zagrosek et al 2011). W hen the right-sided heart pressures exceed left
heart pressures, the shunt reverses, with worsening cyanosis. W omen with this
condition are advised against pregnancy as maternal mortality lies in the region of 30–
50%. Risk of prematurity contributes to the high perinatal mortality rate.
Marfan syndrome
This syndrome is caused by an autosomal dominant defect on chromosome 15. I t is a
connective tissue disease affecting the musculoskeletal system, the cardiovascular
system and eyes. The cardiovascular abnormalities are the most life-threatening as the
elastic fibres in the media of the blood vessels weaken. Dilatation of the ascending and
descending aorta results, followed in some instances by dissection or rupture, or both.
Pregnancy poses a significant risk because of the increased stress on the
cardiovascular system. There is a 50% chance of a child inheriting Marfan syndrome if
one parent is affected. W omen who have minimal cardiovascular involvement and
normal aortic root dimensions have a better pregnancy outcome. Careful monitoring is
required throughout pregnancy, including the use of serial echocardiography to
identify progressive aortic root dilatation. Prophylactic antihypertensive therapy using
beta-blockers is recommended to reduce blood pressure and the rate of aortic
dilatation (Roberts and A damson 2013). S ome individuals with Marfan syndrome also
present with dural ectasia which, unless mild, presents an increased risk of a spinal
cerebrospinal fluid (CS F) leak in the case of accidental dural puncture during epidural:
consequently, epidural anaesthesia is not usually recommended. W hilst Marfan
syndrome is a genetic condition, approximately 15% of cases are as a result of new
mutation and thus some individuals remain undiagnosed and do not seek any
preconception counselling. Pregnant women with Marfan syndrome should be
referred to the specialist team containing a cardiologist for immediate assessment and
investigation (RCOG 2011b).
Aortic dissection (acute)
A ortic dissection (acute) may occur in pregnancy in association with severe
hypertension (systolic >160 mmHg) due to pre-eclampsia, coarctation of the aorta or
connective tissue disease such as Marfan syndrome. The woman typically presents
with severe chest or intrascapular pain. Early diagnosis using computed tomography
chest scan, MRI or transoesophageal echocardiogram is critical, as maternal mortality
is high.
Acquired heart disease
Rheumatic heart disease
Rheumatic heart disease causes inflammation and scarring of the heart valves and
results in valve stenosis, with or without regurgitation. The mitral valve is most often
affected with stenosis, occurring in two-thirds of cases. This condition is often
diagnosed for the first time during pregnancy, presenting as severe breathlessness
and tiredness. I t tends to appear in immigrant or refugee women who have not had
access to medical care. Most women with valvular heart disease can be treated
medically, aiming to reduce the heart's workload.
D uring pregnancy, this involves bed rest, oxygen therapy and the use of cardiac
drugs, e.g. diuretics (to reduce the fluid load), digoxin (to reduce and regulate the heart
rate) and heparin (to reduce the risk of thromboembolic disease). W omen with more
severe symptomatic disease may require surgical intervention such as balloon
valvuloplasty or valve replacement, although both of these procedures carry a degree of
maternal and fetal mortality. A ntibiotic prophylaxis is no longer recommended for all
women with valvular lesions during labour although it may still be advisable for those
who have mechanical valves.
Myocardial infarction and ischaemic heart disease
Myocardial infarction (MI ) and ischaemic heart disease (I HD ) are an increasing cause
of maternal death in the UK. I dentifiable risk factors include increasing maternal age,
obesity, diabetes, pre-existing hypertension, smoking, family history and poor
socioeconomic status. A myocardial infarction is most likely to occur in the third
trimester of pregnancy and the peripartum period, when haemodynamic changes are
at their optimum creating a higher risk of thrombotic events due to the
hypercoagulability induced by hormonal changes. I n the immediate postpartum
period, spontaneous coronary artery dissection is the most common cause of MI .
Typically, women present with ischaemic chest pain in the presence of an abnormal
ECG and elevated cardiac enzymes, although these signs and symptoms may be
masked during labour and birth (McLean et al 2013). Atypical features include
abdominal or epigastric pain and vomiting. Coronary angioplasty is the fine line
therapy to improve the patency of blocked arteries (Roberts and Adamson 2013).
Peripartum cardiomyopathy
Peripartum cardiomyopathy is relatively rare but is potentially fatal, with mortality
rates ranging from 25% to 50%. A number of these deaths occur shortly after the onset
of signs and symptoms. The incidence of this type of cardiac disease varies from 1 : 300
to 1 : 4000 pregnancies, with heart failure developing very rapidly in some cases.
Predisposing factors to peripartum cardiomyopathy comprise of multigravidae,
multiple pregnancies, family history, ethnicity, smoking, diabetes, hypertension, pre-
eclampsia, malnutrition, pregnant teenagers or older pregnant women and prolonged
use of beta-agonists (Mclean et al 2013).
Commonly women have no previous history of heart disease and diagnosis is
usually made within a specific period of time between the last month of pregnancy
and the first 5 months postpartum. I nflammation and enlargement of the myocardium
(cardiomegaly) give rise to left ventricular heart failure and thromboembolic
complications. Presenting features include orthopnoea and dyspnoea, chest pain and
palpitations, new resurgent murmurs and pulmonary crackles, raised jugular pressure,
ankle oedema and fatigue. Treatment involves the use of oxygen, diuretics, and
vasodilators to decrease pulmonary congestion and fluid overload, followed by
inotropic agents to improve myometrial contractility and anticoagulation therapy. A s
the cardiomegaly resolves there should be a corresponding improvement in the
woman's condition but this process may take up to 6 months and there is a risk of
recurrence in a subsequent pregnancy. I n some women, left ventricular dysfunction
persists and unless a heart transplant is performed mortality can be high (Regitz-
Zagrosek et al 2011).
Respiratory disorders
Asthma
A sthma is a chronic disorder of the respiratory system entailing an inflammatory
hyper-responsiveness of the airways to certain triggers (see Box 13.12). This causes
episodic narrowing, resulting in obstruction of the airways and mucous production
(Tortora and D errickson 2010). A sthma is characterized by intermi ent episodes of
wheezing and shortness of breath as the individual a empts to inhale and exhale.
These symptoms are variable and can be worse at night (S cullion et al 2013). The
condition is under-diagnosed in female adolescents (Holmes and S cullion 2011). Key
statistics reveal the extent of the problem in the UK:
• Asthma is the most common symptomatic long-term condition in the UK, affecting
5.4 million people, 1.1.million of whom are children (NICE 2013a)
• There are around 1000 deaths per year from asthma, about 90% of which are
associated with preventable factors and 40% of these deaths being in individuals
under 75 years of age.
• Of the nine maternal deaths attributed to respiratory disease in the triennium 2006–
2008, there were five women dying from asthma (0.22/100 000 maternities), which is a
similar rate to the two preceding reports (de Swiet et al 2011).
Box 13.12
T rigge rs for a st hm a
• Pollen and house dust mite allergens
• Chronic nasal rhinitis
• Smoking: primary and passive
• Infection
• Occupational exposure
• Pollution
• Cold air and physical exercise
• Food additives, e.g. monosodium glutamate, tartrazine and sulphites
• Drugs, e.g. aspirin
• Premenstrual conditions and pregnancy
Source: Tortora and Derrickson 2010; Scullion et al 2013
Investigations include:
• peak expiratory flow measurements using a small hand-held device (peak flow meter) to
assess the speed by which air is exhaled
• spirometry via a spirometer to measure the volume and speed of air exhaled
• allergy testing
• chest X-ray to exclude other conditions
• steroid trial: 2 weeks of oral prednisolone or 6 weeks of an inhaled corticosteroid.
Treatment follows a stepwise approach and initial therapy will depend on the
severity of the presentation. S ome individuals may only require salbutamol for
occasional symptoms, whereas others may commence on two inhalers (BTS [British
Thoracic Society]/SIGN 2011):
• corticosteroid inhaler (e.g. betclometasone dipropionate), twice a day: usually colour-
coded brown or orange and described as a preventer inhaler
• bronchodilator inhaler/beta-2 agonist (e.g. salbutamol), when required: colour-coded
blue and described as a reliever inhaler.
Further treatment may involve long acting beta-2 agonists, theophyllines,
leukotriene antagonists and, in extreme cases, oral corticosteroids (Holmes and
Scullion 2011).
I n pregnancy, women are at increased risk of delivering low birth weight and
preterm babies and have a greater tendency to other medical complications such as
pre-eclampsia (S cullion et al 2013). They should be advised of the importance of good
control of their asthma to avoid problems for themselves and the baby and that
medication used to control asthmatic symptoms is generally safe in pregnancy
(Scullion et al 2013). These include:
• short- and long-acting beta-2 agonists
• inhaled steroids
• oral theophyllines
• leukotriene antagonists: if they are already being used, these should continue, but
should not be commenced as a new therapy
• steroid tablets: indicated for severe asthma and exacerbations and should never be
withheld because of pregnancy (BTS/SIGN 2011).
I n addition, pregnant women should be encouraged to cease smoking and avoid
passive cigarette smoke.
S evere acute asthma, also termed status asthmaticus or asthma a ack , occurs when
there is spasm of the smooth muscle in the walls of the smaller bronchi and
bronchioles leading to partial or complete obstruction of the airways, known as
bronchoconstriction. This manifests with periods of coughing, wheezing and difficulty
with exhalation. A ir may become trapped in the alveoli during exhalation. Excessive
secretion of mucous may obstruct the bronchioles and worsen the a ack. This is a
medical emergency and pregnant women should be treated in hospital.
High flow oxygen should be administered immediately to maintain saturations
between 94 and 98%, a systemic corticosteroid given and inhaled short-acting beta-2
agonists administered via a large volume spacer or nebulizer (BTS /S I GN 2011 ). I f the
response is poor, inhaled ipratropium bromide may be given and arrangements made
to transfer the woman to the ICU/HDCU for ventilatory support.
The labour of a woman whose asthma is well controlled may progress
physiologically, supported by the midwife. Those women who have been receiving oral
steroids may require hydrocortisone during labour. I f anaesthesia is required, epidural
is preferable to general anaesthesia. I f ergometrine and syntometrine are used to
control blood loss following the birth of the placenta, extreme caution should be taken
to reduce the risk of inducing bronchoconstriction (BTS /S I GN 2011 ; S cullion et al
2013). Breastfeeding should be encouraged and the woman should continue to take all
prescribed medication for her asthma during lactation.
Thromboembolic disease
Thromboembolic disease is of considerable importance to midwifery practice because
of the associated maternal mortality. A lthough maternal mortality a ributed to
thromboembolic disease has declined in the UK over recent years, it remains the third
leading cause of direct maternal death with 18 deaths occurring in the last triennial
report, 2006–2008 (D rife 2011). The pregnant woman has a ten-fold increased risk of
developing venous thromboembolism (VTE) compared with the non-pregnant
population, which rises to 25-fold in the puerperium (Clark et al 2012).
Thromboprophylaxis in pregnancy
This is the prevention of thromboembolic disease and is an important part of the
midwife's role. There are additional risk factors for VTE in pregnancy and theRCOG
(2009) provides a risk assessment scale, as summarized in Box 13.13.
Box 13.13
R isk fa ct ors for ve nous t hrom boe m bolism
Pre-existing factors
• Previous VTE
• Family history of VTE (e.g. deficiency of protein C or S, antithrombin
deficiency, prothrombin gene variant, Factor V Leiden)
• Known thrombophilia
• Lupus anticoagulant
• Medical co-morbidities (e.g. sickle cell disease, cardiac disease,
proteinuria >3 g/day)
• Age >35 years
• Obesity (BMI >30 kg/m2)
• Parity >3
• Smoking
• Intravenous drug user
• Varicose veins
Obstetric factors
• Pre-eclampsia
• Dehydration/hyperemesis gravidarum
• Multiple pregnancy
• Caesarean section or forceps delivery
• Prolonged labour
• Postpartum haemorrhage
Transient factors
• Systemic infection
• Paraplegia or immobility
• Recent surgical procedure
• Ovarian hyperstimulation syndrome
• Travel >4 hours
Pregnant women with three or more risk factors should receive prophylactic low
molecular weight heparin (LMWH).
Source: RCOG 2009, 2010a
Most UK N HS Trusts will have a risk assessment based on the criteria inBox 13.13.
The midwife should perform and document this risk assessment on the following
occasions:
• initial meeting with the woman (booking visit)
• any hospital admission
• following the birth of the baby.
I f this assessment identifies women at risk of developing VTE, the midwife should
promptly refer her to a consultant-led maternity unit with an expert in thrombosis in
pregnancy (Ellio and Pavord 2013). The woman is likely to be commenced on
subcutaneous injections of low molecular weight heparin (LMW H), as this does not
cross the placental barrier with consequential effects on the fetus. The midwife, or
specialist nurse, should educate the woman in self-administration of the heparin,
alerting her to carry a medical alert card containing such details with her at all times.
The woman should be provided with a sharps bin for safe disposal of the injection
devices.
Gradient compression stockings or TED stockings are likely to be prescribed. S uch
stockings are available in two lengths, below the knee or thigh, and are designed to
give a pressure gradient from the ankle to the knee or thigh that mimics the pumping
action of the deep leg vein calf muscles, with the highest pressure being at the ankle.
I t is important that the woman is measured correctly around the ankle and calf or
thigh circumference depending upon the type of stocking prescribed (Llewelyn 2013).
Midwives should be trained in their use to be able to instruct the woman how to wear
them correctly and monitor their use (Ellio and Pavord 2013). For hygiene purposes,
stockings should be removed daily, but this should be no more than 30 minutes. The
legs should be inspected and measured by the midwife every three days to detect any
changes in size or tissue damage (Llewelyn 2013).
The woman should be given advice about avoiding dehydration, ceasing smoking
and eating a healthy diet (Copple and Coser 2013). I f the pregnant woman is expecting
to travel long distances, especially by air, she will benefit by wearing loose fi ing
clothing and flight socks (TED stockings), drinking plenty of water, avoiding alcohol
and remaining ambulant for as long as possible/performing leg exercises when at rest
(Elliott and Pavord 2013).
D uring labour, the midwife should encourage mobility with regular changes of
position and passive leg exercises when the woman is at rest. I t is important that
hydration is maintained and regular observations are undertaken, including frequent
examination of the woman's legs. I f the woman has been prescribed LMW H in
pregnancy, this should be omi ed at the onset of contractions and regional
anaesthesia avoided within 12 hours of the last administered dose. There should be
active management of the third stage of labour with the oxytoxic drug being
administered I V. I f perineal suturing is required, the midwife should undertake this
promptly to avoid the woman being in the lithotomy position for a prolonged time, as
this further increases the risk for deep vein thrombosis (D VT). I f surgery is necessary,
intermittent calf compression will be required in theatre.
The postnatal period presents further risk to the woman for both D VT and
pulmonary embolism (PE), and early mobilization should be encouraged. Routine
postnatal observations are important, especially respiration rate and the development
of any leg swelling. I f either condition is suspected the woman must be referred
urgently to a haematologist, or if at home she must be re-admitted to hospital.
Deep vein thrombosis
A blood clot formed within a blood vessel is termed a thrombus, which can become
detached and lodge in another blood vessel and partially or wholly occlude it.
Virchow's triad (see Fig. 13.1) outlines predisposing factors for thrombus formation
(Bagot and Arya 2008).
FIG. 13.1 Virchow's triad (after Bagot and Arya 2008).
I n pregnancy, Virchow's triad is affected by the physiological changes to the
haematological system (Greer et al 2007) (see Chapter 9). D espite pregnancy
presenting a state of hypervolaemia, by term hypercoagulability also develops to
compensate for the demands of the forthcoming labour and maintenance of
haemostasis. I n addition, there is relative venous stasis with a gradual 50% reduction
in venous flow velocity, reaching its peak at 36 weeks and declining to pre-pregnancy
values by 6 weeks following the baby's birth (Greer et al 2007). Furthermore, the
physical effect of the gravid uterus exerts pressure on the pelvic veins and the inferior
vena cava, increasing the woman's risk of developing a D VT in the veins of the calf,
thigh and pelvis (Elliott and Pavord 2013).
I n pregnancy, 90% of D VT occur in the left leg compared with 55% in the non-
pregnant woman due to compression of the left iliac vein by the left iliac artery in
pregnancy (Clark et al 2012). The ileofemoral veins are the most common location,
having 70% of pregnancy occurrences versus 9% in the non-pregnant woman, and are
more likely to result in pulmonary embolism (Clark et al 2012).
The complications of D VT arepulmonary embolism (PE) and post-thrombotic syndrome
arising from damage to the venous valves that result in a backflow of blood, venous
hypertension, oedema and tissue hypoxia (Elliott and Pavord 2013). The midwife needs
to be aware of the signs of D VT (listed below) as she may be the first person to
identify this when undertaking an antenatal or postnatal examination on the woman:
• pain in the area of the clot
• swelling (usually one-sided)
• red discoloration
• difficulty in weight-bearing on the affected leg
• low grade pyrexia
• lower abdominal or back pain.
I f the leg appears swollen a tape measure should be used to assess the
circumference of both legs at the affected area for comparison. A D VT is potentially
life threatening and the midwife must refer the woman immediately to hospital for
medical examination, investigation and treatment (RCO G 2010a). The classic
diagnostic use of dorsiflexion of the foot (H oman's sign) is considered unreliable in
pregnancy and the presence of severe lower back pain has greater significance (James
et al 2011). Medical investigations involve D oppler ultrasound and serum
investigations might be performed; however, Ellio and Pavord (2013) debate the
usefulness of measuring D -dimers levels in pregnancy. Venography is generally
avoided in pregnancy due to the small radiation risk to the fetus.
Treatment of D VT in pregnancy is with LMW H administered 12-hourly by
subcutaneous injection to sustain the levels, and which should continue for at least 6
months after the diagnosis. Gradient compression stockings should be prescribed and
the woman taught how to put them on. The woman will need to wear one on the
affected leg for two years to reduce the risk of post-thrombotic syndrome (Ellio and
Pavord 2013). A nticoagulation therapy should continue for at least 6 months after the
diagnosis (RCOG 2010a).
The woman should be seen by the anaesthetist prior to labour to discuss the risks
that thromboembolic disorders have on the administration of regional/general
anaesthesia. A s soon as labour commences, heparin should be omi ed and
compression stockings should be worn. A s regional anaesthesia carries a risk of spinal
bleeding, this should be avoided within 12 hours of administration of heparin.
A lthough general anaesthetic is itself a thrombotic risk, it may have to be considered
for caesarean section. The woman should be encouraged to remain mobile or
undertake passive leg exercises and maintain hydration. A n I VI should be sited, and
drugs given I V instead of intramuscularly (I M). Prolonged use of the lithotomy
position should be avoided, as this is a D VT risk. The third stage of labour should be
actively managed with the oxytoxic drug being administered I V to prompt
haemostasis. I f perineal suturing is required, it should be undertaken promptly to
limit the length of time the woman is in the lithotomy position (RCO G 2010a; Elliott
and Pavord 2013).
The midwife should be aware that there is a 25-fold increased risk of D VT and the
potential for PE during the postnatal period. A s a consequence, the woman who has
had a previous D VT is especially at high risk and thus the midwife is required to be
particularly vigilant is assessing her condition, encouraging early ambulation and
hydration. Heparin is recommenced as directed by the medical team. This is usually 2
hours after a vaginal birth or longer if the woman had an epidural and/or caesarean
section, and should continue until at least the 6-week postnatal appointment, at which
point a decision to change to warfarin may be made (RCO G 2010b; Ellio and Pavord
2013). O estrogen-based contraceptive pills are contraindicated so depo-provera or
barrier methods of contraception should be discussed with the woman and her
partner.
Pulmonary embolism
Pulmonary embolism (PE) occurs when a D VT detaches and becomes mobile, known
as an embolus. A large embolus might lodge in the pulmonary artery and smaller ones
can travel distally to small vessels in the lung periphery, where they may wholly or
partially occlude the blood vessel (J ames et al 2011; Ellio and Pavord 2013). I nitially
the lung tissue is ventilated but not perfused, producing intrapulmonary dead space,
and there is impaired gaseous exchange (Kumar and Clarke 2004). A fter some hours,
surfactant production by the affected lung ceases, the alveoli collapse and hypoxaemia
results. Pulmonary arterial pressure rises and there is a reduction in cardiac output.
The area of the lung affected by the embolism may become infracted; however, in
some instances, oxygenation of tissue continues to some extent from the bronchial
circulation and airways (Kumar and Clarke 2004).
I n the case of a small embolism, there is likely to be dyspnoea, discomfort or pain in
the chest, haemoptysis and low grade pyrexia, all of which can be misdiagnosed as a
chest infection. Cardiovascular examination is usually normal (Kumar and Clarke 2004;
James et al 2011).
A larger embolism that occludes a major vessel will result in a more acute
presentation, because of sudden obstruction of the right ventricle and its outflow
(Kumar and Clarke 2004). There is severe central chest pain due to ischaemia, and
pallor with sweating as shock develops. Tachycardia occurs and a gallop rhythm of the
heart may be heard on examination. Hypotension develops as peripheral shutdown
occurs. S yncope may result when cardiac output is suddenly reduced (Kumar and
Clarke 2004). A dmission to an intensive care unit is highly likely as there is a
significant risk of death if treatment is delayed.
Pulmonary embolism is a medical emergency and urgent referral to hospital is
indicated. D iagnosis is made from a combination of clinical probability score and
radiological imaging. Heparin, usually LW MH, is commenced at presentation with
subsequent anticoagulation treatment and management in labour and the postnatal
period being similar to that for a woman presenting with D VT (E llio and Pavord
2013).
Disseminated intravascular coagulation (DIC)
I n D I C (also known as disseminated intravascular coagulopathy), damage to the
endothelium (lining of blood vessel walls) arising from pre-eclampsia, placental
abruption, major haemorrhage, embolism, intrauterine fetal death or retained
placenta results in thromboplastins being released from the damaged cells, causing
the extrinsic pathway to mount a coagulation cascade. Blood clo ing occurs at the
original site and then small clots (micro-thrombi) disperse throughout the rest of the
vascular system. Large quantities of fibrinogen, thrombocytes (platelets) and clo ing
factors V and VI I I are consumed. The micro-thrombi produced can occlude small
blood vessels, resulting in ischaemia, hence some organ tissue dies and releases more
thromboplastins and the cycle re-commences. A ll clo ing factors and platelets are
subsequently consumed and bleeding results. There is simultaneously widespread
blood clo ing and a clo ing deficiency. Bleeding occurs, petechiae develop in the skin
and, if untreated, major haemorrhage can result (Kumar and Clarke 2004; Craig et al
2006).
Haematological disorders
Anaemia
A naemia is a condition in which the number of red blood cells or their oxygen-
carrying capacity is insufficient to meet the physiological needs of the individual,
which consequently will vary by age, sex, altitude, smoking and pregnancy status
(W HO 2013). I n its severe form, it is associated with fatigue, weakness, dizziness and
drowsiness, pregnant women and children being particularly vulnerable (W HO 2013).
A naemia in pregnancy is defined as a haemoglobin (Hb) concentration of less than
11 g/dl (James et al 2011).
Physiological anaemia of pregnancy
The increase of blood plasma in pregnancy causes a state of haemodilution (see
Chapter 9). O n laboratory testing, the Hb values decline, reaching the lowest in the
second trimester followed by a gradual rise in the third trimester. This situation is not
pathological unless the Hb reduces to such an extent that iron deficiency anaemia
results.
Iron deficiency anaemia
I ron deficiency is thought to be the most common cause of anaemia globally and is
defined by trimester, as shown in Table 13.4 (WHO et al 2001; NICE 2013b).
Table 13.4
Anaemia defined by trimester
Trimester Serum ferritin concentration Haemoglobin
1 <30 µg/l <11 g/dl
2 and 3 <30 µg/l <10.5 g/dl
The daily iron requirement for a healthy woman is 1.3 mg, which can be acquired
through a diet rich in iron and folate. I n pregnancy this requirement rises to 3 mg per
day, further increasing to 7 mg per day after 32 weeks (A ddo et al 2013). Prophylactic
antenatal iron supplementation is no longer administered routinely in the UK, unless
the woman is at risk of developing iron deficiency anaemia.
Iron deficiency is associated with:
• reduced intake of iron due to gastric malabsorption, gastric surgery or dietary
deficiency
• short intervals between pregnancies
• chronic infection such as malaria or human immunodeficiency virus (HIV)
• chronic blood loss, e.g. menorrhagia or gastric ulcer
• haemorrhage
• secondary cause to medical disorders
• multiple pregnancy.
Iron deficiency interferes with body functions, leading to:
• tiredness
• irritability and depression
• breathlessness
• poor memory
• muscle aches
• palpitations
• cardiac failure
• maternal exhaustion in labour
• poor recovery from blood loss at the birth and during the postnatal period.
Routine serum blood samples should be taken from healthy pregnant women at
intervals during the antenatal period according to local protocols for the early
identification of anaemia. W hen anaemia is identified serum ferritin should be
measured as an indication of the level of stored iron. I t is recommended that women
with known anaemia be screened at every antenatal appointment (A ddo et al 2013).
Borderline anaemia can be managed in the community se ing, however severe or
chronic cases should be referred to a consultant-led maternity unit as should those
women who are symptomatic (Addo et al 2013).
The initial treatment is with iron tablets, such as Pregaday®, one tablet per day for 2
weeks. The woman should be advised to take the tablet 1 hour before food with orange
juice, which contains ascorbic acid (vitamin C) to aid absorption of the iron.
Unfortunately many brands of oral iron tablets have unpleasant gastric side-effects
which reduce maternal compliance in taking them. S erum Hb estimation is
undertaken after 2 weeks, and if the Hb appears to be rising, the woman should
continue taking the iron tablets. However, if the Hb does not rise or there is
intolerance or poor compliance, the woman should be referred to a haematology clinic
for further management. A dditional investigations may be undertaken to determine
the cause of the anaemia and other oral iron, such as ferrous sulphate (200 mg 2–3
times daily) may be prescribed. I f there is still intolerance to oral iron, then parenteral
iron injections will be offered. These injections, however, are uncomfortable and can
cause iron staining on the skin, so the z-track injection method should be used. Blood
transfusion is used only in extreme cases during pregnancy (Addo et al 2013).
I f the anaemia persists then the woman should be assessed regarding her risk for
haemorrhage. A n I VI should be sited in labour and blood samples taken for full blood
count (FBC) and for group and save. The FBC results should be reviewed before the
woman either eats or drinks. The midwife should be alert for signs of maternal
exhaustion during labour with active management of the third stage of labour being
undertaken, and all perineal trauma should be sutured to minimize the effects of
blood loss at the time of the birth.
I n the postnatal period the woman with anaemia is at risk of infection, postpartum
haemorrhage, depression and poor wound healing. The midwife should observe and
support her accordingly and ensure that a FBC blood sample is taken to identify
further treatment requirements. Contraceptive advice should be given for adequate
spacing of pregnancies along with dietary advice and a follow-up appointment. The
FBC will also need repeating at the 6 week postnatal examination.
Folic acid deficiency
Folic acid is part of the vitamin B complex. I n pregnancy it is necessary for effective
cell growth and synthesis of ribonucleic acid (RN A) and deoxyribonucleic acid (D N A)
especially the embryo, and a deficiency is associated with neural tube defects in the
fetus. D eficiency can be due to multiple pregnancy, poor diet, adverse social
circumstances and may arise secondary to drug therapy such as antiepileptic drugs
(A ED s). The average daily folate requirements rise in pregnancy from 50 to 400 µg/day
(Addo et al 2013). A lthough this can usually be met through a healthy diet, women are
encouraged to take prophylactic folic acid 400 µg/day (0.4 mg) routinely in the first
trimester, which should be increased to 5 mg if the woman is also taking A ED s or
other drugs affecting folate metabolism. Chronic maternal folate deficiency can lead to
megaloblastic anaemia (Greer et al 2007).
Megaloblastic anaemia
Megaloblastic anaemia refers to an abnormality of the erythroblasts in the bone
marrow in which the maturation of the nucleus is delayed due to defective D N A
synthesis resulting in the production of larger than normal red blood cells
(macrocytosis). This arises from a deficiency of either of two B vitamins, folic acid and
cyanocobalmin (B12), both of which are necessary for D N A synthesis K( umar and Clark
2004). A deficiency of vitamin B12 alone is termed pernicious anaemia. O ne third of
pregnancies worldwide are affected by megaloblastic anaemia, but the UK incidence is
low at 0.5%. Megaloblastic anaemia is secondary to dietary deficiency (especially a
vegan diet), alcoholism; gastrointestinal surgery, autoimmune disease, medical
disorders, especially sickle cell disease, and drug therapy, e.g. azathioprine ( Kumar
and Clark 2004; NICE 2013).
D iagnosis is made through taking a detailed history from the woman, undertaking a
physical examination and investigations including a FBC, blood film and assessing
serum concentrations of vitamin B12 and folate. I f vitamin B12 deficiency is evident,
serum anti-intrinsic factor and antiparietal cell antibodies should be examined. I f
folate levels are low, tests for anti-endomysial or anti-transglutaminase antibodies are
likely to be performed (NICE 2013). Treatment is determined according to the identity
of the underlying cause. S upplements of folic acid and cyanocobalamin will be
prescribed as necessary, and a referral to a dietician may be necessary.
The midwife has an important role in identifying at-risk women and referring them
to appropriate personnel, encouraging compliance with medication and providing
dietary advice.
Haemoglobinopathies
Haemoglobinopathies are a group of inherited conditions with abnormalities of the
Hb. Haemoglobin consists of a group of four molecules, each of which as a haem unit
made up of an iron porphyrin complex and a protein or globin chain. A total of 97% of
adult Hb (HbA) has two α- and two β-chains and the remaining 3% is composed of two
α- and two δ-chains. Fetal Hb (HbF) has two α- and two γ-chains, the la er being
gradually replaced by the β-chain by around the age of 6 months. The type of globin
chain is genetically determined and defective genes lead to the formation of abnormal
haemoglobin. This may be as a result of impaired globin synthesis (thalassaemia
syndromes) or from structural abnormality of globin (haemoglobin variants such as sickle
cell anaemia). Haemoglobinopathies mainly affect people from A frica, West I ndies,
A sia, the Middle East and the eastern Mediterranean and the theory is that the carrier
state offers some protection against malaria (Greer et al 2007).
Thalassaemia
There are different types of thalassaemia depending upon which haemoglobin chain
has been affected: α -chains are formed by two genes from each parent whereas β-
chains are formed by one gene from each parent. I n α-thalassaemia, the production of
α-globin is deficient and in β-thalassaemia the production of β-globin is defective. The
classifications are:
α-thalassaemia
• Normal: genotype = α/α, α/α.
• α+-thalassaemia heterozygous: genotype = α/−, α/α. One defective α gene. Borderline
Hb level and mean corpuscular volume (MCV), low mean corpuscular Hb (MCH):
clinically asymptomatic.
• α+-thalassaemia homozygous: genotype = α/−, α/−. Two defective α genes. Slightly
anaemic, low MCV and MCH; clinically asymptomatic. This is known as thalassaemia
trait and is associated with Africans.
• αo-thalassaemia heterozygous: genotype = α/α, −/−. Two defective α genes. Slightly
anaemic, low MCV and MCH; clinically asymptomatic. This is also known as
thalassaemia trait and is associated with Asians.
• Haemoglobin H disease (HbH): genotype = α/−, −/−. Three defective α genes. Mild to
moderate anaemia with very low MCV and MCH; splenomegaly and variable bone
changes.
• α-thalassaemia major: genotype = −/−, −/−. Four defective α genes. This type is also
known as Hb Bart's. It presents as severe non-immune intrauterine haemolytic
anaemia where the fetus has little circulating haemoglobin that is all tetrametric γ-
chains. As a result the fetus becomes oedematous: known as hydrops fetalis/Hb Bart's
hydrops, which is usually fatal (Addo et al 2013).
β-thalassaemia
• Normal: genotype = β2, β2.
• β-thalassaemia trait: genotype = −, β2. One defective β gene is inherited. HbA2 is >4%
and the individual presents with mild anaemia, a low MCV and MCH, but is clinically
asymptomatic.
• β-thalassaemia intermedia: genotype = −, βo or β+, β+. Both defective β genes are
inherited. This type presents with high levels of HbF which can fluctuate, resulting in
anaemia upon which symptoms usually develop when the haemoglobin level remains
below 7.0 g/dl, a very low MCV and MCH, splenomegaly and variable bone changes.
The dependency on blood transfusion to improve an individual's wellbeing is
variable.
• β-thalassaemia major: genotype = −o/−o. In this type, both defective β genes are also
inherited, but the Hb is comprised of >90% HbF (untransfused). As a result, the
individual presents with severe haemolytic anaemia, a very low MCV and MCH, and
hepatosplenomegaly, such that they are chronically dependent on frequent blood
transfusions (Addo et al 2013).
Diagnosis is made by identifying those at high risk and performing the following:
• full blood count that would reveal a low mean corpuscular haemoglobin (MCH
<27 pg) and a low mean cell volume (MCV <75 fl)
• bone marrow examination would reveal microcytic, hypochromic red blood cells
• haemoglobin analysis would reveal elevated HbA2 levels (Addo et al 2013).
Pre-conception care is important and genetic counselling may be required,
especially if there is inter-marriage of cousins. There is a 1 in 4 chance of a baby
inheriting a major condition if both parents are carriers (see Fig. 13.2).
FIG. 13.2 The inheritance of a haemoglobinopathy when both parents are heterozygous.
I n early pregnancy diagnostic tests are offered to the woman, consisting of D N A
analysis of chorionic villi and fetal blood sampling (A ddo et al 2013) with termination
of pregnancy being discussed should the fetus be adversely affected. A ntenatal care
should be provided within an obstetric unit where the woman can be assessed within a
combined clinic with a haematologist in a endance. The treatment would entail
regular assessment of FBC and serum ferritin. I ron is prescribed only if serum ferritin
levels are low as there is a risk of iron overload, which may lead to congestive cardiac
failure. Consequently, further investigations may be required to assess cardiac
function. Folic acid deficiency must be treated and dietary advice given by the midwife
(Addo et al 2013).
I f the woman has thalassaemia major she is at risk of pre-term labour, which might
be iatrogenic, as well as both maternal and fetal hypoxia in labour. I f the woman has
any bone deformities, caesarean section may be necessary. There should be
continuous fetal monitoring in labour and strict monitoring of blood pressure and
fluid balance. D ue to the risk of haemorrhage, it would be wise for the midwife to
facilitate active management of the third stage of labour.
D uring the postnatal period, the woman should be observed for signs of infection and
haemorrhage and any wound should be inspected for signs of poor healing.
Furthermore, the anaemia might worsen following the birth if the baby and tiredness
could also predispose to depression. The baby will require paediatric assessment prior
to transfer home from hospital and any follow-up appointments should be made to
monitor growth and development as well as determine the baby's thalassaemia status.
Sickle cell disease
S ickle cell disease refers to a group of disorders arising from defective genes that
produce abnormal Hb molecules (HbS ). D efective genes produce abnormal
haemoglobin α- or β-chains resulting in HbS . There are several variations and those of
most significance to the midwife are the homozygous sickle cell anaemia/sickle cell
disease (HbSS) and heterozygous sickle cell trait (HbAS).
Other variations can be summarized as follows.
• Sickle cell HbC disease (HbSC): double heterozygote for HbS and HbC with
intermediate clinical severity.
• Sickle cell βo -thalassaemia (HbS/βo ): severe double heterozygote for HbS and βo-
thalassaemia with no normal β-chains produced. It is almost clinically
indistinguishable from sickle cell anaemia.
• Sickle cell β+-thalassaemia (HbS/β+): In this type a reduced amount of chains are made
resulting in mild-to-moderate anaemia.
I n sickle cell anaemia (H bSS)the erythrocytes are fragile, with a short life span of 17
days, compared with 120 days in a healthy individual. The erythrocytes have a
characteristic crescent, or sickle, shape which blocks up the capillaries. This
predisposes to clot formation in the capillaries. D iagnosis is by Hb electrophoresis,
and identification of the abnormal sickle-shaped cells on a blood film. A bone marrow
biopsy may also be required. Treatment outside of pregnancy includes the
administration of 1 mg/day oral folic acid tablets, prophylactic penicillin,
thromboprophylaxis, iron chelation agents and exchange blood transfusion.
A sickle cell crisis arises when the sickle cells form clots in the capillaries resulting
in deoxygenation, and tissue death as a result of infarction. The crisis presents acutely
with severe pain, breathlessness, pallor, fever, joint swelling and pain, and general
weakness (A ddo et al 2013). The crisis can be triggered, or exacerbated, by infection,
cold temperature, dehydration, stress and exercise. O ther complications are chronic
anaemia, bone marrow suppression, thromboembolic disease, cardiac failure due to
chronic hypoxaemia and aplastic anaemia, as well as sudden death (Addo et al 2013).
Pre-conception care is important to optimize the health of the woman, during which
time the folic acid should be increased to 5 mg/day and iron chelation discontinued 3–
6 months prior to conception due to possible teratogenicity (A ddo et al 2013). I f the
woman has pulmonary hypertension, pregnancy is contraindicated due to the 50%
maternal mortality risk (Oteng-Ntim et al 2006).
I n pregnancy the woman's care should be shared between the obstetric and
haematology team, with appointments being made for every 2–4 weeks to assess
maternal and fetal wellbeing. The woman presenting with sickle cell anaemia is at risk
of experiencing a sickle cell crisis secondary to infection, pre-eclampsia, miscarriage,
I UGR, stillbirth and possible maternal death. I nvestigations include FBC, blood group
and antibody screen, reticulocyte count, serum ferritin levels, HI V and hepatitis
screening (because of history of blood transfusions) renal and liver function tests.
Folic acid should be increased to 5 mg/day if not done so pre-conceptually, and iron
supplements only given if indicated by serum ferritin results. A ntibiotic therapy may
need to be continued. I n the third trimester serial growth scans should be undertaken
(RCOG 2011c; Addo et al 2013).
I n labour an epidural is recommended for pain relief as opiates should be avoided.
Blood should be taken for FBC, group and save. Graduated compression stockings are
used to reduce the risk of VTE and the woman should be kept warm and hydrated to
prevent any sickle cell crisis from occurring. O xygen therapy might be required to
maintain adequate oxygenation and improve cardiac function. Prophylactic antibiotics
may be considered to reduce infection. A prolonged labour should be avoided and
active management or caesarean section may be advised depending on the woman's
health (RCO G 2011c; A ddo et al 2013). W here there is I UGR, continuous fetal
monitoring would also be recommended.
D uring the postnatal period, the midwife should be vigilant in her observations as
the woman is at increased risk of sickle cell crisis, thromboembolism and postpartum
haemorrhage. Prophylactic antibiotics and thromboprophylaxis should continue and
early mobilization is encouraged. Four-hourly observations should be undertaken,
including respiration rate. The woman should be advised about subsequent
pregnancies and the risk they carry in increasing the frequency of crises. I t is therefore
important that the woman uses appropriate contraception in order to maximize her
health as intrauterine contraceptive devices (I UCD s) are relatively contraindicated due
to the risk of infection. N eonatal screening of babies must be undertaken by obtaining
a capillary or venous sample of blood at birth. Those with a positive result require a
follow-up appointment and electrophoresis at 6 weeks, including prophylactic
antibiotic cover from 3 months of age (Addo et al 2013).
I n sickle cell trait (H bAS)the individual is usually asymptomatic. A lthough the sickle
screening test is positive, the blood appears normal. I n pregnancy the woman may
present with mild anaemia and so 5 mg/day folic acid is recommended to improve
erythropoiesis.
Neurological disorders
Epilepsy
Epilepsy is a common neurological disorder characterized by two or more seizures,
with a UK prevalence of 9.7 per 1000 (0.97%) and a reduction in life expectancy of 2–10
years. I t mainly presents in childhood, although there is a second peak of incidence in
older years and women of childbearing age account for 23% of the population affected
by epilepsy, with a prevalence in pregnancy of 0.35%.
Seizures result from a sudden excess of electricity to the brain disrupting the normal
message passing between the cortical neurons (brain cells). The messages become
mixed or halted, and a seizure results. These seizures can be subcategorized as partial
and generalized (McAuliffe et al 2013), as shown in Table 13.5.
Table 13.5
Categories of epileptic seizures
Source: Adapted from McAuliffe et al 2013
Complications associated with epilepsy are:
• Trauma occurring during the seizure and include tongue biting and head or limb
injury.
• Status epilepticus: a seizure lasting for >30 minutes, or a series of seizures without
regaining consciousness in between.
• Sudden Unexpected Death in Epilepsy (SUDEP) of which there is no cause found for the
sudden death.
• Maternal death: the risk of sudden maternal death in pregnancy remains higher in
women with epilepsy than those with other long-term conditions. A number of these
maternal deaths are classified as SUDEP.
Treatment is with antiepileptic drugs (A ED s) with monotherapy (one drug) or
polytherapy (two or more) if seizure control is more problematic. I n certain cases
surgery or vagus nerve stimulation might be used (McAuliffe et al 2013).
Pre-conception care is of paramount importance as many A ED s are associated with
folate deficiency and fetal abnormalities. The drug therapy may be changed to
monotherapy after careful counselling about the risks of teratogenicity to the fetus
and folic acid should be prescribed at an increased dose of 5 mg/day for 12 weeks prior
to conception (McAuliffe et al 2013).
Management in pregnancy presents challenges and this is a high-risk pregnancy
that requires referral and birth in a consultant obstetric unit. I t is important to involve
family and partners, as they may need to initiate first aid and safety measures as the
seizure risk increases by 15–37% (McAuliffe et al 2013). Folic acid of 5 mg/day should
be given throughout the first trimester, and if the woman is taking sodium valproate
this should continue for all three trimesters. W omen taking enzyme-inducing A ED s
will require oral vitamin K for 4 weeks prior to the baby's birth to decrease the risk of
fetal coagulopathy (McAuliffe et al 2013). A ntiepileptic drug levels should be
monitored at regular intervals and the drugs and dosage reviewed by the obstetric
team. The midwife should encourage the woman to comply with the prescribed
medication. I n addition advice should be given to avoid bathing alone and steamy
environments, and to keep bathroom doors unlocked in case of a seizure. S creening
for fetal anomalies should be discussed and then initiated after informed consent. A
detailed structural ultrasound scan is offered between 18 and 22 weeks of pregnancy.
For labour the midwife should discuss a realistic birth plan, and be aware that water
birth is contraindicated on safety grounds (McAuliffe et al 2013). The risk of tonic–
clonic seizure in labour is low at 1–2% but measures should be taken to react speedily
should a seizure result. The management principles for an epileptic seizure are the
same as for eclampsia (see Box 13.7). A nticonvulsant medication is continued
throughout labour and regular review by the obstetric team is indicated. I f seizures
recur, short-acting benzodiazepines are administered (McAuliffe et al 2013). The
woman should not be left alone in labour, and dehydration, hyperventilation and
exhaustion should be avoided as they can all trigger a seizure. S hould a seizure result,
the differential diagnosis of eclampsia needs to be considered (Lowe and S en 2005).
Pethidine is contraindicated as it is metabolized to norpethidine which can also induce
seizure, and either trans-electrical nerve stimulation (TEN S ) or epidural should be
considered as an alternative. The birth can be spontaneously facilitated by the
midwife. Following obtaining informed consent from the woman, vitamin K should be
administered to the baby promptly after birth to protect against A ED -induced
haemorrhagic disease (McAuliffe et al 2013).
I n the first 24 hours following the birth the woman has an increased risk of a seizure
and so should remain in hospital. Breastfeeding is encouraged and the medical team
and pharmacist should discuss suitable A ED s while lactating. The baby should be
carefully observed and any concerns reported to the paediatrician immediately.
A ntiepileptic drugs affect hormonal contraceptives and alternative contraception such
as barrier methods are recommended (see Chapter 27). A dvice should be given about
safety when caring for the baby in case of maternal seizure. The midwife should
encourage the woman to dress, change and feed the baby on a changing mat on the
floor to prevent falling during a seizure while a ending to the baby. I t is advisable
that the baby is bathed by the mother in shallow water when someone else is around
to assist if necessary and a carrycot or baby car seat should be used to carry the baby
up and down stairs. W hen parents choose a pram/buggy for their baby, the midwife
should advise them to ensure that they select one with brakes that initiate when the
handle is released.
Infection/sepsis
Genital tract sepsis
Genital tract sepsis is a major cause of maternal morbidity and mortality and
accounted for 29 deaths in the most recent triennial report, being the leading cause of
direct maternal deaths in the UK (Harper 2011). O f these deaths, three were classified
a s late direct deaths occurring more than 6 weeks after the baby's birth, albeit the
women became ill before or soon after they had given birth and so should be of great
concern to all health professionals undertaking maternity care.
Genital tract sepsis arises from polymicrobial infections, usually from streptococcal
bacteria, which can lead to overwhelming septicaemia that can affect not only the
wellbeing of the pregnant woman but also the fetus. S igns and symptoms include
pyrexia, swinging pyrexia and hypothermia, abdominal pain, diarrhoea, vomiting,
tachycardia and tachypnoea. A ll childbearing woman should be advised of the
possible signs and symptoms of infection at all stages and be encouraged to seek
advice promptly, to pay a ention to effective hygiene and be aware of the risk from
others , particularly any who have bacterial throat infections (Draycott et al 2011).
Candida albicans
Candida albicans is a yeast that causes itching, soreness and swelling of the genital area
producing a creamy-white vaginal discharge. I t is not strictly a sexually transmi ed
infection (S TI ) as it commonly occurs during pregnancy, following antibiotic therapy
and in individuals who have diabetes or a lowered immune system. I t is easily
diagnosed by a high vaginal swab (HVS ) and treatment in pregnancy is via topical
cream and/or vaginal pessaries, rather than via the oral route. Candida does not affect
fertility or pregnancy outcome, but the baby may develop oral or genital thrush. This
in turn may affect breastfeeding should candida be transferred to the breast while
feeding (Francis-Morrill et al 2004; Weiner 2006).
Chlamydia trachomatis
Chlamydia is the most commonly diagnosed S TI , especially in under 25-year-olds, and
is caused by the bacterium Chlamydia trachomatis. Between 70 and 80% of women
affected by chlamydia are asymptomatic. S igns and symptoms usually occur from 1 to
3 weeks following infection and include dysuria, vaginal discharge, lower abdominal
pain, post-coital and inter-menstrual bleeding, anal discharge, conjunctivitis, eye
infections and sore throats following anal or oral sexual practices. I f left untreated,
chlamydial infection can cause pelvic inflammatory disease (PI D ), which increases
infertility and the risk of miscarriage and ectopic pregnancy.
Methods of testing are varied and can include urine testing, low vaginal swab (self-
testing kits) and cervical swab. The N HS N ational Chlamydia S creening Programme
(2012) recommends annual screening for under 25-year-olds if sexually active.
Chlamydia can be transmi ed to the neonate during vaginal birth and can result in
neonatal eye infections and pneumonia. Treatment entails antibiotics such as
azithromycin.
Cytomegalovirus
Cytomegalovirus (CMV) is a common viral infection from theherpes family, which may
lie dormant and recur at a later time. I t is estimated that 50% of the adult population
has had the infection at some point in their lives. The virus causes a mild flu-like
illness and pregnant women have an increased susceptibility to infection during
pregnancy. However, primary infection in pregnancy is low, at around 1%. There is a
40% chance of transmission to the fetus causing congenital malformations such as
hearing loss, learning difficulties and cerebral palsy. A round 5–10% of infected babies
are symptomatic at birth and consequently their prognosis is poor. Furthermore, the
risk relative to gestation is unclear. A lthough antiviral drugs have been used to treat
CMV, there is currently no screening programme due to a lack of sensitivity in
pregnancy or evidence-based effective treatment interventions (UK National Screening
Committee 2012).
Gonorrhoea
Gonorrhoea is a common S TI in the UK, affecting the genital tract (especially the
cervix) and rectum. I t is transmi ed by sexual activity with an infected individual and
is caused by the bacterium N eisseria gonorrhoea. Most infected individuals are
symptomatic with signs and symptoms occurring 2–10 days after the initial contact.
S uch symptoms include painful micturition, yellow/bloodstained vaginal discharge
and post-coital bleeding.
I f untreated, in women it can cause PI D , giving rise to abdominal cramps, fever and
inter-menstrual bleeding, with an increased risk of ectopic pregnancy. I ndividuals are
also at a greater risk of acquiring HIV.
Testing for gonorrhoea is via urine and cervical swabs. More effective screening
programmes detect the genes of the bacteria, rather than try to culture the bacteria.
Treatment is with antibiotics, but drug resistance can be problematic. Gonorrhoea can
be transmitted to the neonate during vaginal birth and can result in eye infections.
Hepatitis A, B and C
Hepatitis comprises a group of blood-borne viruses that cause hepatocellular
inflammation and necrosis. They are found in bodily fluids, e.g. blood, saliva and
semen, and are often transmi ed via sexual activity, by sharing injecting equipment
and via the placenta to the fetus during pregnancy. Vaccination for hepatitis A and B
are available. Hepatitis B and C can lead to liver failure and death and are therefore
notifiable diseases in the UK.
Pregnant women are offered routine screening for hepatitis B during early
pregnancy and those at risk, e.g. sex workers, can be tested for hepatitis C. Any woman
found to have hepatitis B virus (HBV) should have further tests to determine whether
she is acutely or chronically infected; the presence of the e-antigen (HBeA g) denotes
high infectivity, while the presence of antibodies (antiHBe) suggest a lower infectivity.
D uring pregnancy women are counselled as to how they can reduce transmission and
infants should be given hepatitis B immunization and immunoglobulin with their
mother's consent, which can reduce vertical transmission by 90% (Watkins et al 2013).
Breastfeeding is not contraindicated, although the presence of cracked nipples is a
significant transmission risk.
Human immunodeficiency virus (HIV) and acquired
immune deficiency syndrome (AIDS)
The human immunodeficiency virus (HI V) is aretrovirus that weakens an individual's
immune system by invading the T4-helper cells making it difficult to mount an
immune response to infection. There are two types of HI V which belong to the
lentivirus subfamily of retroviruses that cause acquired immunodeficiency syndrome
(A I D S ). HI V-1 is the cause of the world pandemic of acquired immune deficiency
syndrome (A I D S ), whereas HI V-2 is largely confined to West A frica. HI V i
transmi ed through unprotected sexual activity with an infected person, contact with
infected bodily fluids, e.g. blood, or perinatally via mother-to-fetus-transmission. Two
to six weeks after exposure to HI V, 50–70% develop a transient non-specific illness
(primary infection or seroconversion illness) with flu-like symptoms, e.g. pyrexia, rash
and sore throat. This coincides with the development of serum antibodies to the core
and surface proteins of the virus. The illness begins abruptly and usually lasts for 1–2
weeks, but may be more protracted.
D iagnosis is through an HI V test, where blood is examined for the presence of
antibodies and/or antigens; this is known as the combined test. Pregnant women are
offered an HI V test in early pregnancy (RCO G 2010b). A lthough there is no cure for
HI V, antiretroviral (A RT) therapy has significantly reduced the morbidity and
mortality observed in previous decades. Without A RT, seroconversion is followed by a
clinically latent phase of about 10 years. D uring this time there is intense viral and
lymphocyte turnover with worsening immunodeficiency and about one-third of
infected individuals will experience persistent lymphadenopathy. The average time for
progression from HIV to AIDS is between 5 and 20 years.
The prevalence of HI V in pregnancy is around 1 in 500 maternities and management
aims to reduce the rate of transmission to the fetus, however, this is <2%, as most
transmission occurs during birth or in the postnatal period through breastfeeding
(RCO G 2010b). Highly active antiretroviral therapy (HA A RT) should continue, with
elective caesarean section and the avoidance of breastfeeding. Fakoya et al (2008)
reported that a planned vaginal birth should be considered for those women who have
plasma viral loads of <50 copies/ml. A s a result, this management regime has reduced
the rates of HIV transmission to the fetus to <1% (RCOG 2010b).
Human papillomavirus
The human papillomavirus (HPV) is a ributed to causing the second most common
S TI in the UK. I t has over 100 strains, of which strains 6 and 11 are known to cause
genital warts, which are more common in teenagers and young adults. They present as
small, fleshy, painless growths, single or in clusters, appearing on the vaginal and anal
regions following close genital contact or sexual activity with an affected person. The
warts usually appear within 2–3 months of infection, but can take up to a year to
become evident.
Treatment is either with topical lotions/creams or physical ablation, or a
combination. Pregnancy may affect the size and number of warts and there is a small
risk that they may affect progress in labour, as well as there being evidence of rare
cases of transmissions to the baby during birth. Human papillomavirus strains 16 and
18 are associated with cervical cancer and vaccinations are available to all young
women up to the age of 18 years. Emerging evidence from A li et al (2013) would
indicate that vaccination is reducing genital wart prevalence in young women.
Streptococcus A and B
Group A streptococcus (GA S ) bacteria cause a variety of infections, such as acute
pharyngitis, toxic shock syndrome, cellulitis and puerperal sepsis. Group B
streptococcus (GBS ) bacteria are commonly found in the vagina and lower bowel of
around 40% of healthy adult women, where they remain dormant. GBS is not
contagious, but it can cause neonatal GBS infection if the fetus comes into contact with
the bacteria, usually during birth. However, GBS infection has been known to pass
across the membranes and colonize the fetus in utero.
W omen at higher risk of GBS include those in preterm labour, those with premature
pre-labour rupture of membranes, prolonged rupture of membranes (>18 hr), and
those with maternal pyrexia and a previous history of GBS . S creening is not currently
offered routinely to all women but may be in the future, according to Plumb and
Clayton (2013), and consists of lower vaginal swabs and rectal swabs in those at risk
and IV antibiotics administered between 4 and 6 hours before birth (RCOG 2012).
GBS affects 1 in 1000 of all babies and has a mortality rate of 1 in 10, with survivors
often having severe long-term disabilities (Plumb and Clayton 2013). There are two
types of neonatal GBS . The most common type isearly onset GBS, which is seen in 75%
of cases and occurs within the first week of life, usually presenting within 24 hours of
birth. The other type is late onset GBS, which presents in 25% of cases within the first 3
months of life. S igns and symptoms in an affected neonate may be vague and include
problems maintaining their temperature, grunting, limpness, poor feeding behaviours
and seizures. I t is very important that midwives inform women of the signs and
symptoms and promptly refer any ill baby.
Syphilis
S yphilis is a S TI caused by the spirochete bacteriumTreponema pallidum. Transmission
occurs through contact with a syphilitic sore or chancre. A lthough the incidence of
syphilis is low in the UK, worldwide the incidence in developing countries is 90%.
There are four stages to the progression of the infection:
• Primary: occurring on average 21 days after exposure, where a single painless, firm,
non-itchy ulcer or chancre appears.
• Secondary: occurs between 4 and 10 weeks after exposure, with the appearance of a
non-itchy, diffuse rash with fever and sore throat evident. In the latent stage, the
individual is generally asymptomatic, but still contagious to others.
• Tertiary: can occur between 3 to 15 years after the initial exposure. If the individual
does not seek treatment, they will exhibit neurological symptoms such as general
paresis and seizures, as well as cardiac symptoms including aneurysms.
The presence of syphilitic sores increases the transmission risk of HI V. D iagnosis is
via a blood test and the treatment is penicillin. I t is highly likely that transmission of
syphilis will occur in pregnancy, causing preterm birth, stillbirth or perinatal death,
thus screening for syphilis should be routinely offered to all pregnant women during
the early antenatal period (N I CE 2010c; Watkins et al 2013). The baby may be born
with congenital syphilis, which is asymptomatic during infancy, but later in childhood
they may develop multi-organ conditions such as deafness, seizures and cataracts.
Urinary tract infection
Urinary tract infection (UTI ) is a common problem in pregnancy if pathogenic bacteria
colonize the urinary tract. The bacteria originate from the bowel and the most
commonly encountered is Escherichia coli (E. coli). S uch an infection may be
asymptomatic or present with symptoms of dysuria (a burning pain on micturition),
frequency (small regular amounts of urine), suprapubic discomfort and haematuria (blood
in the urine). I f the infection is confined to the bladder it is termed cystitis, and in
addition to these symptoms there may be urgency of micturition.
The infection can ascend to the kidneys and pyelonephritis develops. A cute
pyelonephritis may present with nausea and vomiting, pyrexia, rigors and abdominal
pain (J ames et al 2011). I f inadequately treated, septicaemia may result, leading to
acute renal failure, multiple organ failure and death (Brunskill and Goodlife 2013).
Asymptomatic bacteriuria (A BU), as the name implies, is an infection without
symptoms and occurs in 2–10% of pregnancies (NICE 2010c). The presence of 105/ml of
the same bacterial species in a midstream specimen of urine (MS S U) in the absence of
symptoms confirms the diagnosis. This is of significance in pregnancy, as 25% of
women will proceed to develop pyelonephritis and there is also risk of preterm labour
(James et al 2011).
A ll pregnant women should have their urine tested for nitrates (which are produced
by most urinary pathogens) at each antenatal visit. A mid-stream specimen of urine
(MS S U) should be taken early in pregnancy N ( I CE 2010c), and repeated if there are
symptoms of a UTI . Treatment is with antibiotics according to the culture and
sensitivity from the MS S U results, and the MS S U should be repeated following
treatment. I f the causative organism is group B streptococcus, an alert note should be
placed on the woman's maternity case notes. The midwife should encourage the
woman to drink at least 2 litres of fluid per day, comply with antibiotic therapy, give
advice on personal hygiene, especially following micturition, and recommend
cranberry juice which may reduce infection and its symptoms (Brunskill and Goodlife
2013).
I f the infection is still active when the woman commences labour she should be
reviewed by the obstetrician and I V antibiotics may be commenced for the duration of
labour and the immediate postnatal period. Urinary catheterization should be
avoided. I f the UTI persists into the postnatal period, then further investigations are
indicated (Brunskill and Goodlife 2013).
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Further reading
Raynor MD, Marshall JE, Jackson K. Midwifery practice: critical illness,
complications and emergencies case book. Open University Press: Maidenhead;
2012.
Part of a case book series, this text explores and explains the pathology, pharmacology
and care principles of women presenting with, or who develop medical conditions and
complications of pregnancy using test question and answers to assess learning..
Robson SE, Waugh J. Medical disorders of pregnancy: a manual for midwives. 2nd
edn. Wiley–Blackwell: Oxford; 2013.
This second edition clearly outlines existing and pre-existing conditions that women can
experience during pregnancy and explores possible complications, an outline of
recommended treatment and the specific midwifery care. The text includes physiology,
more illustrations and algorithms, and its accessible reference-style text enables
information to be found quickly and easily..
Useful websites
Action on Pre-eclampsia. www.apec.org.uk.
Association for the Study of Obesity. www.aso.org.uk.
Asthma UK. www.asthma.org.uk.
British Heart Foundation. www.bhf.org.uk.
British Hypertension Society. www.bhsoc.org.
British Society for Haematology. www.b-s-h.org.uk.
British Thoracic Society. www.brit-thoracic.org.uk.
British Thyroid Foundation. www.btf-thyroid.org.uk.
Diabetes UK. www.diabetes.org.uk.
Epilepsy Action (British Epilepsy Association). www.epilepsy.org.uk.
Group B Strep Support. www.gbss.org.uk.
Hepatitis Foundation. www.hepatitisfoundation.org.
International Sepsis Forum. www.sepsisforum.org.
National Chlamydia Screening Programme. www.chlamydiascreening.nhs.uk.
National Institute for Health and Care (formerly Clinical) Excellence.
www.nice.org.uk.
Obstetric Cholestasis Support. www.ocsupport.org.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
Scottish Intercollegiate Guidelines Network. www.sign.ac.uk.
UK National Screening Committee. www.screening.nhs.uk.
C H AP T E R 1 4
Multiple pregnancy
Margie Davies
CHAPTER CONTENTS
Incidence 288
Twin pregnancy 288
Types of twin pregnancy 288
Determination of zygosity and chorionicity 288
Diagnosis of twin pregnancy 292
The pregnancy 292
Antenatal screening 292
Ultrasound examination 292
Antenatal care and preparation 293
Parent education 293
Preparation for breastfeeding 293
Abdominal examination 293
Effects of pregnancy 294
Labour and the birth 294
Onset 294
Management of labour 295
Management of the birth 296
Complications associated with multiple pregnancy 297
Polyhydramnios 297
Twin-to-twin transfusion 297
Fetal malformations 297
Conjoined twins 298
Twin reversed arterial perfusion 298
Fetus-in-fetu 298
Malpresentations 298
Preterm rupture of the membranes 298
Cord prolapsed 298
Prolonged labour 298
Monoamniotic twins 298
Locked twins 298
Delay in the birth of the second twin 299
Premature expulsion of the placenta 299
Postpartum haemorrhage 299
Undiagnosed twins 299
Delayed interval in birth of the second twin 299
Postnatal period 299
Care of the babies 299
Temperature control 299
Feeding 299
Mother–baby relationships 301
Mother–partner relationships 302
Care of the mother 302
Development of twins 302
Identity and individuality 303
Siblings of multiples 303
Triplets and higher order births 303
Disability and bereavement 304
Multifetal pregnancy reduction (MFPR) 305
Selective feticide 305
Sources of help 305
The Multiple Births Foundation (MBF) 305
TAMBA (Twins and Multiple Births Association) 305
References 306
Further reading 307
Useful websites and contact details 307
The term ‘multiple pregnancy’ is used to describe the development of more
than one fetus in utero at the same time. Families expecting a multiple birth
have different health needs, requiring extra practical support and
understanding throughout pregnancy, the postnatal period and the early
years. Information and support from well-informed healthcare professionals
from the time the multiple pregnancy is diagnosed will help to prepare the
parents and avoid potential problems.
The chapter aims to:
• describe how types of multiple pregnancy may be distinguished
• consider the diagnosis and management of twin pregnancy, the labour and the care of
the mother and babies after birth
• give an overview of the problems particularly associated with twins and higher order
births and the fetal anomalies unique to the twinning process
• explain the special needs of the parents and identify the sources of help available.
Incidence
The incidence of multiple births in England and Wales continues to rise. I n 2012 there
were 11 441 multiple births, a rate of 15.7 per 1000 maternities or 1 in 63 with 11 330
twins, 208 triplets and 5 quads (Table 14.1, Fig. 14.1) (O N S [O ffice of N ational
Statistics] 2013).
Table 14.1
Multiple birth statistics, England and Wales 1985–2011
NB: Figures include live and still births.
a
For 2011 and 2012 this is a combined figure for quads and above.
Source: Office of National Statistics, London (various years)
FIG. 14.1 Twinning rates, 1940–2012. Data from Office of National Statistics.
I n the 1940s and 1950s, the incidence of twins was 1 in 80 but then fell to 1 in 104 in
1979. The full explanation for the fall is unknown. The number of triplets born more
than trebled in the 15 years up to 2001 (Blondel and Kaminski 2002). The highest
number in any one year was 323 in 1998; this was due to the rise in treatments for
infertility such as in vitro fertilization (IVF) and ovulation-stimulating drugs.
The single most important reason for the rise in multiple births is assisted
conception (Black and Bhattacharya 2010), although women having children when they
are older is a contributory factor though less significant. Multiple birth is the greatest
single risk to the health and welfare of babies born after I VF due to the increased rates
of stillbirth, preterm birth, neonatal death and disabilities. Maternal complications are
also higher with a multiple pregnancy. Concern about the increased morbidity and
mortality and high costs for health and social care led the Human Fertilisation and
Embryology Authority (HFEA) to commission an expert group to review multiple
births after I VF. The report ‘O ne Child at a Time’Braude
( 2006) has led to significant
changes in practice to reduce iatrogenic multiple births. Elective single embryo
transfer in I VF cycles is the normal practice in the UK with spare good-quality
embryos frozen for replacement in later cycles (Cutting et al 2008). The ‘O ne at a Time’
policy is supported by professional bodies and relevant organizations (Consensus
Statement 2011).
Twin pregnancy
Types of twin pregnancy
Twins will be either monozygotic (MZ) or dizygotic (D Z). Monozygotic or uniovular
twins are also referred to as ‘identical twins’. They develop from the fusion of one
oocyte and one spermatozoon, which after fertilization splits into two (Chapter 5).
These twins will be of the same sex and have the same genes, blood groups and
physical features, such as eye and hair colour, ear shapes and palm creases. However,
they may be of different sizes and often have very different personalities and
characters.
D izygotic or binovular twins develop when two separate oocytes are fertilized by
two different spermatozoa; they are often referred to as fraternal or non-identical
twins. They are no more alike than any brother or sister and can be of the same or
different sex. I n any multiple pregnancy there is a 50 : 50 chance of a girl or boy, half of
dizygotic twins will be boy–girl pairs. A quarter of dizygotic twins will be both boys
and a quarter, both girls. O f all twins born in the UK, two-thirds will be dizygotic and
one-third monozygotic. Therefore, approximately one-third of twins are girls, one-third
boys and one-third girl–boy pairs.
Determination of zygosity and chorionicity
Midwives must understand the differences between these two terms (Table 14.2) and
why it is important.
Table 14.2
Relationship between zygosity and chorionicity
Dichorionic Monochorionic
Two placentae (may be fused) One placenta
Two chorions One chorion
Two amnions Two amnions (one amnion in monoamniotic twins is very rare)
These twins can be either dizygotic or monozygotic These twins can only be monozygotic
D etermination of zygosity means determining whether or not the twins are
monozygotic (identical) or dizygotic (non-identical). I n about one-third of all twins
born, it will be obvious as the children will be of a different sex. O f the remaining
same-sex twins, zygosity will usually be apparent from physical features by the time
the children are 2 years old, although parents are not usually prepared to wait this
long. By the age of 2, parents know their children so well and see their differences in
character and personalities that they often find it difficult to believe they are identical.
At birth, monochorionic twins can have a greater weight variation than dichorionic
twins. I n approximately two-thirds of monozygotic twins, a monochorionic diamniotic
placenta (MCD A) will confirm monozygosity. I f the babies have a single outer
membrane, the chorion, they must be monochorionic and so monozygotic (Fig. 14.2).
I n one-third of monozygotic twins, the placenta will have two chorions and two
amnions (D CD A), and either fused placentas (F ig. 14.2C) or two separate placentas
(dichorionic) (Fig. 14.2A), which is indistinguishable from the situation in dizygotic
twins.
FIG. 14.2 Placentation of twins. After Bryan 1984, with permission of Edward Arnold.
With monozygotic twins the type of placenta produced is determined by the time at
which the fertilized oocyte splits:
• 0–4 days: dichorionic diamniotic placenta DCDA (approx. 33% – 1/3 cases) (Fig. 14.2
A,C)
• 4–8 days: monochorionic diamniotic placenta MCDA (approx. 66% – 2/3 cases) (Fig.
14.2B)
• 8–12 days: monochorionic monoamniotic placenta MCMA (approx. 1% of cases) (Fig.
14.2D)
• 12–13 days: (very rare indeed) conjoined twins can develop when the division is
incomplete (Bomsel-Helmreich 2005).
D espite the well-established facts about placentation and zygosity, professionals are
still giving couples incorrect information. S ame-sex dichorionic twins can be either
non-identical or identical and it is only from either an amniocentesis whilst pregnant
or deoxyribonucleic acid (D N A) testing after the birth that accurate zygosity can be
known.
Chorionicity: why is it important to know?
This knowledge is important clinically because monochorionic twin pregnancies have
a 3–5 times higher risk of perinatal mortality and morbidity than dichorionic twin
pregnancies (Pasquini et al 2004).
Zygosity determination after birth
The most accurate method of determining zygosity is to compare D N A from each
baby. The D N A can be extracted from cells taken from a cheek swab from inside the
mouth. S pecific genetic markers extracted from different chromosomes are compared
and the results are up to 99.99% accurate. (For D N A testing, contact the Multiple
Births Foundation [MBF].)
Zygosity determination should be routinely offered to all same-sex dichorionic twins
for the following reasons:
• Most parents will want to know whether or not their twins are identical, so they can
answer the most commonly asked question: ‘Are they identical?’ Also as the twins
get older, they usually want to know.
• If couples are considering further pregnancies, the risk in DZ twin pregnancy
increases approximately five-fold: these tend to run in families, usually on the female
side. MZ twins do not run in families and the likelihood does not change (except in
rare families who carry a dominant gene for monozygotic twinning). The chance of
any fertile woman having MZ twins is approximately 1 in 350–400.
• It will help the twins in establishing their sense of identity; influence their life and
family relationships.
• The information is important for genetic reasons, not just with monogenic disorders
but with any serious illness later in life.
• Twins are frequently asked to be involved in research and for this knowledge of
zygosity is essential.
Diagnosis of twin pregnancy
This is usually through ultrasound examination. D iagnosis can be made as early as 6
weeks, particularly for women who have had treatment for infertility, but usually at
the early scan between 11 weeks and 13 weeks and 6 days (Chapter 11). I f the
pregnancy is diagnosed at 6 weeks, the woman should be told about the risk of
‘vanishing twin syndrome’ (Landy et al 1998).
The differences between the two types of placenta are more pronounced in the first
trimester, so it is important to establish chorionicity at the early scan. The chorions
forming the septum between the amniotic sacs can be seen more clearly and the
membrane thickness measured, or by studying the septum at its base adjacent to the
placenta where a tongue of placental tissue is seen ultrasonically between the two
chorions; this is termed the lambda or T-sign (Wood et al 1996).
O nce a multiple pregnancy has been diagnosed nomenclature should be assigned to
each baby (e.g. A and B, or upper and lower).
The news that a woman is expecting a multiple pregnancy should be broken to the
couple in a sensitive manner as it may be a huge shock. At diagnosis the mother must
be given relevant information about the pregnancy, be referred to a specialist multiple
pregnancy clinic, and given website addresses or telephone numbers of local and
national support organizations (see Useful Websites).
S ince the advent of routine ultrasound scanning, it is very rare for a woman to get to
term with undiagnosed twins, but this will not apply in areas where this technology is
unavailable, or where the mother declines.
The pregnancy
A multiple pregnancy tends to be shorter than a single pregnancy. The average
gestation for twins is 37 weeks, triplets 34 weeks and quadruplets 32 weeks.
Antenatal screening
• A healthcare professional experienced in twin and triplet pregnancies should offer
information and counselling before and after every screening test.
• Screening for Down syndrome is by the combined test (see Chapter 11).
• Amniocentesis can be performed in twin pregnancies, usually between 15 and 20
weeks. It should be performed in a specialist fetal medicine unit. Most obstetricians
prefer to do a dual needle insertion so there is no chance of contamination between
the two sac.
• The role of chorionic villus sampling (CVS) with dichorionic placentas remains
controversial because of a relatively high risk of cross-contamination of chorionic
tissue, which may lead to false-positive or false-negative results. Such procedures
should only be performed after detailed counseling (RCOG (Royal College of
Obstetricians and Gynaecologists) 2010).
Ultrasound examination
• Monochorionic twin pregnancies should be scanned every 2 weeks from 16 to 24
weeks to check for discordant fetal growth and signs of twin-to-twin transfusion
syndrome (TTTS). A detailed cardiac scan should be included with the anomaly scan
due to increased incidence of cardiac problems with MZ twins; if uncomplicated after
24 weeks, then the same as dichorionic twins.
• Dichorionic twin pregnancies should be scanned monthly from 16 weeks, with the
anomaly scan between 18+0 to 20+6 weeks.
Antenatal care and preparation
Early diagnosis of a twin pregnancy and of chorionicity is extremely important in order
to give parents the specialist support and advice they will need.
Clinical care for women with twin and triplet pregnancies should be provided by a
nominated multidisciplinary team consisting of: a core team of named specialist
obstetricians, specialist midwives and ultrasonographers, all of whom have experience
and knowledge of managing multiple pregnancies.
A n enhanced team for referrals should include: a women's physiotherapist, an
infant feeding specialist, a dietitian and a perinatal mental health professional. The
type of care pathway the woman will follow for her antenatal care will depend on
whether she is expecting monochorionic or dichorionic twins. W omen expecting an
uncomplicated monochorionic twin pregnancy should be offered at least nine
antenatal appointments with healthcare professionals from the core team. At least two
of these should be with the specialist obstetrician. W omen with uncomplicated
dichorionic twin pregnancies should be offered at least eight antenatal appointments
with a healthcare professional from the core team, and two of these with the specialist
obstetrician (NICE [National Institute for Health and Clinical Excellence] 2011).
Parent education
Routine parent education classes should be offered earlier for women expecting twins,
ideally around 22–24 weeks' gestation. A specialist class for couples expecting a
multiple birth would be the ideal (O wen et al 2004). W hen planning these classes,
contact with a local twins club can provide a valuable source of practical information.
Mothers from twins clubs are usually delighted to participate in the classes and talk on
the practical issues such as coping with two or more babies, equipment and
breastfeeding (Leonard and Denton 2006). Suggestions for class topics are listed in Box
14.1.
Box 14.1
T opics for pa re nt e duca t ion cla sse s
• Facts and figures on twins and twinning
• Diet and exercise
• Parental anxieties about obstetric complications
• Labour, pain relief and the birth
• Possibilities of premature labour and birth the outcome
• Visit to the special care baby unit
• Breastfeeding and bottle-feeding
• Zygosity
• Equipment (prams and buggies, car seats, layette, etc.)
• Coping with newborn twins or more
• Development of twins including individuality and identity
• Sources of help.
The news a multiple pregnancy is expected can come as a considerable shock and
the midwife should give couples the opportunity to discuss any worries or problems
they have, as two babies will add a considerable financial burden to any family's
income (Denton and Bryan 1995).
Preparation for breastfeeding
W omen will inevitably give a lot of thought to how they are going to feed their babies,
not only from the nutritional but also from the practical point of view, as feeding will
take up a large amount of their time during the first 6 months. W omen should be
encouraged right from the beginning that it is not only possible to breastfeed two, and
in some cases three babies, but it is the best way for her to feed her babies
nutritionally and it can be a very rewarding experience for her (see Fig. 14.6). Many
sets of twins have been entirely breastfed, some beyond their first birthdays. Very few
sets of triplets are totally breastfed (Leonard 2000), but many mothers manage to
combine breast and bottlefeeding very successfully.
Early in the antenatal period the woman should be given full information and advice
about both breast- and bo lefeeding, so she can make an informed choice on how to
feed her babies. Both parents should have the opportunity to ask questions and be
encouraged to meet another mother who is successfully breastfeeding her babies (Box
14.2). I ntroductions can usually be made through a local twins group (MBF 2011a,
2011b).
Box 14.2
S upport ne e de d by t he bre a st fe e ding m ot he r of t wins
or m ore
• Consistent professional advice
• Reassurance of her ability to produce enough milk to satisfy her babies
• Encouragement from professionals and family in her ability to cope with
feeding two or more
• Support from her partner
• Help at home with household chores
• Help with older siblings
• A high calorie and high protein diet
Abdominal examination
Inspection
O n inspection, the size of the uterus may be larger than expected for the period of
gestation, particularly after the 20th week. The uterus may look broad or round and
fetal movements may be seen over a wide area, although the findings are not
diagnostic of twins. Fresh striae gravidarum may be apparent. Up to twice the amount
of amniotic fluid is normal in a twin pregnancy but polyhydramnios is not an
uncommon complication of a twin pregnancy, particularly with monochorionic twins.
Palpation
O n palpation, the fundal height may be greater than expected for the period of
gestation. The presence of two fetal poles (head or breech) in the fundus of the uterus
may be revealed on palpation and multiple fetal limbs may also be palpable. The head
may be small in relation to the size of the uterus and may suggest that the fetus is also
small and therefore there may be more than one present. Lateral palpation may reveal
two fetal backs, or limbs on both sides. Pelvic palpation may give findings similar to
those on fundal palpation, although one fetus may lie behind the other and make
detection difficult. Location of three poles in total is diagnostic of at least two fetuses.
Auscultation
Hearing two fetal hearts is not diagnostic as one can often be heard over a wide area in
a singleton pregnancy. I f simultaneous comparison over one minute of the heart rates
reveals a difference of at least 10 bpm, it may be assumed that two hearts are being
heard beating.
Effects of pregnancy
Exacerbation of common disorders
The presence of more than one fetus in utero and the higher levels of circulating
hormones often exacerbate the common disorders of pregnancy. S ickness, nausea and
heartburn may be more persistent and more troublesome than in a singleton
pregnancy.
Anaemia
I ron and folic acid deficiency anaemias are common in twin pregnancies. Early growth
and development of the uterus and its contents make greater demands on the
maternal iron stores; in later pregnancy (after the 28th week), fetal demands may lead
to anaemia. Routine oral iron supplementation remains a controversial issue (Lassi
et al 2013), but all pregnant women are advised to take folic acid daily (NICE 2008).
Polyhydramnios
This is also common and is particularly associated with monochorionic twins and with
fetal abnormalities. Polyhydramnios will add to any discomfort that the woman is
already experiencing. I f acute polyhydramnios occurs, it can lead to miscarriage or
preterm labour.
Pressure symptoms
The increased weight and size of the uterus and its contents may be troublesome.
I mpaired venous return from the lower limbs increases the tendency to varicose veins
and oedema of the legs. Backache is common and the increased uterine size may also
lead to marked dyspnoea and indigestion.
Other
There can be an increase in complications of pregnancy such as obstetric cholestasis,
and pelvic girdle pain (PGP) (see Chapters 12 and 13).
Labour and the birth
Onset
The more fetuses the woman is carrying, the earlier labour is likely to start. Twins are
usually born around 37 weeks rather than 40 weeks, and approximately 60% of twins
are born spontaneously before 37 weeks' gestation. I n addition to being preterm, the
babies may be small for gestational age (S FGA) and therefore prone to the associated
complications of both conditions. I f spontaneous labour begins before 24 weeks, the
chances of survival outside the uterus are very small, but it is possible the woman can
be given drugs to inhibit uterine activity. Causes of preterm labour must, if at all
possible, be diagnosed and treated quickly; for example, urinary tract infection should
be treated with antibiotics. A ntenatal corticosteroids are usually given to all women of
multiple pregnancies before 36 weeks' gestation (NICE 2011).
Evidence shows that after 38 weeks' gestation there is increased risk of higher
mortality in babies (Udom-Rice et al 2000), most obstetricians advise induction of
labour by 38 weeks for dichorionic twins and between 36 and 37 weeks (Box 14.3) for
monochorionic twins (RCO G 2006). I n dichorionic pregnancies, if the first twin is a
cephalic presentation, labour is usually allowed to continue to a vaginal birth, but if
the first twin is presenting in any other way, an elective caesarean section (CS ) is
usually recommended (Fig. 14.3). For uncomplicated monochorionic twin pregnancies
women are generally offered a vaginal birth, but for complicated monochorionic
pregnancies birth is by elective CS . For triplets and above, the mode of birth is almost
always by CS.
Box 14.3
C a se hist ory 1
A 34-year-old primigravida was diagnosed with D CD A twins, no family
history, so it was a complete shock. At the ultrasound department, a leaflet
with local twin organizations and contacts was given to the mother.
Through the hospital specialist, multiple birth midwife and twins club the
mother started to come to terms with the prospect of twins. S he knew she
was expecting two boys and began to wonder if they were identical or not,
but would have to wait until they were born and have D N A tests if they
looked alike. S he had a straightforward birth with her first child, so she was
keen to have a vaginal birth again, but felt there was pressure on her to
have an elective caesarean section. The pregnancy progressed normally and
with support from the specialist midwife, she wrote her birth plan. The
presenting baby was cephalic, and at 38 weeks labour was induced. The
woman had an epidural and progressed to birth both babies vaginally after
a short labour. Both babies were put to her breast in the labour suite; twin
one sucked well but twin two was not interested. A s establishing feeding
was more problematic than she expected and she felt she needed a lot of
help from the midwives, the mother stayed in hospital until day 5. Both
babies were sucking well on return home, although twin two did
occasionally need a ‘top up’ from the bottle.
FIG. 14.3 Presentation of twins before birth. After Bryan 1984, with permission of Edward Arnold.
Management of labour
D uring antenatal classes the couple must be warned that a multiple birth is less
common and therefore, for educational purposes in the hospital se ing, a number of
professionals may ask to observe the birth. I f the woman has any objection to this, her
wishes must be respected and a record made in her notes that she wants only those
concerned with her care to be present. Home births are not advisable with a multiple
pregnancy, but some women may still request one, in which case every effort should
be made to support her decision with an uncomplicated pregnancy. This will require
meticulous risk assessment and planning, including the involvement of midwifery
supervision in order that a plan of care for labour is clearly articulated and
documented in the woman's records. A skilled team of midwives with confidence to
deliver intrapartum care to women with twin pregnancies at home will need to be
identified to be on call. I t is good practice for the midwifery team to liaise with and
communicate the plan of care to the paramedic team and local consultant-led unit.
The majority of women expecting twins will go into labour spontaneously.
Theoretically the duration of the first stage of labour should be no different from that
of a single pregnancy. However, there is an increased incidence of dysfunctional
labour in twin pregnancies, possibly because of overdistension of the uterus.
The presence of complications such as pregnancy-induced hypertension, obstetric
cholestasis, intrauterine growth restriction (I UGR) or twin-to-twin transfusion
syndrome may be reasons for earlier induction of labour.
Labour for women expecting twins must be recognized as high risk and continuous
electronic fetal heart monitoring (EFM) of both fetuses is advocated. This can be
achieved either with two external transducers or, once the membranes are ruptured, a
scalp electrode on the presenting twin and an external transducer on the second. I f a
‘twin monitor’ is available, both heartbeats can be monitored simultaneously to give a
more reliable reading. Uterine activity will also need to be monitored.
I f cardiotocography (CTG) is not available (e.g. a home birth), use of hand-held
D opplers may be more pragmatic for structured intermi ent fetal heart rates (FHRs)
auscultation than a Pinard's stethoscope. I f the la er has to be used, two people must
auscultate simultaneously, so that the two distinct FHRs are counted over the same
minute.
W hile in labour, the woman should be encouraged to adopt whichever position she
finds most comfortable. A foam rubber wedge under the side of the ma ress will help
to prevent supine hypotensive syndrome by giving a lateral tilt. I t may be preferable
for her to adopt a left lateral position, well supported by pillows or a beanbag. A
birthing chair or a reclining chair, if available, may be more comfortable than a
conventional labour suite birthing bed.
Regional epidural block provides excellent analgesia, and if necessary, allows easier
instrumental births and also manipulation of the second twin. The use of Entonox
analgesia may be helpful, either before the epidural is in situ or during the second
stage, if the effect of the epidural is wearing off.
The woman should be encouraged to use whatever form of relaxation she finds
helpful. I f she chooses to use pharmacological means of analgesia only after non-
pharmacological methods are no longer effective, her wishes should be respected. The
midwife should explain that, if complications arise, intervention and the use of
pharmacological analgesia might be necessary. I deally this should be discussed with
the woman antenatally so that the physiology of labour is not disturbed with new
information (Chapter 16).
I f fetal compromise occurs during labour, the birth will need to be expedited,
usually by CS . A ction may also need to be taken if the woman's condition gives cause
for concern.
I f uterine activity is poor, the use of intravenous oxytocin may be required once the
membranes have been ruptured. A rtificial rupture of the membranes (A RM) may be
sufficient to stimulate good uterine activity but it may need to be used in conjunction
with intravenous oxytocin. The CTG will give a good indication of the pa ern of
uterine activity, whether the labour is induced or spontaneous. The response of the
fetal hearts to uterine contractions can be observed on the CTG.
I f the babies are expected to be preterm, low birth weight, or known to have any
other problems, the neonatal intensive care unit (N I CU) must be informed that the
woman is in labour so they can make the necessary preparations to receive the babies.
When birth is imminent, the paediatric team should be summoned.
Throughout labour, the emotional and general physical condition of the woman
must be considered. S he requires the presence of her birthing partner and one-to-one
care from the midwife.
Management of the birth
The onset of the second stage of labour should be confirmed by a vaginal examination.
I n the hospital se ing, the obstetrician, paediatric team and anaesthetist should be
present for the birth as there is a risk of complications.
Epidural analgesia may need to be ‘topped up’ prior to the birth. The possibility of
emergency CS is ever present and the operating theatre should be ready to receive the
mother at short notice. Monitoring of both FHRs should continue until birth. Provided
that the first twin is presenting by the vertex, the birth can be expected to proceed
normally, as with a singleton pregnancy. W hen the first twin is born, the time of birth
and the sex are noted. This baby and cord must be labelled as ‘twin one’ immediately.
The identity tags should be checked with the mother or father before they are applied
to the baby in accordance with local policy. The baby may be given to the mother for
skin-to-skin contact and encouraged to go to the breast as sucking stimulates uterine
contractions (Chapter 34).
A fter the birth of the first twin, abdominal palpation is made to ascertain the lie,
presentation (in the event of doubt a portable ultrasound machine should be
available) and position of the second twin and to auscultate the FHR to ensure
continuous EFM. A n assistant may need to stabilize the lie of the second twin. I f the
lie is not longitudinal, an a empt may be made to correct it by external cephalic
version (ECV) (seeChapter 17). ECV in this context in the UK should only be
performed or supervised by a senior obstetrician (RCO G 2006). ECV is less invasive
than internal podalic version, and will often be the default manoeuvre employed by
obstetricians (RCOG 2006; Masson 2007).
I f it is longitudinal, a vaginal examination is made to confirm the presentation. I f
the presenting part is not engaged it should be gently guided into the pelvis and kept
in place until it firmly engages. A RM must not be performed on the second sac of
membranes until the presenting part engages, as risk of cord prolapse is ever present.
The FHR must be auscultated again; a scalp electrode might be required following
A RM if external monitoring of the FHR is of poor quality I f uterine activity does no
recommence, intravenous oxytocin may be used.
W hen the presenting part becomes visible, the mother should be encouraged to
birth her second twin with contractions. The midwife should always be aware there is
a risk the placenta may start to separate before the birth of the second twin, causing
oxygen deprivation. The birth will proceed as normal if the presentation is vertex, but
if the fetus presents by the breech and the midwife is not experienced in breech births
she will need a doctor's assistance.
The birth of the second twin should ideally be completed within 45 minutes of the
first twin but, as long as there are no signs of fetal compromise in the second twin, it
may be allowed to continue longer. I f there are signs of compromise, the birth must be
expedited and the second twin may need to be born by CS . A n uterotonic drug
(S yntometrine or oxytocin) is usually given intramuscularly or intravenously,
depending on local policy, after the birth of the anterior shoulder as with a singleton
pregnancy. This baby and cord are labelled as ‘twin two’. The time of birth and sex of
child must be noted. I f either twin needs to be transferred to the N I CU for
observation, the mother should have a chance to see and hold the baby whenever
possible.
O nce the uterotonic drug has taken effect, controlled cord traction is applied to both
cords simultaneously to aid birth of the placentas without delay. Emptying the uterus
enables bleeding to be controlled and postpartum haemorrhage prevented.
The placenta(s) should be examined not only to check completion but the number of
amniotic sacs, chorions and placentas noted (see Fig. 14.2). I f the babies are of
different sexes, they are dizygotic. I f the placenta is monochorionic (MCD A), they
must be monozygotic. I f they are of the same sex and the placenta is dichorionic
(D CD A), then further tests will be needed (see Zygosity). The umbilical cords should
also be examined and the number of cord vessels and the presence of any
abnormalities noted.
Complications associated with multiple pregnancy
The higher perinatal mortality associated with twinning is largely due to complications
of pregnancy, such as the preterm onset of labour, I UGR and complications at birth.
There is a six-fold increase in perinatal mortality comparing twins to singletons
(CMA CE [Centre for Maternal and Child Enquiries] 2011 ). The management of
multiple pregnancy is concerned with the prevention, early detection and treatment of
these complications.
Polyhydramnios
Mentioned earlier in the chapter, acute polyhydramnios may occur as early as 16
weeks. I t may be associated with fetal abnormality but is more likely to be due to twin-
to-twin transfusion syndrome (TTTS ), which can also be known as feto-fetal
transfusion syndrome (FFTS).
Twin-to-twin transfusion syndrome
Twin-to-twin transfusion syndrome (TTTS ) can be acute or chronic. The acute form
usually occurs during labour and is the result of blood transfusing from one fetus
(donor) to the other (recipient) through vascular anastomosis in a monochorionic
placenta. Both fetuses may die of cardiac failure if not treated urgently.
Chronic TTTS occurs in about 15% of monochorionic twin pregnancies D ( ennes et al
2006) and accounts for 15% of perinatal mortality in twins (Yamamoto and Ville 2006).
The placenta in TTTS transfuses blood from one twin fetus to the other. These cases
are characterized by one or more deep unidirectional arteriovenous anastomoses. This
results in anaemia and growth restriction in the donor twin (stuck twin) and
polycythaemia with circulatory overload in the recipient twin (hydrops). The fetal and
neonatal mortality is high but infants may be saved by early diagnosis and prenatal
treatment with either amnioreduction, which may have to be repeated regularly as
fluid can reaccumulate rapidly (Box 14.4), or laser ablation therapy of communicating
placental vessels, or septostomy (MBF 2010).
Box 14.4
C a se hist ory 2
A 26-year-old primigravida's early scan showed MCD A twins. The mother
read on the I nternet that problems can be associated with MCD A
pregnancy and was very worried about TTTS.
From 16 weeks, she had 2-weekly scans for signs of TTTS and growth
discordancy. At 20 weeks, she noticed a rapid increase in abdominal size
and her tummy was hard and uncomfortable. Her local hospital referred
her to the Centre for Fetal Care (CFC) at a tertiary level hospital, where type
2 TTTS was diagnosed. I mmediate treatment was amnio-reduction of over 2
litres and laser ablation of connecting blood vessels. Her care was
transferred to CFC for weekly scans. Here she mainly saw doctors and felt
she missed out on midwife contact. Unfortunately at 32 weeks she was
diagnosed as type 3 TTTS , with very abnormal D opplers in the donor twin.
S teroid injections were given and an emergency caesarean section was
performed at 33 weeks. Both babies were born in a fair condition and were
admi ed to the N I CU. The mother was encouraged to hand express her
milk as soon as she felt well enough, to continue 2–3-hourly during the day
and on the 6th day she started expressing using an electric pump. The twins
were able to go to the breast after 2 weeks and started sucking for very
short periods. Progress continued and both babies were discharged home
at 5 weeks of age, fully breastfeeding.
The midwife should always be alert to the woman who complains of a rapid increase
in her abdominal girth in the second trimester, as well as a uterus that feels hard and
uncomfortable continuously. The skin over the uterus may look shiny and tight; this is
usually due to polyhydramnios and if not treated urgently can cause preterm labour.
Fetal malformations
This is particularly associated with monochorionic twins.
Conjoined twins
This extremely rare malformation of monozygotic twinning results from the
incomplete division of the fertilized oocyte; it occurs once in 50 000 births and over
half the cases are stillborn. Birth has to be by CS . The site and extent of fusion of the
fetuses are infinitely variable. Thoracopagus (conjoined twins united at the thorax) is
the commonest form of fusion (over 70% of cases). The feasibility of separating
conjoined twins depends on the site and extent of fusion and the degree to which
organs are shared (O leszczuk and O leszczuk 2005). Many conjoined twins can now be
successfully separated. Others pose major ethical dilemmas – particularly if one can be
saved at the expense of the other (Mifflin 2001).
Twin reversed arterial perfusion
Twin reversed arterial perfusion (TRA P) occurs in about 1 in 30 000 births. I n TRA P
one twin presents without a well-defined cardiac structure and is kept alive through
placental anastomoses to the circulatory system of the viable fetus (S ebire and
Sepulveda 2006).
Fetus-in-fetu
I n fetus-in-fetu (endoparasite), parts of a fetus may be lodged within another fetus;
this can happen only in MZ twins (Hoeffel et al 2000).
Malpresentations
A lthough the uterus is large and distended, the fetuses are less mobile than may be
supposed. They can restrict each other's movements, which may result in
malpresentations (Chapter 20), particularly of the second twin. A fter the birth of the
first twin, the presentation of the second twin may change.
Preterm rupture of the membranes
Malpresentations due to polyhydramnios may predispose to preterm rupture of the
membranes.
Cord prolapse
This too is associated with malpresentations and polyhydramnios and is more likely if
there is a poorly fi ing presenting part. The second twin is particularly at risk of cord
prolapse.
Prolonged labour
Malpresentations are a poor stimulus to good uterine action and a distended uterus is
likely to lead to poor uterine activity and consequently prolonged labour (Chapter 19).
Monoamniotic twins
A pproximately 1% of MZ twins share the same amniotic sac. Monoamniotic (MCMA
twins risk cord entanglement with occlusion of the blood supply through the umbilical
cords to one or both fetuses. I n some centres this is treated with sulindac, which
reduces the amniotic fluid levels, and birth is usually around 32–34 weeks and by
elective CS.
Locked twins
This is a very rare but serious complication of twin pregnancy. There are two types.
O ne occurs when the first twin presents by the breech and the second by the vertex;
the other when both are vertex presentations (Fig. 14.4). I n both instances, the head of
the second twin prevents the continued descent of the first. Primigravidae are more at
risk than multiparous women.
FIG. 14.4 Locked twins.
Delay in the birth of the second twin
A fter the birth of the first twin, uterine activity should recommence within 5 minutes.
I deally, as stated previously, the birth of the second twin should be completed within
45 minutes of the first twin being born but with close monitoring can be extended if
there are no signs of fetal compromise. Poor uterine action as a result of
malpresentation may be the cause of delay. The risks of such delay are intrauterine
hypoxia, birth asphyxia following premature separation of the placenta and sepsis as a
result of ascending infection from the first umbilical cord, which lies outside the vulva.
A fter the birth of the first twin the lower uterine segment begins to reform and the
cervical canal may have to dilate fully again.
The midwife may need to ‘rub up’ a contraction and put the first twin to the breast
to stimulate uterine activity. I f there appears to be an obstruction, medical aid is
summoned and a CS may be necessary. I f there is no obstruction, oxytocin infusion
may be commenced or forceps-assisted birth considered.
Premature expulsion of the placenta
The placenta may be expelled before the birth of the second twin. I n dichorionic twins
with separate placentas, one placenta may be delivered separately; in monochorionic
twins the shared placenta may be expelled. The risks of severe asphyxia and death of
the second twin are very high. Haemorrhage is also likely if one twin is retained in
utero as this prevents adequate retraction of the placental site.
Postpartum haemorrhage
Poor uterine tone as a result of overdistension or hypotonic activity is likely to lead to
postpartum haemorrhage (Chapter 18). There is also a much larger placental site to
contract down.
Undiagnosed twins
The possibility of an unexpected, undiagnosed second baby (in the UK this is unlikely
with ultrasound scanning) should be considered if the uterus appears larger than
expected after the birth of the first baby or if the baby is surprisingly smaller than
expected. I f an uterotonic drug has been given after the birth of the anterior shoulder
of the first baby, the second twin is in great danger of birth asphyxia and birth should
be expedited. The midwife must break the news of undiagnosed twins gently to the
parents. These parents will require special support and guidance during the postnatal
period.
Delayed interval birth of the second twin
There have been several reported cases where the first twin has been born, often very
prematurely, and then a long gap before labour recommences; it can be days or even
weeks before the second twin is born (Zhang et al 2004). This opportunity can be used
to give antenatal corticosteroids to the mother to help mature the lungs of the second
twin. Careful observations of the mother's condition must be made during this time
for signs of infection and fetal compromise. The mother will need additional support
from the midwives to cope with her anxieties for her preterm baby on the N I CU,
which may not survive, or time to grieve if the baby has died, as well as still being
pregnant and her concerns for the outcome of her pregnancy.
Postnatal period
Care of the babies
I mmediate care after the birth is the same as for a single baby. Maintenance of body
temperature is vital, particularly if the babies are small; use of overhead heaters will
help to prevent heat loss. I dentification of the babies should be clear and the parents
given the opportunity to check the identity bracelets and cuddle the babies. The
babies may need to be admi ed to the N I CU from the labour suite, otherwise they can
be encouraged to have skin-to-skin contact, and go to the breast if they are to be
breastfed before being transferred to the postnatal ward with their mother.
Temperature control
Maintenance of a thermoneutral environment is essential, particularly for babies in
the N I CU. A merican studies have shown that a sick baby can benefit from sharing the
incubator with its twin (Hedberg et al 1998). Clothing should be light but warm, and
allow air to circulate.
Feeding
The mother may choose to feed her babies by breast or with formula milk, but
whatever her choice, the midwife must support her in her decision. With
breastfeeding, both babies may be breastfed separately or simultaneously. I n the
initial postnatal days, it is recommended she breastfeeds her twins separately, as this
gives her time to get to know each baby individually and to feel confident in her ability
to cope. I f the babies are S FGA or preterm, the paediatricians may recommend that
the babies be ‘topped up’ after a breastfeed. Expressed breastmilk is best for these
babies. I f the babies are not able to suck adequately at the breast the mother should
be encouraged to express her milk regularly. Expressing should be initiated ideally
within 6 hours of birth, then regularly every 2–3 hours during the day and once at
night or on average 8 times per 24 hours. I n some N I CUs with a Millbank donor milk
may be offered to preterm babies, this reduces the risk of necrotizing enterocolitis
(N EC) (P atole and de Klerk 2005). A s twin babies are more likely to be preterm or
S FGA , their ability to coordinate the sucking and swallowing reflexes may be poor. I f
so, they may need to be fed intravenously or by nasogastric tube, depending on their
size and general condition. The mother should be encouraged to participate in
whatever method is used. Careful monitoring of weight gain is required.
Hypoglycaemia may occur and regular capillary blood glucose estimations may be
needed.
I n the early postnatal days, mothers often worry that their milk supply is inadequate
for two babies. The midwife should reassure her that lactation responds to the
demands made by the babies sucking at the breast or expressing. The more
stimulation the breasts are given, the more milk she will produce. At feeding times,
the midwife must be with the mother to offer support and advice on positioning and
fixing the babies (Fig. 14.5), as well as encouraging her in her ability to cope with
breastfeeding two babies.
FIG. 14.5 Breastfeeding positions for twins.
Breastfeeding
The advantages of breastfeeding twins are the same as for singletons (Chapter 34), but
as twins have a higher tendency to be born preterm and S FGA , it is even more
important that they should be breastfed. A s well as the medical and nutritional
advantages, there are practical reasons too, many of which are outlined in Chapter 34.
A dditionally, as time is limited for a mother of twins in the early days, twins can be
breastfed together, when the feeds will take only a li le longer than with a single
baby. Some mothers will, however, prefer to feed separately.
Separate feeding
• It allows her to give one-to-one attention to each baby, something mothers of twins
feel they have very little time for.
• It is easier for the mother, as she has both hands free to position and attach one baby
at a time.
• If she does feed separately, it is recommended that she adopts a routine where
whichever baby wakes first is fed and the second one is woken straight afterwards so
keeping her feeds together.
Simultaneous feeding
• It saves time as both babies are feeding together, though the mother will need to be
organized, and will need help in the early days to get both babies attached to the
breast.
• If the mother does want to feed the babies together, it is advisable to try this before
going home from hospital, where a midwife can stay with her throughout the entire
feed, providing advice, support and an extra pair of hands.
• The woman will need additional pillows to support her back and take the weight of
the babies, to avoid putting strain on her arms and back (Figs 14.5, 14.6).
FIG. 14.6 Simultaneous feeding can be a very rewarding experience for the mother.
Routine is the key to coping with two or more babies. I t may take 4–6 weeks for a
feeding routine to get established (MBF 2010).
Mother–baby relationships
Mothers with a multiple birth often worry they will find it more difficult to bond with
each baby equally. This is a common concern and reassurance that their feelings are
not unusual should be given. O nce the mother gets to know her babies these feelings
usually disappear. I f, for example, they are of markedly different sizes, a mother may
favour one over the other, or if one baby is in the N I CU while the other is on the
postnatal ward with her, she may find she bonds with the one on the ward much more
quickly. I n such cases the mother should be encouraged to spend as much time as
possible with the baby on the N I CU and to visit as soon after the birth as she feels
able. I f she has had an operative birth, she may find it difficult to care for two babies
and extreme tiredness or anaemia will exacerbate the situation. S he may have feelings
of guilt if the birth and immediate postnatal period have not gone as she had planned.
The midwife should be alert for such circumstances and help the mother to divide her
a ention between both babies and to give plenty of reassurance that she is not the
first mother to feel the same way.
Mother–partner relationships
Mother–partner relationships
A mother who has had twins or more will inevitably turn to her partner for help with
the care of the babies, and many families work well together in the care and
upbringing of their children, despite the added strains and stresses a multiple birth
puts on a family. I n some cases her partner may feel that she is devoting too much
time to the babies and not enough to him, thus making him feel excluded, especially if
when he comes home from work she is too exhausted to take any interest in him. The
strain on any relationship when a new baby is born can be quite difficult for the couple
to adjust to, but with a multiple birth it is even worse. The midwife should always
encourage the partner to be involved in the daily care of the babies, either in hospital
or at home.
Care of the mother
I nvolution of the uterus will be slower because of its increased bulk. ‘A fter pains’ may
be more troublesome and analgesia should be offered. A good diet is essential and if
the mother is breastfeeding she requires a high protein, high calorie diet. I t is quite
common for breastfeeding mothers to feel hungry between meals and they should be
encouraged to keep sensible snacks to hand for such times. A dietician may be able to
offer help. The physiotherapist or midwife should instruct the mother in her postnatal
exercises.
The midwife must give the mother of twins extra support. Teaching her simple
parenting skills and encouraging her to carry them out with increasing assurance will
build up her confidence.
The mother may feel ‘in the way’ if her babies are in a N I CU and require a lot of
intensive care. S he may have feelings of guilt because of their prematurity and feel it
was something she did or did not do that caused them to be born early. S he should be
given the opportunity to talk her feelings through. O n the N I CU she should always be
kept up to date with the care and condition of her infants. Most N I CUs now have a
named nurse caring for each baby so parents know who to talk to. I f one infant is very
ill or dies, the parents will experience additional psychological problems. S ome N I CUs
have psychologists as part of the team and parents can be referred to them.
Most units have a rooming-in policy so mothers can stay in the hospital with their
babies for two or three nights before they are transferred home, to give them a chance
to take over their total care and prepare them for coping at home.
Best practice is that twins or more should all be transferred home together from the
N I CU but this is not always possible. I f they go home at different intervals, greater
demands are placed on the mother, as she has to care for one baby at home and still
visit the sick baby in hospital.
I t is advisable for a mother of twins to organize help at home for the first 3–4 weeks
after transfer. I nitially, this may be in the form of her partner taking time off work. I f
relations or friends have offered to help, the mother should be sure to let them know
what kind of help she is expecting from them before it is needed. I f the parents are
fortunate enough to be able to afford paid help, then they can say exactly what it is
they expect to be done. There is no statutory help available for twins or triplets in
England and Wales.
The community midwife will contact the mother after transfer home from hospital
to arrange visits. The health visitor will also arrange to see the mother and her babies
after the community midwife has transferred care to the health visitor.
At home the mother must be encouraged to rest and catch up on her sleep
especially during the day, and eat a well-balanced diet. A good routine is the only way
of coping with new babies and all mothers should be encouraged to establish one as
soon as possible.
I t may be wise to discourage visitors in the first week at home while the mother
adjusts to the new circumstances. Her partner should be encouraged to help as much
as possible.
I solation can be a real problem for new mothers. The thought of ge ing two babies
ready to go out can be quite fearful. S tudies have shown the incidence of postnatal
depression to be significantly higher in mothers of twins (Thorpe et al 1991). S tress,
isolation and exhaustion are all significant precipitants of depression (Chapter 25);
mothers of twins are therefore more vulnerable.
Development of twins
Twins in most respects will do as well as a single baby, but the one area they can fall
behind is language development. With twins, the mother tends to talk to both of them
together, so there is less one-to-one communication. I nevitably, she will be much
busier and the temptation to leave the twins to amuse themselves is much greater.
Talking to each other, the twins act as each other's role model for language (unlike the
singleton baby, who has his or her mother). I f one child speaks a word incorrectly the
twin will copy it, reinforcing the mistake. This is how the so-called ‘secret language’ of
twins develops, otherwise known as ‘cryptophasia’ or ‘idioglossia’. I t is essential that
each twin is spoken to individually as much as possible. Eye contact is vital in any
relationship but especially for language development. I f one twin is more responsive
and makes eye contact more easily than the other, the mother may respond much
more readily to this twin without realizing it.
Identity and individuality
Parents of twins should be encouraged to think of their children as individuals. The
distinction between twins can start in the postnatal ward with differently coloured
blankets, or different small soft toys. A s they grow up, dressing them in different style
of clothes, giving them different hairstyles can make children individual. People
should be encouraged to refer to the children by name, or ‘the girls’ or ‘boys’ and not
‘the twins’. At birthdays or Christmas, separate cards and different presents help to
retain individuality. The twins should be given the opportunity to spend time apart.
Siblings of multiples
A n elder brother or sister of twins may find their arrival very difficult, especially if
they have had a number of years of undivided parental a ention. Parents must be
alert to the feelings of their other children and include them as much as possible in all
activities with the twins. A single older sibling may see the parents as a pair, the twins
as a pair, while he or she feels isolated. I t can be very helpful to find a ‘special friend’
for the older child, for instance a godparent, or other friend. A good idea is for the
parents to arrange not only for the twins to have a present for the older child but for
the older child to choose a present for each of the twins. Two different small cuddly
toys as the first presents the twins receive can become very special gifts.
Triplets and higher order births
The increasing number of surviving triplets and higher order births (Fig. 14.7) will
produce many more families needing special advice and support from healthcare
workers. I n the 1980s the UK Triplet S tudy Bo
( ing et al 1990) revealed the problems
these families face are even greater than were previously realized.
FIG. 14.7 Triplet rates, 1955–2012. Data from Office of National Statistics.
A woman expecting three or more babies is at risk of all the same complications as
one expecting twins, but magnified. S he is more likely to have a period in hospital
resting before the triplets' birth and they will almost certainly be born preterm.
Perinatal mortality rates are higher for triplets than twins and the incidence of
cerebral palsy is also increased (Pharoah et al 2002; CMACE 2011).
Triplets or more are almost always born by CS . The midwives must be prepared to
receive several small babies within a very short time span. I t is essential the paediatric
team be present as specialist care may be required. The dangers associated with these
births are asphyxia, intracranial injury and perinatal death.
The main difficulties these families experience are insufficient practical and
financial help and the lack of awareness of their problems by professionals. The
emotional stress and anxiety of the birth, having babies in the N I CU and the worries
of coping with the babies when they go home will seem overwhelming if no
arrangements for extra help have been made before the babies are born. A mother
should never be expected to manage by herself. Taking triplets out for a walk or any
expedition can need major organization, even without the parents having to cope with
uninvited comments from passers-by. S ome of these can be insensitive and hurtful,
making inferences about fertility and the parents bringing extra work on themselves.
The midwife must ensure that the mother's health visitor and, if necessary, a social
worker are involved in her care. I f the family needs extra outside help, this must be
organized before the babies are born. A pplications to the council for rehousing may
also be needed.
Disability and bereavement
Perinatal mortality and long-term morbidity are both more common among multiple
births than singletons. The perinatal mortality rate for twins is about four times that of
singletons, and for triplets, 12 times (Figs 14.8, 14.9).
FIG. 14.8 Stillbirth rates, 1975–2009. Data from Office of National Statistics 2011.
FIG. 14.9 Infant mortality, 1975–2009. Data from Office for National Statistics 2011.
The grief of parents following the death of one of a multiple set is often
underestimated. The specific problems they face are not understood and their needs
poorly met. I t often feels ‘easier’ to concentrate on the survivor(s), thus denying the
parents essential time and space to grieve. A ll too often people say that they are lucky
because they still have one healthy child (or more). N o one ever says that to parents
who lose one of their two or three singleton children (Bryan 1986). The conflicting
emotions the parents will feel and the need to grieve for the child who has died, while
wanting to rejoice at the birth of the healthy twin, can be confusing. Birthdays and
anniversaries and the constant presence of the survivor(s) are all reminders of the
dead child. The parents may need help in relating to the survivor(s). A ddresses of
organizations that offer support should be made available to the parents. W here one
or more of a multiple set has a disability it is often the healthy child who needs
additional special a ention. He or she may feel guilt that it was something they did
that caused the twin's disability and may be resentful of the a ention the other one
needs, or of the loss of twinship. A ny of these may lead to emotional and behavioral
problems if not addressed early on.
Multifetal pregnancy reduction (MFPR)
This is the reduction of an apparently healthy higher-order multiple pregnancy down
to two or even one embryo so the chances of survival are much higher. I t may be
offered to parents who have conceived triplets or more, whether spontaneously or as a
result of assisted reproduction.
The procedure is usually carried out between the 10th and 12th week of the
pregnancy. Various techniques may be used, either inserting a needle under
ultrasound guidance via the vagina or, more commonly, through the abdominal wall
into the fetal thorax. Potassium chloride is usually used, although some doctors prefer
saline. W hichever technique is used, all embryos remain in the uterus until birth.
Usually the pregnancy is reduced to two embryos, but in some cases to three or even
one (Wimalasundera 2006). A ny parents who have been offered this treatment must
be given counselling, which should include:
• the advantages and disadvantages of reducing the pregnancy
• the risks of continuing with a higher multiple pregnancy
• the risks of MFPR
• the effects on the surviving children
• how the parents may feel afterwards
• help for the parents to reach the right decision for them
• organizations who can help them
• the offer of long-term support if and when required.
Selective feticide
This may be offered to parents with a multiple pregnancy, where one of the babies has
a serious abnormality. The affected fetus is injected as described in MFPR, but this is
not usually performed until much later in the pregnancy so allowing the healthy fetus
time to grow and develop normally. Counselling must again be offered to the parents.
The full impact of either of these procedures and their bereavement will often not be
felt until the birth of all their babies (including the dead baby) often many weeks later.
Moreover, unlike the termination of a single pregnancy, the parents will be more
aware of what could have been as they watch the survivor(s) grow up. W hen it comes
to the labour, midwives must be ready to offer the appropriate care and understanding
of the parents' bereavement. The bereavement should be clearly indicated in the notes
so it is not forgo en when the mother comes back for her postnatal check and for
future pregnancies.
Sources of help
I n the UK, there is at present no statutory obligation to provide any extra help for
families with twins, triplets or more. The support provided by social services varies
greatly so it is always advisable for families with triplets to apply. Healthcare workers
should be prepared to write le ers supporting any applications these families have
made. I n the UK child benefit is paid to all children whose parents have an individual
income of less than £50,000. The firstborn child receives a higher allowance than
subsequent children. I n multiple pregnancies, it is only the firstborn child that
receives the higher allowance.
Parents should be advised to contact organizations such as Home S tart (seeUseful
Websites), or local colleges with nursery training courses, both of which may be able
to offer assistance.
The Multiple Births Foundation (MBF)
The MBF offers advice and support to families as soon as their multiple pregnancy is
diagnosed, as well as to couples considering treatment for infertility. I t offers
information through its antenatal meetings for couples and professionals. The MBF
also provides information and support to professionals through its education
programme – study days, courses, lectures and publications.
M ultiple births and their impact on families is a series of publications for
professionals. I t comprises a set of five books, which can be bought together or
individually:
• Facts about multiple births
• Multiple pregnancy
• Bereavement
• Special needs in twins
• Twins and triplets: the first five years and beyond
See the MBF website for a complete list of the publications available.
TAMBA (Twins and Multiple Births Association)
This is the umbrella organization for the 150+ local twins clubs throughout the
country. The clubs are run by parents of twins and are the best source of practical
advice and support for parents expecting twins or more. TA MBA also runs a number
of specialist groups.
TA MBA Twinline is a national, confidential listening and information telephone
service for all parents of twins, triplets and more (see Useful Websites).
References
Black M, Bhattacharya S. Epidemiology of multiple pregnancy and the effect of
assisted conception. Seminars in Fetal and Neonatal Medicine. 2010;15(6):306–
312.
Blondel B, Kaminski M. Trends in the occurrence, determinants, and
consequences of multiple births. Seminars in Perinatology. 2002;26(4):239–249.
Bomsel-Helmreich O, Al Mufti W. Multiple pregnancy: epidemiology, gestation and
perinatal outcome. Informa Healthcare: New York; 2005.
Botting B, Macfarlane AJ, Price FV. Three, four and more: a study of triplets and
higher order births. HMSO: London; 1990.
Braude P. One child at a time: reducing multiple births after IVF. Human
Fertilisation & Embryology Authority: London; 2006.
Bryan EM. Twins in the family (a parent's guide). Constable: London; 1984.
Bryan EM. The death of a newborn twin. How can support for parents be
improved? Acta Geneticae Medicae et Gemellologiae. 1986;5:166–170.
CMACE (Centre for Maternal and Child Enquiries). Perinatal Mortality 2009:
United Kingdom. CMACE: London; 2011 www.hqip.org.uk/assets/NCAPOP-
Library/CMACE-Reports/35.-March-2011-Perinatal-Mortality-2009.pdf.
Consensus Statement. Multiple births from fertility treatment in the UK. Human
Fertility. 2011;14(3):151–153.
Cutting R, Morroll D, Stephen A, et al. Elective single embryo transfer:
guidelines for practice. British Fertility Society and Association of Clinical
Embryologists Human Fertility. 2008;11(3):131–146.
Dennes W J B, Sullivan M F H, Fisk NM. Scientific basis of twin-to twin
transfusion syndrome. Kilby M, Baker P, Critchley H, et al. Multiple pregnancy.
RCOG Press: London; 2006:167–181.
Denton J, Bryan EM. Prenatal preparation for parenting twins, triplets or more:
the social aspect. Whittle M, Ward RH. Multiple pregnancy. RCOG Press:
London; 1995:119.
Hedberg Nyquist K, Lutes LM. Co-bedding twins: a developmentally supportive
care strategy. Journal of Obstetrics, Gynecology and Neonatal Nursing.
1998;27(4):450–456.
Hoeffel CC, Nguyen KQ, Phan HT, et al. Fetus-in-fetu: a case report and a
literature review. Pediatrics. 2000;105:1335–1344.
Landy HJ, Keith LG. The vanishing twin. A review. Human Reproduction.
1998;4:177.
Lassi ZS, Salam RA, Haider BA, et al. Folic acid supplementation during
pregnancy for maternal health and pregnancy outcomes. Cochrane Database of
Systematic Reviews. 2013.
Leonard LG. Breastfeeding triplets: the at-home experience. Public Health
Nursing. 2000;17(3):211–221.
Leonard LG, Denton J. Preparation for parenting multiple birth children. Early
Human Development. 2006;82:371–378.
Masson G. Twin pregnancy. Grady K, Howell C, Cox C. (eds) The MOET course
manual: managing obstetric emergencies and trauma. 2nd edition. RCOG: London;
2007:295–300.
Mifflin PC. Jodie and Mary: ethical and legal implications of separating
conjoined twins. Practising Midwife. 2001;4(7):48–49.
MBF (Multiple Births Foundation). Monochorionic pregnancy when twins share one
placenta. [Online] MBF: London; 2010.
MBF (Multiple Births Foundation). Feeding twins, triplets and more. [A booklet for
parents with advice and information.]. MBF: London; 2011.
MBF (Multiple Births Foundation). Guidance for health professionals on feeding
twins, triplets and higher order multiples. MBF: London; 2011.
NICE (National Institute for Health and Clinical Excellence). Antenatal care:
routine care for the healthy pregnant woman. CG62. NICE: London; 2008.
NICE (National Institute for Health and Clinical Excellence). Multiple pregnancy:
the management of twin and triplet pregnancies in the antenatal period. CG 129.
NICE: London; 2011.
ONS (Office of National Statistics). Childhood, infant and perinatal mortality in
England and Wales 2011. www.ons.gov.uk/ons/dcp171778_300596.pdf; 2011
[(accessed 12 June 2013)] .
ONS (Office of National Statistics). Births in England and Wales by characteristics
of birth. www.ons.gov.uk; 2013 [(accessed 12 June 2013)] .
Oleszczuk JJ, Oleszczuk AK. Conjoined twins. Keith LG, Blickenstein I. Multiple
pregnancy. 2nd edn. Parthenon: London; 2005:233–245.
Owen DJ, Wood L, Neilson JP. Antenatal care for women with multiple
pregnancies. The Liverpool approach. Clinical Obstetrics and Gynecology.
2004;47(1):263–271.
Pasquini L, Wimalasundera RC, Fisk NM. Management of other complications
specific to monochorionic twin pregnancies. Best Practice and Research in
Clinical Obstetrics and Gynaecology. 2004;18(4):577–599.
Patole SK, de Klerk N. Impact of standardised feeding regimens on incident of
neonatal necrotising entercolitis: a systematic review and meta-analysis of
observational studies. Archives of Disease in Childhood Fetal and Neonatal
Edition. 2005;90(2):F147–F151.
Pharoah P O D, Price TS, Plomin R. Cerebral palsy in twins: a national study.
Archives of Disease in Childhood Fetal Neonatal Edition. 2002;87(2):F122–F124.
RCOG (Royal College of Obstetricians and Gynaecologists). Multiple pregnancy.
Consensus views arising from the 50th Study Group. RCOG: London; 2006.
RCOG (Royal College of Obstetricians and Gynaecologists). Amniocentesis and
chorionic villus sampling. Greentop guideline No 8. RCOG: London; 2010.
Sebire NJ, Sepulveda W. Management of twin reversed arterial perfusion (TRAP)
sequence. Kilby M, Baker P, Critchley H, et al. Multiple pregnancy. RCOG:
London; 2006:199–222.
Thorpe K, Golding J, MacGillivray I, et al. Comparisons of prevalence of
depression in mothers of twins and mothers of singletons. British Medical
Journal. 1991;302:875–878.
Udom-Rice I, Inglis SR, Skupski D, et al. Optimal gestational age for twin
delivery. Journal of Perinatalology. 2000;20(4):231–234.
Wimalasundera R. Selective reduction and termination of multiple pregnancies.
Kilby M, Baker P, Critchley H, et al. Multiple pregnancy. RCOG: London;
2006:95–108.
Wood SL, Onge RS, Connors G, et al. Evaluation of the twin peak or lambda sign
in determining chorionicity in multiple pregnancy. Obstetrics and Gynecology.
1996;88(1):6–9.
Yamamoto M, Ville Y. Twin-to-twin transfusion syndrome. Kilby M, Baker P,
Critchley H, et al. Multiple pregnancy. RCOG: London; 2006:183–197.
Zhang J, Hamilton B, Martin J, et al. Delayed interval delivery and infant survival:
a population-based study. American Journal of Obstetrics and Gynecology.
2004;191(2):470–476.
Further reading
Cooper C. Twins and multiple births. Vermilion: London; 2004.
A GP and mother of twins gives practical advice on coping with twins and more.
Suitable for parents and professionals alike..
Royal College of Obstetricians and Gynaecologists (RCOG). Multiple pregnancy.
RCOG Press: London; 2006.
Written by specialists in multiple pregnancy..
Useful websites and Contact Details
Homestart UK. www.home-start.org.uk.
Multiple Births Foundation. www.multiplebirths.org.uk.
Tel: 020 8383 3519 or 020 3313 3519. e-mail: [email protected].
Twins and Multiple Births Association. www.tamba.org.uk.
Tel: 01483 304442; TAMBA Twinline: 0800 138 0509.
S E CT I ON 4
Labour
OU T LIN E
Chapter 15 Care of the perineum, repair and female genital mutilation
Chapter 16 Physiology and care during the first stage of labour
Chapter 17 Physiology and care during the transition and second stage phases of
labour
Chapter 18 Physiology and care during the third stage of labour
Chapter 19 Prolonged pregnancy and disorders of uterine action
Chapter 20 Malpositions of the occiput and malpresentations
Chapter 21 Operative births
Chapter 22 Midwifery and obstetric emergencies
C H AP T E R 1 5
Care of the perineum, repair and female
genital mutilation
Ranee Thakar, Abdul H Sultan, Maureen D Raynor, Carol McCormick, Kinsi Clarke
CHAPTER CONTENTS
Factors associated with reduced incidence of perineal trauma 312
Definition of perineal trauma 312
Episiotomy 313
Diagnosis of perineal trauma 313
Importance of anorectal examination 314
Female genital mutilation/genital cutting/female circumcision 314
Background 314
The role of the midwife 317
Repair of perineal trauma 318
Basic principles prior to repairing perineal trauma 318
First-degree tears and labial lacerations 318
Episiotomy and second-degree tears 318
Technique for perineal repair 318
Obstetric anal sphincter injuries (OASIS) 319
Technique for OASIS repair 320
Basic principles after repair of perineal tears 320
Postoperative care after oasis 320
Follow up 321
Medicolegal considerations 321
Training 321
References 324
Further reading 325
Useful websites 325
In the United Kingdom (UK), approximately 85% of women sustain some
degree of perineal trauma following vaginal birth and it can be extrapolated
that millions of women will be affected worldwide. Morbidity in the short and
long term following trauma and repair can lead to major physical,
psychological, sexual and social problems affecting the woman's ability to
care for her newborn baby and other members of the family. Midwives
should be aware that suturing is a major and sometimes traumatic event for
women (Green et al 1998). The repair of the perineum is an important part of
the continuing care of a woman during labour and birth (Kettle 2012). The
permanent presence of midwives who are trained and continually developing
expertise in perineal repair, minimizes the problems associated with the
rotation of inexperienced junior medical staff (Draper and Newell 1996) and
provides continuity of care for women.
This chapter presents an overview of key issues relating to perineal care
during labour and childbirth. It is important that the reader has knowledge
and understanding of the anatomy and physiology of the pelvic floor (see
Chapter 3) prior to engaging with this chapter.
The chapter aims to:
• draw on the evidence base to identify some of the factors associated with a reduced
incidence of perineal trauma during the second stage of labour
• examine the standard classification used to describe the different types of perineal
trauma
• discuss the systematic assessment necessary in order to accurately diagnose perineal
trauma
• highlight the significance of female genital mutilation and the inherent consequences for
birth and women's psychosexual wellbeing and health more broadly
• consider the basic principles involved in repairing perineal trauma
• examine the midwife's role and medicolegal considerations involved in perineal trauma.
Factors associated with reduced incidence of perineal
trauma
Many studies have compared interventions to prevent perineal trauma during the
second stage of labour, starting with antenatal considerations such as diet and
nutrition as well as the recommended antenatal perineal massage for nulliparous
women (Beckmann and Garre 2006). Coupled with this there are some well-
documented risk factors associated with more complex perineal trauma (third- and
fourth-degree tears) such as fetal macrosomia, A sian ethnicity, persistent
occipitoposterior position, instrumental births and nulliparity (Groutz et al 2011; Chan
et al 2012). Box 15.1 summarizes some of the factors that might lead to a reduction in
perineal trauma.
Box 15.1
S t ra t e gie s t o pre ve nt /m inim iz e pe rine a l t ra um a
during la bour
Influencing factors The evidence
Antenatal perineal massage but not perineal massage during the Beckmann M M, Garrett A J 2006
second stage of labour (Cochrane review) and NICE 2007
Use of warm perineal compresses during the second stage of labour Aasheim et al 2011 (Cochrane review)
Restricted use of episiotomy Carroli and Mignini 2009 (Cochrane
review)
Upright birth positions – freedom of woman to choose Gupta et al 2004 (Cochrane review) and
NICE 20007
Non-directed pushing (woman using her own urges to bear down NICE 2007
without coaching from the midwife or doctor)
Definition of perineal trauma
Perineal trauma may occur spontaneously during vaginal birth or when a surgical
incision (episiotomy) is intentionally made to facilitate birth. I t is possible to have an
episiotomy and a spontaneous tear (e.g. extension of an episiotomy). A nterior perineal
trauma is defined as injury to the labia, anterior vaginal wall, urethra or clitoris.
Posterior perineal trauma is defined as any injury to the posterior vaginal wall or
perineal muscles and may include disruption of the anal sphincters.
I n order to standardize definitions of perineal tears, the classification outlined in
Table 15.1 is recommended (Royal College of O bstetricians and Gynaecologists
[RCO G] 2007; N ational I nstitute for Health and Clinical Excellence [N I CE] 2007 ). (S ee
Chapter 3 for details of pelvic floor anatomy) (Fig. 15.1.)
Table 15.1
Classification of perineal trauma
First degree Injury to perineal skin only
Second degree Injury to perineum involving perineal muscles but not involving the anal sphincter
Third degree Injury to perineum involving the anal sphincter complex:
3a: Less than 50% of external anal sphincter (EAS) thickness torn
3b: More than 50% of external anal sphincter thickness torn
3c: Both external anal sphincter and internal anal sphincter (IAS) torn
Fourth degree Injury to perineum involving the anal sphincter complex and anal epithelium
Isolated button hole injury of rectum Injury to the rectal mucosa without injury to the anal sphincters
Source: NICE 2007, RCOG 2007
FIG. 15.1 Classification of perineal trauma depicted in a schematic representation of the anal
sphincters (modified from Sultan and Kettle 2007).
Episiotomy
The traditional teaching that episiotomy is protective against more severe perineal
lacerations has not been substantiated (Carroli and Mignini 2009), and therefore the
liberal use of ‘prophylactic’ episiotomy is no longer recommended. However, there are
still valid reasons to perform an episiotomy (for indications see Chapter 00). A variety
of episiotomy techniques are described in the literature (Kalis et al 2012), but two
types of episiotomy are most frequently used:
• Midline episiotomy: Advantages of the midline episiotomy are that it does not cut
through muscle, the two sides of the incised area are anatomically balanced, making
surgical repair easier, and blood loss is less than with mediolateral episiotomy. A
major drawback is that extension through the external anal sphincter and into the
rectum can occur. For this reason midline episiotomy is not recommended in the UK.
• Mediolateral episiotomy: The right mediolateral episiotomy is the technique approved
for use by midwives in the UK. The incision is made starting at the midline of the
posterior fourchette and aimed towards the ischial tuberosity to avoid the anal
sphincter. In addition to the skin and subcutaneous tissues, the bulbospongiosus and
the transverse perineal muscles are cut.
Diagnosis of perineal trauma
Following every vaginal birth a thorough assessment should be performed to exclude
genital trauma. The healthcare professional should explain to the woman what they
plan to do and why, offer inhalational analgesia and ensure that if there is pre-existing
epidural analgesia, it is effective. There must be good lighting and the woman should
be positioned so that she is comfortable and the genital structures can be seen clearly.
I f this is not possible then it is vital to explain to the woman the rationale for the
examination and why it is necessary to place her in a comfortable position, i.e.
lithotomy (N I CE 2007). I n the UK, modern birthing beds in the hospital se ing mean
that the use of lithotomy poles in midwifery practice to support women's legs during
examination of the genital tract or to repair perineal trauma is not always warranted.
However, supported lithotomy (i.e. use of poles) is necessary to aid the diagnosis and
repair of complex trauma to the genital tract. W hen supported lithotomy position is to
be employed, clear explanation should be provided to the woman in a sensitive
manner. The midwife should be mindful that use of lithotomy poles may conjure up
images associated with previous sexual abuse or female genital mutilation/female
cu ing (Ke le and Raynor 2010). Visualization, effective analgesia and systematic
assessment of perineal trauma can be even more challenging at a homebirth, not least
because of poor lighting and the use of se ees or low bedroom furniture. W hen faced
with such complexities it is perfectly acceptable for midwives a ending home births to
transfer women into the hospital se ing for thorough assessment, especially if the
repair is judged not to be straightforward or the midwife does not have the requisite
skills/competence to perform the repair.
Importance of anorectal examination
I nformed consent must be obtained for a vaginal and rectal examination. I f the digital
assessment is restricted because of pain, adequate analgesia must be given prior to
examination. Following inspection of the genitalia, the labia should be parted and a
vaginal examination performed to establish the full extent of the vaginal tear. W hen
multiple or deep tears are present it is best to examine and repair in the supported
lithotomy position, as previously stated.
A rectal examination should then be performed to exclude anal sphincter trauma.
Figure 15.2 shows a partial tear along the external anal sphincter which would have
been missed if a rectal examination was not performed. Every woman should have a
rectal examination prior to suturing in order to avoid missing isolated tears such as a
‘bu on hole’ of the rectal mucosa ( NICE 2007). Furthermore, a third- or fourth-degree
tear may be present beneath apparently intact perineal skin, highlighting the need to
perform a rectal examination in order to exclude obstetric anal sphincter injuries
(O A S I S ) following every vaginal birth S( ultan and Ke le 2007) (Fig. 15.3). Following
diagnosis of the tear it should be graded according to the recommended classification
(NICE 2007; RCOG 2007), as delineated earlier in Table 15.1.
FIG. 15.2 A partial tear (arrow) along the external anal sphincter which would have been missed
if a rectal examination was not performed (Sultan and Kettle 2007).
FIG. 15.3 A third- or fourth-degree tear may be present beneath apparently intact perineal skin
highlighting the need to perform a rectal examination in order to exclude obstetric anal sphincter
injuries (OASIS) following every vaginal delivery (Sultan and Kettle 2007). (a) An apparent intact
perineum. (b) A ‘bucket handle tear’ is demonstrated behind the intact perineal skin. (c) The torn
external anal sphincter.
I n order to diagnose O A S I S , clear visualization is necessary and the injury should
be confirmed by palpation. By inserting the gloved index finger in the anal canal and
the thumb in the vagina, the anal sphincter can be palpated by performing a pill-
rolling motion. I f there is still uncertainty, the woman should be asked to contract her
anal sphincter (in the absence of an epidural) and if the anal sphincter is disrupted,
there will be a distinct gap felt anteriorly. I f the perineal skin is intact there will be an
absence of puckering on the perianal skin anteriorly. This may not be evident under
regional or general anaesthesia. A s the external anal sphincter (EA S ) is normally in a
state of tonic contraction, disruption results in retraction of the sphincter ends. The
internal anal sphincter (I A S ) is a circular smooth muscle that appears paler (similar to
raw fish) (Fig. 15.4) than the striated EA S (similar to raw red meat) (S ultan and Ke le
2007) (Fig. 15.5).
FIG. 15.4 The IAS is a circular smooth muscle that appears pale (similar to raw fish).
FIG. 15.5 The EAS is striated muscle and appears red in colour (similar to raw red meat).
Female genital mutilation/genital cutting/female
circumcision
Background
Partly as a result of immigration and refugee movements, women who have
undergone female genital mutilation (FGM) now present all over the world. Therefore
healthcare professionals in all countries need to be familiar with the practice of genital
cu ing and its implications, particularly for childbirth and safeguarding of the next
generation, as well as to be proactive in eradicating this harmful cultural practice
altogether.
The language used by midwives and doctors when dealing with genital cu ing is
important as parents understandably resent the suggestion that they have mutilated
their daughters. A s a result, the word ‘cu ing’ has increasingly come to be used to
avoid alienating communities (World Health Organization [WHO] 2013).
There has been great debate amongst holy men as to whether, particularly type one,
genital cu ing (sometimes referred to as Sunna circumcision) is required in the
Muslim faith, but it is clear that female genital cu ing is not linked to the Bible or the
Koran. I t is in fact condemned by many I slamic scholars. Genital cu ing predates both
the Koran and the Bible, appearing in the 2nd century BC. It is a cultural practice, not a
religious one. I n countries when there is a mixture of Christians and Muslims it is
practised by both faiths (WHO 2001, 2008, 2013).
W hat actually happens to the girls and women varies from ritualistic herbs rubbed
into the genitalia to complete removal of the clitoris and labia minora, and stitching
(or closing by other means, usually thorns) of the labia majora. The W HO (2001)
define FGM as any procedure that intentionally alters or causes injury to the external
female genital organs for non-medical reasons and describes four types, as depicted in
Fig. 15.6.
Type 1: Clitoridectomy is partial or total removal of the clitoris and/or, in some cases,
only the prepuce (the fold of skin surrounding the clitoris).
Type 2: Excision: partial or total removal of the clitoris and the labia minora, with or
without excision of the labia majora (the labia are ‘the lips’ that surround the
vagina).
Type 3: Infibulation: narrowing of the vaginal opening through the cutting of the labia
minora and suturing or closing of the outer, labia majora, with or without removal
of the clitoris.
Type 4: Other: all other harmful procedures to the female genitalia for non-medical
purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
I n practice, however, it is often difficult to be clear about the classification. Uneven
cu ing, scarring and defects in suture lines are very common findings, therefore every
woman who has undergone genital cu ing should be assessed by an experienced
practitioner and dealt with individually.
FIG. 15.6 Types of female genital mutilation.
The age at which girls undergo genital cu ing varies enormously according to their
community. The procedure may be carried out when the girl is a newborn, during
childhood, adolescence, at marriage or during the first pregnancy. Most commonly it is
performed on girls between four and eight years of age (WHO 2001, 2008).
Girls are usually compliant when they have the procedure carried out as they believe
they will be outcasts if they are not cut. Mothers and other family members believe
they are doing the best for their children, as women are thought to be unclean and
immoral unless they had been cut. In most cultures that practise FGM the girls/women
would be unmarriageable if uncut. S o deep-rooted is this cultural tradition that it is
the opinion of some that a woman will not be promiscuous or unfaithful if she derives
li le or no pleasure from sexual intercourse (Elnashar and A bdelhady 2007). D espite
being aware of the dangers associated with genital cu ing, it is this very strong belief
that makes parents ensure their daughters are cut in accordance with their cultural
custom and tradition.
A naesthetics and antiseptic treatment are not generally used and the practice is
usually carried out using basic tools such as circumcision knives, scissors, scalpels,
pieces of glass and razor blades. O ften iodine or a mixture of herbs is placed on the
wound to tighten the vagina and stop the bleeding.
I mmediate complications include severe pain, shock, haemorrhage, tetanus, sepsis
and urinary retention. I nexperienced or very old cu ers may inadvertently cause
injury to adjacent tissue. Late complications include sexual dysfunction with
anorgasmia, keloid scar formation, dermoid cysts and psychological issues. There is an
increasing trend for medically trained personnel to perform FGM in hospitals and
institutions (Hassanin et al 2008). There are no known health benefits associated with
FGM.
I n the UK the Prohibition of Female Circumcision A ct 1985 makes it an offence to
carry out FGM or to aid, abet or procure the service of another person. The Female
Genital Mutilation amendment to the A ct 2003 makes it against the law for FGM to be
performed anywhere in the world on UK permanent residents of any age and carries a
maximum sentence of 14 years imprisonment (Home O ffice 2004). Europe and many
other countries also have laws against FGM.
The role of the midwife
I n order to have a robust plan of care during labour, identification of women from
countries that practise FGM is essential antenatally.N I CE (2008) highlights the
importance of antenatal screening of these women. This should be performed in a
timely manner so that referral and consultation with a practitioner who can address
both the physical needs of the woman plus the safeguarding and legal issues for the
unborn child in a sensitive manner can take place.
A ntenatally, physical examination is necessary to assess the extent of genital cu ing
and make a birth plan, also to identify whether antenatal surgery (deinfibulation)
would be beneficial before 20 weeks of pregnancy. Most women would prefer a
deinfibulation in labour but a plan to deinfibulate during labour means all staff must
have adequate training and experience in performing the procedure, which in most
hospitals is an unrealistic expectation. Even women who have given birth before or
have had a previous deinfibulation should be examined as they may have suffered
trauma at the last birth and some women will have undergone a reinfibulation (being
‘closed’ again), usually in their country of origin.
There is contradicting evidence as to whether FGM is associated with prolonged or
obstructed labour (D e S ilva 1989; A l-Hussaini 2003; Millogo-Traore et al 2007).
However, during the second stage of labour the reduced labia and inelastic anterior
tissue may be scarred and adherent to the labial vault and/or urethra, and therefore
the birth process can cause significant anterior trauma to these structures. A low
threshold for a right mediolateral episiotomy should be discussed with the woman
antenatally, particularly if the type of cu ing has left scar tissue that may prevent
progress or cause additional trauma in the form of an anterior tear in the second stage
of labour (RCOG 2009).
A proforma including a predrawn diagram, akin to that outlined in the RCO G (2009)
guideline, should be completed for the identification of the type of FGM and the
agreed birth plan as part of good note-keeping. The impact of FGM is very profound,
as captured by the personal narrative at the end of the chapter (Box 15.2).
Repair of perineal trauma
Basic principles prior to repairing perineal trauma
(NICE 2007; Sultan and Thakar 2007)
The skills and knowledge of the operator are important factors in achieving a
successful repair. I deally the repair should be conducted in a timely manner by the
same midwife who a ended the woman in labour. This ensures seamless continuity of
care, as the midwife would have established a good rapport and trust with the woman.
The woman should be referred to a more experienced healthcare professional if
uncertainty exists as to the nature or extent of trauma sustained. Having fully
informed the woman why a detailed examination is required and to gain her consent,
an initial systematic assessment of the perineal trauma must be performed including a
sensitive rectal examination to exclude any trauma to the I A S /EA S is not missed
(NICE 2007).
I n order to reduce maternal morbidity, repair of the perineum should be
undertaken as soon as possible to minimize the risk of bleeding and oedema of the
perineum as this makes it more difficult to recognize tissue structures and planes
when the repair eventually takes place. Perineal trauma should be repaired using
aseptic techniques. Equipment should be checked and swabs and needles counted
before and after the procedure.
A repair undertaken on a non-cooperative woman, due to pain, is likely to result in a
poor repair. Ensure that the wound is adequately anaesthetized prior to commencing
the repair. I t is recommended that 10–20 ml of lidocaine 1% (maximum dose 3 mg/kg)
is injected evenly into the perineal wound. I f the woman has an epidural it may be
‘topped-up’ instead of injecting local anaesthetic.
The issue of obstetric anal sphincter injuries is addressed in more detail later in the
chapter, but it is worth noting here that repair of such trauma should be undertaken in
theatre, under general or regional anaesthesia. I n addition to providing pain relief,
this provides the added advantage of relaxing the muscles, enabling the operator to
retrieve the ends of the torn sphincter and identify the full length of the anal sphincter
prior to repair. A n indwelling catheter should be inserted for at least 12 hours to avoid
urinary retention.
I n the case of FGM, if a woman undergoes a deliberate traumatic deinfibulation in
labour without antenatal preparation she may ask to be reinfibulated (closed again),
but any repair carried out after birth, whether following spontaneous laceration or
deliberate defibulation, should be sufficient to oppose the raw edges of the perineal
trauma and control bleeding. I t must not result in a vaginal opening that makes
intercourse difficult or impossible, as this would be in breach of the law. The W HO
(2001, 2008, 2013) recommends suturing of raw edges to prevent spontaneous
reinfibulation but an individual assessment should be made.
First-degree tears and labial lacerations
W omen should be advised that, in the case of first-degree trauma, the wound should
be sutured in order to improve healing, unless the skin edges are well opposed (NICE
2007). I f the tear is left unsutured, the midwife or doctor must discuss the implications
with the woman and obtain her informed consent. D etails regarding the discussion
and consent must be fully documented in the woman's case notes.
Labial lacerations are usually very superficial but may be very painful. S ome
practitioners do not recommend suturing, but if the trauma is bilateral the lacerations
can sometimes adhere together over the urethra and the woman may present with
voiding difficulties. I t is important to advise the woman to part the labia daily during
bathing to prevent adhesions forming. This is particularly important when caring for
women with type 3 FGM.
Episiotomy and second-degree tears
A lthough the repair of these tears was previously carried out using the interrupted
technique, the continuous suturing technique for perineal skin closure has been
shown to be associated with less short-term pain. Moreover, if the continuous
technique is used for all layers (vagina, perineal muscles and skin), the reduction in
pain is even greater (Ke le et al 2007). The perineal muscles should be repaired using
absorbable polyglactin material which is available in standard and rapidly absorbable
forms. A recent Cochrane review has shown that there are few differences in short-
term and long-term pain, between standard and rapidly absorbing synthetic sutures,
but more women need standard sutures to be removed (Kettle et al 2010).
Technique for perineal repair
Technique is important, as is the suturing material used (Kettle and Fenner 2007).
Suturing the vagina (Fig. 15.7a)
Using 2/0 absorbable polyglactin 910 material (Vicryl rapide®), the first stitch is inserted
above the apex of the vaginal skin laceration to secure any bleeding points. The vaginal
laceration is closed using a loose, continuous, non-locking technique ensuring that
each stitch is inserted not more than 1 cm apart to avoid vaginal narrowing. S uturing
is continued down to the hymenal remnants and the needle is inserted through the
skin at the fourchette to emerge in the centre of the perineal wound.
FIG. 15.7 Continuous suturing technique for mediolateral episiotomy (Kettle and Fenner 2007):
(a) loose continuous non-locking stitch to the vaginal wall; (b) loose, continuous non-locking stitch
to the perineal muscle; (c) closure of skin using a loose subcutaneous stitch.
Suturing the muscle layer (Fig. 15.7b)
The muscle layer is then approximated after assessing the depth of the trauma and the
perineal muscles (deep and superficial) are approximated with continuous non-locking
stitches. I f the trauma is deep, two layers of continuous stitches can be inserted
through the perineal muscles.
Suturing the perineal skin (Figure 15.7c)
To suture the perineal skin the needle is brought out at the inferior end of the wound,
just under the skin surface. The skin sutures are placed below the skin surface in the
subcutaneous tissue, thus avoiding the profusion of nerve endings. Bites of tissue are
taken from each side of the wound edges until the hymenal remnants are reached. A
loop or Aberdeen knot is placed in the vagina behind the hymenal remnants.
A vaginal examination is carried out to ensure that the vagina is not narrowed and a
rectal examination carried out to ensure that sutures have not been inadvertently
placed through the anorectal epithelium.
Obstetric anal sphincter injuries (OASIS)
The quoted rate of O A S I S is 1% of all vaginal births RCO
( G 2007), although a more
recent analysis reveals the rate to be 3.2% in consultant-led units (unpublished data).
However, ‘occult’ O A S I S (i.e. defects in the anal sphincter detected only by anal
endosonography) has been identified in 33% of primiparous women following vaginal
birth (Sultan et al 1993). More recent work has shown that these defects were not really
occult but could have been identified by an adequately trained doctor or midwife
(A ndrews et al 2006a). The most plausible explanation for what was previously
believed to be an ‘occult’ O A S I S is either an injury that has been missed, recognized
but not reported, or, wrongly classified as a second-degree tear ( S ultan and Thakar
2007).
Technique for OASIS repair (Sultan and Thakar 2007)
I n the presence of a fourth-degree tear, the torn anorectal epithelium is sutured with a
continuous 3/0 Vicryl suture. W hen torn (Grade 3c tear/fourth-degree), the internal
anal sphincter tends to retract and can be identified lateral to the torn anal epithelium.
I t should be repaired with ma ress sutures using 3-0 PD S (Polydioxanone) or modern
braided sutures such as 2/0 Vicryl (polyglactin – Vicryl®). To repair a torn external anal
sphincter, the ends are grasped using A llis forceps and the muscle is mobilized. W hen
the EAS is only partially torn (Grade 3a and some 3b) then an end-to-end repair should
be performed using two or three ma ress sutures. Haemostatic ‘figure of eight’
sutures must not be used to repair the mucosa or sphincter muscle. I f there is a full-
thickness EA S tear (some 3b, 3c or fourth-degree), either an overlapping or end-to-end
method can be used with equivalent outcome. The limited data available from the
Cochrane review on the topic showed that compared to immediate primary end-to-end
repair of O A S I S , early primary overlap repair appears to be associated with lower risks
of faecal urgency and anal incontinence symptoms and deterioration of anal
incontinence over time. However, as the experience of the surgeon was addressed in
only one of the three studies reviewed, it would be inappropriate to recommend one
type of repair over the other (Fernando et al 2006). A fter either technique of repairing
the external sphincter the remainder of the tear is closed using the same principles
and suture material outlined in the repair of episiotomy.
Basic principles after repair of perineal tears (NICE 2007;
Sultan and Thakar 2007)
A fter repair, complete haemostasis should be achieved. A rectal and vaginal
examination should be performed to confirm adequate repair, to ensure that no other
tears have been missed and that a suture is not inadvertently placed through the rectal
mucosa. Confirm that all tampons (if used) or swabs have been removed.
D etailed notes should be made of the findings and repair. Completion of a pre-
designed proforma and a pictorial representation of the tears can prove very useful
when notes are being reviewed following complications, audit or litigation. A n
accurate detailed account of the repair should be documented in the woman's case
notes following completion of the procedure, including details of suture method and
materials used.
The woman should be informed regarding the use of appropriate analgesia, hygiene
and the importance of a good diet and daily pelvic floor exercises. I t is important that
the woman is given a full explanation of the injury sustained and contact details if she
has any problems during the postnatal period. I n presence of O A S I S women should
be advised that the prognosis following EA S repair is good, with 60–80% being
asymptomatic at 12 months (RCO G 2007). I n the case of FGM, the woman and her
partner must be advised about the legalities regarding reinfibulation and
safeguarding issues if the baby is female.
Postoperative care after OASIS
Broad-spectrum antibiotics should be given intraoperatively (intravenously) and
continued orally for 3 days. S evere perineal discomfort, particularly following
instrumental delivery, is a known cause of urinary retention, and following regional
anaesthesia it can take up to 12 hours before bladder sensation returns. A Foley
catheter should be inserted for at least hours unless medical staff can ensure that
spontaneous voiding occurs at least every 3–4 hours without undue overdistension of
the bladder.
The degree of pain following perineal trauma is related to the extent of the injury
and O A S I S is frequently associated with other more extensive injuries, such as
paravaginal tears. I n a systematic review, Hedayati et al (2003) found that rectal
analgesia such as diclofenac is effective in reducing pain from perineal trauma within
the first 24 hours after birth and women used less additional analgesia within the first
48 hours after birth. D iclofenac is almost completely protein-bound and therefore
excretion in breast milk is negligible. I n women who had a repair of a fourth-degree
tear diclofenac should be administered orally as insertion of suppositories may be
uncomfortable and there is a theoretical risk of poor healing associated with local anti-
inflammatory agents. Codeine based preparations are best avoided as they may cause
constipation leading to excessive straining and possible disruption of the repair. I t is
of utmost importance that constipation is avoided as passage of constipated stool or
indeed faecal impaction may disrupt the repair. S tool softeners (Lactulose) should be
prescribed for the first 10–14 days postpartum and the dose titrated to keep the stools
soft. The addition of isphagula husk (Fybogel) should be avoided as it has been shown
to be non-beneficial (Eogan 2007). I t is recommended that women with O A S I S be
contacted by a healthcare provider 24 or 48 hours after hospital discharge to ensure
bowel evacuation has occurred (Sultan and Thakar 2007).
Follow-up
S pecial designated multidisciplinary clinics should be available for women with
perineal problems to ensure that they receive appropriate, sensitive and effective
management. A ll women who sustain O A S I S should be assessed by a senior
obstetrician at 6–12 weeks after birth (RCOG 2007). I f facilities are available, follow-up
of women with O A S I S should be in a dedicated clinic with access to endoanal
ultrasonography and anal manometry, as this can aid decision on future mode of birth
(RCOG 2007; Scheer et al 2009).
I n the clinic a genital examination is performed looking specifically for scarring,
residual granulation tissue and tenderness. W here facilities are available, women
would undergo anal manometry and endosonography. The women are assessed by the
physiotherapists and advised to continue pelvic floor exercises while others with
minimal sphincter contractility may need electrical nerve stimulation.
I f a perineal clinic is not available, women with O A S I S should be given clear
instructions, preferably in writing, before leaving the hospital. I n the first six weeks
following birth, they should look for signs of infection or wound dehiscence and call
with any increase in pain or swelling, rectal bleeding, or purulent discharge. A ny
incontinence of stool or flatus should also be reported. Under such circumstances
referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasound and
manometry should be considered (RCOG 2007).
Medicolegal considerations
A lthough creating a third- or fourth-degree tear is seldom found to be culpable,
missing a tear is considered to be negligent. I t is essential that a rectal examination is
performed before and after any perineal repair and findings must be carefully
documented in the notes. D elay in repairing in theatre, poor note-keeping, repair by
untrained personnel, poor lighting and inadequate exposure, inadequate anaesthesia,
failure to recognize extent of the tear, use of wrong suture material, forgo en swab in
the vagina, deviation from recommended safe practice, failure to inform and counsel
the woman, failure to inform the general practitioner, inappropriate follow-up and
advice regarding subsequent pregnancy are common issues raised at litigation. I n the
UK a recent report by the N ational Health S ervice Litigation AuthorityN ( HS LA 2012)
demonstrated that during the review period, from 1 A pril 2000 to 31 March 2010, the
N HS LA received 441 claims in which allegations of negligence were made arising out
of perineal damage (principally third- and fourth-degree tears) caused during labour.
The total value of those claims, including both damages and legal costs, was estimated
to be £31.2 million. A llegations of negligence included failure to consider a caesarean
section or perform or extend the episiotomy, and failure to diagnose the true extent
and grade of the injury including failure to perform a rectal examination. Failure to
perform the repair and the adequacy of the repair itself were also raised as allegations
in this cohort of claims (NHSLA 2012).
Training
Throughout the centuries, midwives have received very li le formal training in the art
of perineal suturing. I n J une 1967, midwives working in the United Kingdom were
permi ed by their then regulatory body, the Central Midwives Board (CMB), to
perform episiotomies, but they were not allowed to suture perineal trauma. I n J une
1970 the Chairman of the CMB issued a statement that midwives who were working in
‘remote areas overseas’ may be authorized by the doctor concerned to repair
episiotomies, provided they have been taught the technique and were judged to be
competent, but the final responsibility lay with the doctor. I t was not until 1983,
however, that perineal repair was included in the midwifery curriculum in the UK,
when the European Community Midwives D irectives came into force and the CMB
issued the statement that midwives may undertake repair of the perineum provided
they received the necessary instruction and are deemed competent to undertake the
procedure (Thakar and Ke le 2010) . Tohill and Ke le (2013) have provided evidence-
based guidelines for midwives on how to suture correctly.
However, it has been reported that there is a lack of general knowledge on the
agreed classification of perineal trauma and that midwives feel inadequately prepared
to assess or repair perineal trauma (Mutema 2007). I t has also been demonstrated that
practitioners require more focused training relating to performing mediolateral
episiotomies. A ndrews et al (2006b) carried out a prospective study over a 12-month
period of women having their first vaginal birth to assess positioning of mediolateral
episiotomies. The depth, length, distance from the midline, the shortest distance from
the midpoint of the anal canal, and the angle subtended from the sagi al or
parasagi al plane were measured following suturing of the episiotomy. Results of the
study demonstrated that no midwife and only 13 (22%) doctors performed a truly
mediolateral episiotomy and that the majority of the incisions were in fact directed
closer to the midline (A ndrews et al 2006b). The current recommendation is that all
relevant healthcare professionals should a end training in perineal/genital
assessment and repair, and ensure that they maintain these skills (NICE 2007).
Box 15.2
A pe rsona l pe rspe ct ive of F G M
Kinsi Clarke
W hen I was asked if I minded sharing a short personal account on the
effects of FGM for inclusion in a textbook for midwives, I was quite hesitant
because the effects of FGM can be different for each woman and girl. But
then I realized that is the whole point – how it affected me is what was asked.
I was born in one of the East A frican countries where the practice of FGM
was, and still is, very prevalent; around 95 to 98 per cent. I remember very
clearly the day I had to face my fate and join a long list of women (older
sister, mother, grandmother, great grandmother, aunties, cousins, etc.) who
went through the same process. There was never any doubt or question that
I , along with all my sisters, would undergo FGM. I t was always a ma er of
when, not if.
I was about 8 years old when the day arrived. A few days earlier I was
told that I would be made clean, proper and a real girl going into
womanhood. I was shown a li le bag, containing a present for me, a new
dress, which I would be allowed to wear on the day. The day before it
happened, my mum said I would not need to do any household chores the
following day and I could sleep longer in the morning, and enjoy a special
breakfast, just for me. I was ge ing really excited about all these special
treats and the promise of being the centre of a ention all day. Li le did I
know what it all meant.
I woke up late that morning, had a full wash, which was itself a treat, put
on my new dress and had a specially prepared breakfast including a small
glass of milk. I t must have been approaching midday when a strange
looking old woman arrived with dusty and dirty looking sack of unknown
contents. My mum, my aunty and a neighbour were already present. My
family lived in the bush where water had to be fetched on the back of a
camel once a fortnight from a village 20 miles away. We lived in a small hut
made of straw and twigs in the middle of the open land. S o there was no
running water, no hygienic environment, and no sanitized equipment. I
was told to empty my bladder (and bowels if necessary) and then join the
ladies. I sat down in the middle, had my dress pulled up towards my
shoulders and the first thing I can remember was a razor blade. I
remember the old lady showing it to my mum, presumably reassuring her
that it was clean and not too rusty. I remember feeling alarmed and
frightened by the sight of the razor blade, and mum reassuring me and
telling me to be a brave girl like so and so, and to fill my mouth with my
dress and keep gripping it with my teeth all the time.
Things became rather too blurred too quickly. The first cut was so sharp
and the pain so indescribable I remember my whole body convulsing
violently and the women using all their strength to keep me still. I can't say
how long it lasted. I think I might have fainted or was paralysed by the pain
but I do not remember struggling too long. I had type I I I FGM where all
the inner and external genitalia including major labia were removed and
then sewn up. The gap that was left open for me to pass water was the size
of the head of a co on bud. I know this because I once went to see a doctor
later, when I was growing up and had an infection, and I remember him
struggling to put a cotton bud into the hole.
Recovery was very painful. I was ‘stitched-up’ using 16 long thorns, 8 in
each direction in an alternate pa ern. The tips of the thorns were broken
off once they were in place to prevent them pricking my groin. However it
was impossible not to feel the heads of the thorns whichever side I lay on.
My legs were tied together and I was told to lie on my side, not on my back
or front, to aid the process of the two edges sealing together. I was not
allowed much food, just a very small amount of porridge and milk every
other day. This was to prevent or minimize bowel movement which could
put pressure in the sewn-up area and cause the sides to become undone.
Passing water was unbearable and I remember how much I hated it and
tried to avoid it by not drinking much. I was told to force myself to urinate
once a day, otherwise the bladder (I was told) would eventually burst, open
everything up, and I would have to go through the whole thing all over
again.
The threat of undergoing the same thing again was so terrifying that I
eventually had to let the water trickle through, stopping it every so often to
catch my breath and bite my dress again. I was aware that a lot of girls
didn't heal properly first time and they had to face being stitched-up again,
but mine sealed up all the way and there was no need to repeat it. I t was 8
days later when the old lady came back, inspected her handiwork and
declared it a success. S he took the thorns out and told me to start walking
with very li le steps. S he also loosened the rope that was tied around my
legs, from the hips to the toes, to stop my legs parting. I remember that so
well because it was the first time in days that I slept a normal, full night's
sleep. The removal of the thorns made sleeping not just possible but so
peaceful and thoroughly enjoyable. A nother week passed before I was
allowed to remove the rope around my legs altogether and walk slowly with
short steps on my own.
A s I said at the start, FGM probably affects every woman and girl
differently. I am not medically trained but I heard many stories of girls
dying during the operation. I have been lucky to the extent that I am alive
and well.
I remember getting vaginal infections three or four times in my late teens
and early 20s. I t was always impossible for the doctor to see what was going
on down there due to the almost total closure of the vagina but they used to
give me oral antibiotics which did not always work. I t used to itch like mad
and smell too during those episodes and I wanted to rip it open so that I
could wash and scratch it well!
W hen I was 18, I remember once asking my aunt who looked after me, if
I could have it opened and leave it that way. S he said it was possible if the
hospital could give us a certificate stating I was opened on medical grounds
necessitating internal treatment. However, said my aunty, my advice would
be not to open yourself (literally and figuratively) to accusations which
would damage your reputation irrevocably and would inevitably lessen
your chances of a good marriage. I took her advice.
N onetheless, in my case, I would say the effects have been more
psychological than physical. O f course I have mutilated genitals, which is a
daily reminder of the brutal way my clitoris and other parts were removed.
I t still takes me a lot longer to pass water than the average ‘intact’ woman,
despite being fully ‘opened-up’ for 17 years. However, the greatest impact
has been the loss of my childhood and the loss of my womanhood. Loss of a
childhood because FGM ended who I was: a happy, carefree, playful and a
popular child who was full of excitement and of the possibilities of what the
future might bring. I emerged as traumatized, subdued, passive, docile,
quiet and indifferent young person who was neither a child nor a woman. I
do not remember playing or behaving like a child after that day. N or was I
expected to be one. This was the passage to womanhood, to prosperity, to a
good marriage and motherhood.
The irony, for me, is that what should have completed me as a woman
deprived me of the very thing.
I n my country women are inspected and opened-up on their wedding
night. I t's every husband's duty to have intercourse with his new bride soon
after the flesh is cut open, to prevent the raw edges sealing up again. I
heard many horror stories from my friends of how painful having sex with
their new husbands was. Those were girls who had no anaesthetic during
the actual procedure of deinfibulation and who then had to face obligatory
‘lawful’ intercourse with their husbands soon after the flesh was sliced
opened; in many cases, with another razor blade. A ny husband who
hesitated to carry out his duty would be considered weak and cowardly,
given that an inspection would take place in the morning to prove that the
groom had ‘had his way’, as indicated by the amount of fresh blood on the
sheets.
A gain I was lucky, or shall I say shrewd, in that I didn't face this second
ordeal of bridal duty because, at the age 25, I married my husband who was
from outside my culture and country. A kind, compassionate and
understanding husband whose main concern was my welfare and comfort.
I underwent deinfibulation by a qualified surgeon, under hygienic
conditions, and I was allowed to heal naturally. N onetheless, I found sexual
intercourse extremely painful and unpleasant. Having lost all sensitive
parts of my genitals, compounded by the tightness of shrunken muscles
that had been sewn up for 17 years, made sex not an enjoyable experience,
but an activity to be avoided. This aversion to intimacy naturally led to me
not conceiving a child and thus not becoming a mother, the very thing FGM
was supposed to prepare me for. O f course this had a significant impact on
my relationship with my husband and my self-image as a woman, but we
are fortunate in that sex is not an essential part of our relationship for
either of us. O n the plus side, I did not have to face further complications
in connection with childbirth.
I would have done anything to have my body left intact as it was and to
have experienced a normal sex life. For most women sex is probably a
pleasurable part of a fulfilled life, but, for me, this was something I never
had the chance to find out. I t is difficult to quantify or to explain how FGM
affected me; it has been a life-long physical and psychological pain which
will remain with me for as long as I live. I made a conscious decision not to
resent or hate my dear mum (who has now sadly passed away) and others
who, I am sure, in their own minds, were doing me a good deed. A nd yet I
cannot get the anger and the sense of being robbed of something precious,
the sense of betrayal by the very people I trusted most, out of my head.
I could write a book on the visible and invisible damage caused to me by
the imposition of type I I I FGM at such a tender age, so could every other
victim; but, as midwives supporting women and girls living with the
physical and mental scaring of FGM, I hope this short account will give you
some sense of what it is like for us.
References
Aasheim V, Nilsen A B V, Lukasse M, et al. Perineal techniques during the
second stage of labour for reducing perineal trauma. Cochrane Database of
Systematic Reviews. 2011.
Al-Hussaini TK. Female genital cutting: types, motives and perineal damage in
laboring Egyptian women. Medical Principles and Practice. 2003;12(2):123–128.
Andrews V, Thakar R, Sultan AH. Occult anal sphincter injuries. Myth or reality?
BJOG: An International Journal of Obstetrics and Gynaecology. 2006;113:195–200.
Andrews V, Sultan AH, Thakar R, et al. Are mediolateral episiotomies actually
mediolateral. BJOG: An International Journal of Obstetrics and Gynaecology.
2006;113:24–26.
Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal
trauma. Cochrane Database of Systematic Reviews. 2006.
Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic
Reviews. 2009.
Chan SS, Cheung RY, Lee LL, et al. Prevalence of levator ani muscle injury in
Chinese women after first delivery. Ultrasound in Obstetrics and Gynecology.
2012;36(6):704–709.
De Silva S. Obstetric sequelae of female circumcision. European Journal of
Obstetrics, Gynecology and Reproductive Biology. 1989;32:233–240.
Draper J, Newell R. A discussion of some of the literature relating to history,
repair and consequences of perineal trauma. Midwifery. 1996;12(3):140–145.
Elnashar A, Abdelhady R. The impact of female genital cutting on health of
newly married women. International Journal of Gynaecology and Obstetrics.
2007;97:238–244.
Eogan M, Daly L, Behan M, et al. Randomised clinical trial of a laxative alone
versus a laxative and a bulking agent after primary repair of obstetric anal
sphincter injury. BJOG: An International Journal of Obstetrics and Gynaecology.
2007;114:736–740.
Fernando R, Sultan AH, Kettle C, et al. Methods of repair for obstetric anal
sphincter injury. Cochrane Database of Systematic Reviews. 2006.
Green J, Coupland V, Kitzinger J. Great expectations: a prospective study of women's
expectations and experiences of childbirth. Books for Midwives Press: Hale,
Cheshire; 1998.
Groutz A, Hasson J, Wengier A, et al. Third- and fourth-degree perineal tears:
prevalence and risk factors in the third millennium. American Journal of
Obstetrics and Gynecology. 2011;204(4):347.
Gupta JK, Hoymeyr GJ, Smyth R. Position in the second stage of labour for
women without epidural anaesthesia. Cochrane Database of Systematic Reviews.
2004.
Hassanin IM, Saleh R, Bedaiwy AA, et al. Prevalence of female genital cutting in
Upper Egypt: 6 years after enforcement of prohibition law. Reproductive
Biomedicine. 2008 [Accessed online at] www.rbmonline.com.
Hedayati H, Parsons J, Crowther C. Rectal analgesia for pain from perineal
trauma following childbirth. Cochrane Database of Systematic Reviews. 2003.
Home Office. Circular 10/2004: The Female Genital Mutilation Act 2003. Home
Office: London; 2004 www.circulars.homeoffice.gov.uk.
Kalis V, Laine K, de Leeuw JW, et al. Classification of episiotomy: towards a
standardisation of terminology. BJOG: An International Journal of Obstetrics and
Gynaecology. 2012;119(5):522–526.
Kettle C, Dowswell T, Ismail K. Absorbable suture materials for primary repair
of episiotomy and second degree tears. Cochrane Database of Systematic Reviews.
2010.
Kettle C, Fenner D. Repair of episiotomy, first and second degree tears. Sultan
AH, Thakar R, Fenner D. Perineal and anal sphincter trauma. Springer: London;
2007:20–32.
Kettle C, Hills R, Ismail K. Continuous versus interrupted sutures for repair of
episiotomy or second-degree tears. Cochrane Database of Systematic Reviews.
2007.
Kettle C, Raynor MD. Perineal management and repair. Marshall J E M, Raynor
MD. Advancing skills in midwifery practice. Churchill Livingstone: Edinburgh;
2010:104–120.
Kettle C. Evidence based guidelines for midwifery-led care in labour: suturing the
perineum. Royal College of Midwives: London; 2012.
Millogo-Traore F, Kaba ST, Thieba B, et al. Maternal and foetal prognostic in
excised women delivery. [[In French]] Journal de Gynecologie, Obstetrique et
Biologie de la Reproduction. 2007;36:393–408.
Mutema EK. ‘A tale of two cities’: auditing midwifery practice and perineal
trauma. British Journal of Midwifery. 2007;15(8):511–513.
NHSLA (National Health Service Litigation Authority). Ten years of maternity
claims: an analysis of NHS Litigation Authority data. NHSLA: London; 2012.
NICE (National Institute for Health and Clinical Excellence). Intrapartum care:
care of healthy women and their babies, CG 55. NICE: London; 2007.
NICE (National Institute for Health and Clinical Excellence). Antenatal care.
Routine care for the healthy pregnant women, CG 62. NICE: London; 2008.
RCOG (Royal College of Obstetricians and Gynaecologists). Management of third
and fourth degree perineal tears following vaginal delivery. Guideline No. 29.
RCOG: London; 2007.
RCOG (Royal College of Obstetricians and Gynaecologists). Female genital
mutilation and its management. Guideline No. 53. RCOG: London; 2009.
Scheer I, Thakar R, Sultan AH. Mode of delivery after previous obstetric anal
sphincter injuries (OASIS) – a reappraisal. International Urogynecology Journal.
2009;20:1095–1101.
Sultan AH, Kamm MA, Hudson CN, et al. Anal sphincter disruption during
vaginal delivery. New England Journal of Medicine. 1993;329:1905–1911.
Sultan AH, Kettle C. Diagnosis of perineal trauma. Sultan AH, Thakar R, Fenner
D. Perineal and anal sphincter trauma. Springer-Verlag: London; 2007:13–19.
Sultan AH, Thakar R. Third and fourth degree tears. Sultan AH, Thakar R,
Fenner D. Perineal and anal sphincter trauma. Springer-Verlag: London; 2007:33–
51.
Thakar R, Kettle C. Episiotomy and perineal repair. Cardozo L, Staskin D.
Textbook of female urology and urogynecology. 3rd edn. Martin Dunitz:
Hampshire; 2010:875–882.
Tohill S, Kettle C. How to suture correctly. Midwives. 2013;1:31 www.rcm.org.
WHO (World Health Organization). Management of pregnancy, childbirth and
postpartum period in the presence of female genital mutilation. WHO: Geneva;
2001.
WHO (World Health Organization). Eliminating female genital mutilation. WHO:
Geneva; 2008.
WHO (World Health Organization). Female genital mutilation. Fact sheet number
241. WHO: Geneva; 2013.
Further reading
Bick DE, Ismail K M K, Macdonald S, et al. How good are we at implementing
evidence to support the management of birth related perineal trauma? A UK-
wide survey of midwifery practice. BMC Pregnancy and Childbirth. 2012;12:57.
An informative article, which identifies considerable gaps with implementation of
evidence to support management of perineal trauma..
Chapman V. Clinical issues: issues affecting the left-handed midwife. British
Journal of Midwifery. 2009;17(9):588–592.
This is a useful read for the left-handed practitioner..
HM Government. Multi agency practice guidelines on female genital mutilation. HM
Government: London; 2011 www.dh.gov.uk.
Kettle C. Evidence based guidelines for midwifery led care in labour: care of the
perineum. Royal College of Midwives: London; 2012.
These guidelines summarize the evidence in an accessible way..
Useful websites
Female Genital Mutilation Clinical Group. www.fgmnationalgroup.org.
The FGM National Clinical Group is a registered charity in England & Wales:
1125319..
Foundation for Women's Health Research and Development.
www.forwarduk.org.uk.
National Patient Safety Agency. www.npsa.nhs.uk.
National Society for the Prevention of Cruelty to Children. www.nspcc.org.uk.
World Health Organization. www.who.int.
C H AP T E R 1 6
Physiology and care during the first stage
of labour
Karen Jackson, Jayne E Marshall, Susan Brydon
CHAPTER CONTENTS
Defining labour 328
The onset of spontaneous physiological labour 328
Recognition of the onset of labour 329
Latent phase of labour 329
Active phase of labour 329
Transitional phase of labour 329
Physiology of the first stage of labour 330
Duration 330
Cervical effacement 330
Cervical dilatation 330
Uterine action 330
Mechanical factors 332
Recognition of the first stage of labour 333
Initial meeting with the midwife 334
The language of childbirth 334
Communication 334
Interpreting services 334
Birth plan 334
Emotional and psychological care 335
Companion in labour 335
The concept of continuous support in labour 336
The physical environment 336
Reducing the risk of infection 336
The midwife's initial physical examination of the woman 337
Records 338
Subsequent care in the first stage of labour 338
Assessing progress 338
Assessing the wellbeing of the woman 340
Cleanliness and comfort 343
Position and mobility 343
Nutrition in labour 343
Bladder care 344
Medicine records 344
Assessing the wellbeing of the fetus 344
Intermittent auscultation 344
Continuous electronic fetal monitoring 345
Interpretation of the cardiotocograph 345
Fetal blood sampling 347
Women's control of pain during labour 349
The physiology of pain 349
Theories of pain 351
Physiological responses to pain in labour 352
Non-pharmacological methods for pain control in labour 352
Pharmacological methods for pain control 353
First stage of labour: vaginal breech at term 356
Incidence of breech presentation 356
Types of breech presentation and position 357
Diagnosis of breech presentation 357
Mode of birth: the evidence 359
Place of birth 360
Posture for labour and birth 360
Care in labour 360
Prelabour rupture of fetal membranes at term (PROM) 361
The responsibilities of the midwife 361
References 361
Further reading 366
Useful websites 366
Birth is a dynamic and transforming experience, both on an individual and a
societal level, and has the power to profoundly affect the lives of those
involved. It is a physiological process characterized by non-intervention, a
supportive environment and empowerment of the woman (Lavender et al
2009; Walsh 2012).
The midwife is a key figure in this process, supporting and assisting women
safely through childbirth, recognizing the woman's needs and wellbeing are
central rather than the needs of the maternity service. Consequently, the
midwife is required to be a caring supporter, advocate, skilled practitioner,
vigilant observer and an accurate recorder of facts. Women have differing
needs and the way they approach and experience birth is unique and will
depend on a number of factors, including cultural background, education,
personal beliefs and previous life experience. In order to meet these varying
needs, the midwife should possess wide-ranging skills and knowledge and
have the willingness to place the woman at the centre of the care that is
provided for her. Women and their chosen birth companion(s) should have
an equal partnership with health professionals in all decision-making
processes, so that they can make informed choices about their own labours
and births.
The chapter aims to:
• describe the physical changes taking place as labour progresses
• explore the factors that contribute to a positive birth experience for the woman,
including communication, environment, support, assessment and monitoring
• reflect on the care and support that can optimize the wellbeing of the woman and her
fetus during the course of labour
• consider the various ways in which midwives can support women to work with/relieve
the pain of labour
• describe the principles in the assessment and care of labours presenting by the breech
• reflect on the midwife's role in caring for women who present with prelabour rupture of
the fetal membranes.
Defining labour
A human pregnancy is considered to last approximately 40 weeks, with labour usually
occurring between 37 and 42 weeks' gestation (N ational I nstitute for Health and
Clinical Excellence [N I CE] 2007) (seeChapter 9). Complex physiological and
psychological changes occur during the last few weeks of pregnancy, and also during
the onset of labour, that prepare the woman for the process of labour and birth (Howie
and Novak 2010; McNabb 2011; Walsh 2012) (see Chapter 9).
Labour, purely in the physical sense, may be described as the process by which the
fetus, placenta and membranes are expelled through the birth canal; however, labour
is much more than a purely physical event. W hat happens during labour can affect the
relationship between the mother and baby and can influence the likelihood and/or
experience of future pregnancies.
The W orld Health O rganization (W HO ) definesnormal labour as one that is low risk
throughout, spontaneous in onset with the fetus presenting by the vertex, culminating
in the mother and infant being in good condition following birth (W HO 1999).
However, a labour where the fetus is presenting by the breech with no other risk factors
should also be considered normal (Burvill 2005). Furthermore, all definitions of labour
appear to be purely physiological and do not encompass the psychological wellbeing
of the woman.
Traditionally, three stages of labour are described: the first, second and third stage,
but this is a rather pedantic view, as labour is obviously a continuous process. I t has
also been acknowledged that there are more than three stages of labour, namely the
latent, active and transitional phases, and these not only encompass specific physical
changes but should also account for the emotional effects observed in women during
this time.
Labour for each woman has its own unique ebbs and flows. Walsh (2010a) describes
this as labour rhythms. However, as labour tends to be described and recognized
universally as having distinct stages of labour, this approach will be adopted for the
purposes of this text. The first stage of labour is usually recognized by the onset of
regular uterine contractions, an accompanying effacement and at least 4 cm dilatation
of the cervix and finally culminates in full dilatation of the cervix (N I CE 2007; Howie
and Rankin 2010).
The onset of spontaneous physiological labour
The onset of labour is determined by a complex interaction of maternal and fetal
hormones and is not fully understood. I t would appear to be multifactorial in origin,
being a combination of hormonal and mechanical factors. Levels of maternal
oestrogen rise sharply during the last weeks of pregnancy, resulting in changes that
overcome the inhibiting effects of progesterone. High levels of oestrogens cause
uterine muscle fibres to display oxytocic receptors and form gap junctions with each
other. O estrogen also stimulates the placenta to release prostaglandins that induce a
production of enzymes that will digest collagen in the cervix, helping it to soften
(Tortora and Grabowski 2011). The process is unclear but it is thought that both fetal
and placental factors are involved. There is no clear evidence that concentrations of
oestrogens and progesterone alter at the onset of labour, but the balance between
them does facilitate myometrial activity. Uterine activity may also result from
mechanical stimulation of the uterus and cervix. This may be brought about by
overstretching, as in the case of a multiple pregnancy, or pressure from a presenting
part that is well applied to the cervix (Impey and Child 2012).
Recognition of the onset of labour
The onset of labour is a process, not an event; therefore it is very difficult to identify
exactly when the painless (sometimes painful) contractions of prelabour develop into
the progressive rhythmic contractions of established labour. D iagnosing the onset of
labour is extremely important, since it is on the basis of this finding that decisions are
made that will affect the intrapartum care and support subsequently provided (NICE
2007; Zhang et al 2010).
I t is part of the role of the midwife to ensure that women have sufficient
information to assist them in recognizing the onset of established labour. This
information is also needed to enable women to make informed choices based on
current and unbiased evidence. The complex physical, psychological and emotional
experience of labour affects every woman differently and midwives must have sound
knowledge and experience to enable the woman to maintain control over the birth of
her baby. W omen in labour should be encouraged to trust their own instincts, listen to
their own body and verbalize feelings in order to receive the help and support they
require. A nxiety can increase the production of adrenaline (epinephrine), which
inhibits uterine activity and may in turn prolong labour (Simkin and Ancheta 2011).
I rrespective of whether they have given birth before, many women experience
contractions before the onset of labour which may be painful and regular for a time,
causing them to think that labour has started. Furthermore, some women's lived
experiences of early labour report prolonged contractions or being in labour for days and
thus it is important to note that the discomfort or even pain that the woman is
conscious of is genuine to her. A lthough the contractions that the woman is
experiencing are real, they have yet to se le into the rhythmic pa ern of established
labour, resulting in effacement and dilatation of the cervix. Using terminology such as
spurious or false labour is unhelpful and typically negative in terms of women's genuine
experiences of early labour (Walsh 2012). Reassurance should be given and discussion
of this potential situation earlier in the pregnancy can enable the woman and her
partner to prepare for labour more effectively. Contact with the midwife should be
made when regular, rhythmic, uterine contractions are experienced, and these are
perceived by the woman as uncomfortable or painful.
Latent phase of labour
T he latent phase of labour is prior to the active phase stage of labour and may last 6–8
hours in primigravidae when the cervix dilates from 0 cm to 4 cm dilated (Howie and
Rankin 2010), although McD onald (2010) argues that the latent phase of labour is so
subjective and poorly understood that a normal range is difficult to measure.
A ccording to Mukhopadhyay and Fraser (2009) the cervical canal shortens from 3 cm
long to <0.5 cm in length during this time.
A woman may believe herself to be labouring, whereas sound midwifery judgement
and understanding of the physiology of the first stage of labour may lead the midwife
to the diagnosis of the latent phase of labour. Both the woman and midwife being
aware of the latent phase of labour, and allowing this time to pass with no
intervention, can prevent the medical diagnosis of poor progress or failure to progress
later in labour. I n a hospital se ing, it is good practice not to commence the
partogram until active labour has commenced. A ssessing the active phase of labour has
been highlighted as essential in reducing interventions in normal labour (Lauzon and
Hodnett 2009).
Active phase of labour
T he active phase within the first stage of labour is the time when the cervix usually
undergoes more rapid dilatation. This begins when the cervix is at least 4 cm dilated
and, in the presence of rhythmic contractions, progressively dilates to 10 cm or full
dilatation.
W hen in labour, contractions will often be accompanied or preceded by a
bloodstained mucoid show: that is, the release of the operculum from the cervical canal
as effacement and dilatation progresses. O ccasionally, the membranes will rupture, at
which stage the midwife may seek assurance that there are no significant changes in
the fetal heart rate due to the rare complication of cord prolapse and that meconium is
not present in the liquor, indicating fetal compromise.
Transitional phase of labour
The transitional phase of the first stage of labour is from when the cervix is around 8 cm
dilated until it is fully dilated or until expulsive contractions associated with the
second stage of labour are felt by the woman. There is often a brief lull in the intensity
of uterine activity at this time. Many women may feel the urge to push during
transition. I n addition to physiological responses, women can experience a range of
experiences and emotions. W oods (2006) describes this as being from inner calm to
acute distress. The woman may verbalize her distress, direct it at her birth partner(s),
alternatively she may be quiet and contemplative.
Physiology of the first stage of labour
Duration
The length of labour varies widely and is influenced by parity, birth interval,
psychological state, presentation and position of the fetus. Maternal pelvic shape and
size and the character of uterine contractions also affect timescale.
By far the greatest part of labour is taken up by the first stage and it is common to
expect the active phase to be completed within 6–12 hours (Tortora and Grabowski
2011). O ver the years there has been much debate surrounding the length of
physiological active labour in low-risk populations of childbearing women to refute
the original claim of Friedman (1954) that cervical dilatation occurred at the rate of
1 cm per hour (Albers 1999; Lavender et al 2006; Zhang et al 2010). A cervical dilatation
rate of 0.5 cm per hour, however, has now been incorporated into the N I CE (2007)
intrapartum guidelines as being within the parameters of normal labour.
Cervical effacement
Effacement refers to the inclusion (taking up) of the cervical canal into the lower uterine
segment. I t is believed that this process takes place from above downward, meaning
that the muscle fibres surrounding the internal os are drawn upwards by the retracted
upper segment and the cervix merges into the lower uterine segment. The cervical
canal widens at the level of the internal os, whereas the state of the external os remains
unchanged (Cunningham et al 2010) (Fig. 16.1).
FIG. 16.1 (A) The cervix before effacement. (B) The cervix after effacement. The cervical canal
is now part of the lower uterine segment.
Effacement may occur late in pregnancy, or it may not take place until labour
begins. I n the nulliparous woman the cervix will not usually dilate until effacement is
complete, whereas in the multiparous woman, effacement and dilatation usually
occurs simultaneously and a small canal may be felt in early labour. This is often
referred to by midwives as a multips os (Howie and Rankin 2010).
Cervical dilatation
Dilatation of the cervix is the process of enlargement of the os uteri from a tightly
closed aperture to an opening large enough to permit passage of the fetus. D ilatation
is assessed in centimetres and full dilatation at term equates to about 10 cm. However,
acknowledging that all women are different sizes and shapes means that full cervical
dilatation may be between 9 and 11 cm in individual women (Walsh 2012).
D ilatation occurs as a result of uterine action and the counter-pressure applied by
either the intact bag of membranes or the presenting part, or both. A well-flexed fetal
head closely applied to the cervix favours efficient dilatation. Pressure applied evenly
to the cervix causes the uterine fundus to respond by contraction and retraction, often
referred to as the Ferguson reflex (Howie and Rankin 2010).
Uterine action
Fundal dominance (Fig. 16.2)
Each uterine contraction commences in the fundus near one of the cornua and spreads
across and downwards. The contraction lasts longest in the fundus, where it is also
most intense, but the peak is reached simultaneously over the whole uterus and the
contraction fades from all parts together. This pa ern permits the cervix to dilate and
the strongly contracting fundus to eventually expel the fetus at the end of labour
(Howie and Rankin 2010).
FIG. 16.2 Series of diagrams to show fundal dominance during uterine contractions.
Polarity
Polarity is the term used to describe the neuromuscular harmony that prevails
between the two poles or segments of the uterus throughout labour. D uring each
uterine contraction, these two poles act harmoniously. The upper pole contracts
strongly and retracts to expel the fetus; the lower pole contracts slightly and dilates to
allow expulsion to take place. I f polarity is disorganized then the progress of labour is
inhibited (Bernal and Norwitz 2012).
Contraction and retraction
Uterine muscle has a unique property. D uring labour the contraction does not pass off
entirely, as muscle fibres retain some of the shortening of contraction instead of
becoming completely relaxed (Fig. 16.3). This is termed retraction. This process assists
in the progressive expulsion of the fetus, such that the upper segment of the uterus
becomes gradually shorter and thicker and its cavity diminishes.
FIG. 16.3 Diagram to show how uterine muscle retains some shortening after each contraction.
Intensity and resting tone
Each labour is individual and does not always conform to expectations, but generally
before labour becomes established, uterine contractions may occur every 15–20
minutes, lasting for about 30 seconds. They are often fairly weak and may even be
imperceptible to the woman. The contractions usually occur with rhythmic regularity
and the intervals between them where the muscle relaxes (resting tone) gradually
lessen while the length and strength gradually intensifies through the latent phase
and into the active phase of the first stage of labour. By the end of the first stage, the
contractions may occur at 2–3 minute intervals, last for 50–60 seconds and are very
powerful (Cunningham et al 2010).
Formation of upper and lower uterine segments
By the end of pregnancy, the body of the uterus is described as having divided into
two segments, which are anatomically distinct (Fig. 16.4). The upper uterine segment,
having been formed from the body of the fundus, is mainly concerned with
contraction and retraction, and is thick and muscular. The lower uterine segment is
formed of the isthmus and the cervix, and is about 8–10 cm in length. The lower
segment is prepared for distension and dilatation. Although there is no clear and strict
division of these two segments, the muscle content reduces from the fundus to the
cervix, where it is thinner. W hen labour begins, the retracted longitudinal fibres in the
upper segment pull on the lower segment causing it to stretch. This is aided by the
force applied by the descending presenting part (Howie and Rankin 2010; I mpey and
Child 2012).
FIG. 16.4 Birth canal before labour begins.
The retraction ring
A ridge develops between the upper and lower uterine segments, known as the
retraction ring (Fig. 16.5). The physiological retraction ring gradually rises as the upper
uterine segment contracts and retracts and the lower uterine segment thins out to
accommodate the descending fetus. O nce the cervix is fully dilated and the fetus can
leave the uterus, the retraction ring rises no further. However, in extreme cases of
mechanically obstructed labour, this physiological retraction ring becomes visible above
the symphysis pubis and is described as Bandl's ring. A Bandl's ring may consequently
be associated with fetal compromise (Lauria et al 2007).
FIG. 16.5 Diagram showing the retraction ring (R) between the upper and lower uterine
segments.
Show
A s a result of the dilatation of the cervix, the operculum, which formed the cervical
plug during pregnancy, is released. The woman may observe a bloodstained mucoid
discharge a few hours before, or within a few hours after, labour commences. The
blood comes from ruptured capillaries in the parietal decidua where the chorion has
become detached from the dilating cervix and should only be a staining (I mpey and
Child 2012). Frank, fresh bleeding is atypical at this stage, although during the
transitional phase and as the first stage ends, there is often a small loss of bright red
blood that heralds the second stage of labour. Both occurrences may be referred to as a
show.
Mechanical factors
Formation of the forewaters and hindwaters
A s the lower uterine segment forms and stretches, the chorion becomes detached
from it and the increased intrauterine pressure causes this loosened part of the sac of
fluid to bulge downwards into the internal os, to the depth of 6–12 mm. The well-
flexed fetal head fits snugly into the cervix and cuts off the amniotic fluid in front of
the head from that which surrounds the body, forming two separate pools of fluid. The
former is known as the forewaters and the la er, the hindwaters. I n early labour it is
often possible to feel intact forewaters bulging even when the hindwaters have
ruptured, making ruptured membranes a difficult diagnosis at times.
The effect of separation of the forewaters prevents the pressure that is applied to the
hindwaters during uterine contractions from being applied to the forewaters. This may
help keep the membranes intact during the first stage of labour and be a natural
defence against ascending infection (Bernal and Norwitz 2012).
General fluid pressure
W hile the membranes remain intact, the pressure of the uterine contractions is
exerted on the amniotic fluid and, as fluid is not compressible, the pressure is
equalized throughout the uterus and over the fetal body, known as general fluid
pressure (Fig. 16.6). W hen the membranes rupture and a quantity of fluid emerges, the
fetal head, the placenta and umbilical cord are compressed between the uterine wall
and the fetus during contractions with a consequential reduction in the oxygen supply
to the fetus. Preserving the integrity of the membranes, therefore, optimizes the
oxygen supply to the fetus and also helps to prevent intrauterine and fetal infection
(Howie and Rankin 2010).
FIG. 16.6 General fluid pressure.
Rupture of the membranes
The optimum physiological time for the membranes to rupture spontaneously is at the
end of the first stage of labour, after the cervix becomes fully dilated and no longer
supports the bag of forewaters. The uterine contractions are also applying increasing
expulsive force at this time.
The membranes may sometimes rupture days before labour begins or during the
first stage. I f for any reason there is a badly fi ing presenting part and the forewaters
are not separated effectively then the membranes may rupture early. However, in most
cases there is no apparent reason for early spontaneous membrane rupture.
O ccasionally the membranes do not rupture even in the second stage and appear at
the vulva as a bulging sac covering the fetal head as it is born; this is known as the
caul.
Early rupture of membranes may lead to an increased incidence of variable
decelerations on cardiotocography (CTG), resulting in an increase in caesarean
sections if fetal blood sampling is not available (A lfirevic et al 2013). A systematic
review found that routine artificial rupture of membranes (A RM) does not
significantly reduce the length of labour and thus routine amniotomy should not be
performed (S myth et al 2007). However, there was some evidence that A RM increased
the rate of caesarean section but this finding did not reach significance. A ll women are
required to give consent for this intervention and the midwife should have a clear
indication for performing an A RM: details of which should be recorded in the
woman's labour records (Nursing and Midwifery Council [NMC] 2009, 2012).
Fetal axis pressure
D uring each contraction, the uterus rises forward and the force of the fundal
contraction is transmi ed to the upper pole of the fetus, down the long axis of the
fetus and applied by the presenting part to the cervix. This is known as fetal axis
pressure (Fig. 16.7) and becomes much more significant after rupture of the
membranes and during the second stage of labour.
FIG. 16.7 Fetal axis pressure.
Recognition of the first stage of labour
I t is the woman herself who usually diagnoses the onset of normal labour and many
women and their partners are apprehensive in case the labour is very quick, resulting
in an una ended birth. Education during pregnancy is important to enable the woman
to recognize the beginning of labour and understand the latent phase in order to
consider possible strategies she may use for labour and birth.
W omen should appreciate that in late pregnancy vaginal secretions without any
bloodstaining increase. I n addition, they should be aware that a show, which is usually
a pink or bloodstained jelly-like loss, prior to the onset of labour or in early labour, is
quite common. I f a woman is examined vaginally in late pregnancy they should also be
informed that there may be some slight blood loss after the procedure.
Braxton Hicks contractions are more noticeable in late pregnancy and some women
experience them as painful. They are usually irregular or their regularity is not
maintained for long spells of time, seldom lasting more than one minute. I n active
labour, contractions exhibit a pa ern of rhythm and regularity, usually increasing in
length, strength and frequency as time goes on. W hen the woman first feels
contractions she may be aware only of backache, but if she places a hand on her
abdomen she may perceive simultaneous hardening of the uterus. I f the pregnancy
has been problem-free, with a normal birth anticipated, the midwife should advise the
woman to stay in her own surroundings, continue with her normal activities, to eat, be
active and upright.
I t is sometimes difficult to be certain whether or not the membranes have ruptured
spontaneously prior to labour or in early labour. The woman may be experiencing
some degree of stress incontinence, so she may be unsure if it is liquor or urine that
she is passing. I f there is any doubt, the woman should contact her midwife who may
decide to insert a speculum into the vagina to observe for any amniotic fluid. D igital
examination should be avoided if the woman is not in labour as it can increase the risk
of ascending infection (Shepherd et al 2010).
Initial meeting with the midwife
I deally, the woman should know her own midwife and be able to contact her when
labour starts. W here this is not possible, it is crucial that the first meeting between the
midwife, the labouring woman and her partner establishes a rapport, which sets the
scene for the remainder of labour. I f the woman is planning to birth in hospital, she
may worry about the reception she and her companion will receive and the a itude of
the people a ending her. I n addition, an unfamiliar environment may provoke
feelings of vulnerability and undermine her confidence. Comfortable surroundings, a
welcoming manner and a midwife who greets the woman as an equal in a partnership
will engender feelings of mutual respect, thus enabling the woman to relax and
respond positively to the amazing forces of labour and to her baby after it is born
(Berry 2006; Fisher et al 2006; Raynor and England 2010).
The language of childbirth
I t has been recognized that some of the childbirth terminology used when
communicating with women appears medical, masculine and negative (Robertson
2003). The terms pain and labour are suggestive of difficulty and trouble. I t is therefore
vital the midwife observes what she says to women during childbirth and uses
appropriate and adapted language which is woman-friendly. The word delivery has
been replaced by the term birthing or birth as these appear more suitable when
discussing the concept and practice of normality within midwifery.
Communication
The key issues for women relate to achieving a safe birth, feeling in control within the
birth environment, developing supportive relationships with their carers, and being
treated with kindness, respect, dignity and cultural sensitivity if they are to realize a
positive experience of birth (Helman 2007; Main and Bingham 2008; Redshaw and
Heikkila 2010). Effective communication between the midwife and the woman and her
partner, and with other clinicians in the multidisciplinary team, is essential to
providing effective safe supportive care in labour and achieving the woman's
objectives (Royal College of O bstetricians and Gynaecologists [RCO G] 2008 ).
Communication does not consist only of the content of what is said, but also includes
non-verbal communication and written records, such as the woman's birth plan.
Poor communication is the commonest cause of preventable adverse outcomes in
hospitals and remains a significant cause of wri en complaints ( Health and S ocial
Care I nformation Centre 2012). A n inquiry conducted by the Kings Fund into the
safety of birth in England concluded that the overwhelming majority of births are safe
but when there are increased risks to the woman or baby, that render some births less
safe, functioning teams are the key to improving the outcome for the woman and baby
(Kings Fund 2008).
Interpreting services
I f the woman and midwife are unable to understand each other, communication will
be ineffective and it is essential that adequate interpretation services are available
when necessary. A lthough there is a tendency to rely on family members or friends to
provide interpreting services, the use of such interpreters is deemed inappropriate
when the midwife wishes to discuss sensitive issues such as past history, domestic
abuse or the need for interventions. W herever possible, professional interpretation
services should be provided for all non-English-speaking women (Centre for Maternal
and Child Enquiries [CMA CE] 2011 ). I f a face-to-face interpreter cannot be obtained,
then the use of a telephone or Internet interpretation service should be considered.
Birth plan
Regardless of where the woman plans to give birth, a birth plan is a valuable tool for
midwives to observe and use to facilitate the provision of holistic, individualized care.
This is especially so in situations where the maternity care is fragmented and the
woman first encounters the midwife who will be caring for her in labour when she
a ends the hospital to give birth. The birth plan therefore provides the opportunity
for the midwife to discuss with each woman and her partner any plans about the type
of birth they would like that they may have already prepared with support from their
community midwife. A n outline may be present in the case notes, or the couple may
bring a birth plan with them. Frequently, the partner is involved in this forward
planning, which should be a flexible proposal that can be reviewed and revised as
labour progresses (D epartment of Health [D H] 2007). S ome women, however, may not
have prepared a birth plan and so the midwife should encourage them to consider any
preferences that they may have, for example:
• her choice of birth companion(s)
• her choice of clothes for labour
• ambulation and fetal monitoring (intermittent, electronic or a combination)
• strategies for labour (water immersion, massage, pharmacological pain relief)
• position for labour and birth
• expectant or actively managed third stage of labour
• cutting of the umbilical cord
• skin-to-skin contact and feeding the baby after birth.
Having the opportunity to discuss such issues in early labour enables the
establishment of a trusting relationship between the woman and the midwife to
develop where the woman feels valued and involved in intrapartum decision-making:
all details of which should be clearly documented in the intrapartum records (NMC
2009, 2012).
Emotional and psychological care
W hen a woman begins to labour, she may have a mixture of emotions. Most women
anticipate labour with a degree of excitement, anxiety, fear and hope. Many other
emotions are influenced by cultural expectations and previous life experiences. The
state of the woman's knowledge, her fears and expectations are also influenced by her
companions during labour, including the attitude and behaviour of the caregiver.
By the time labour starts, a decision will already have been reached about where the
woman plans to give birth. S ome women may choose to give birth at home, some in a
midwife-led unit/birthing centre and others in hospital. S ome women may also wish to
labour as long as possible at home but give birth in hospital. W hatever choice the
woman makes, she must be the focus of the care, able to feel she is in control of what
is happening and contributing to the decisions made about her care (S inivaara et al
2004; D H 2007). Hodne et al (2012) assert that there is a powerful effect on maternal
birth satisfaction and labour progress where women feel in control and involved in
decision making.
Providing that there are no complications and labour is not well advanced, the
woman may remain at home as long as she feels comfortable and confident. I f labour
commences prior to term, however, admission to hospital is always advised (Chapter
12).
Companion in labour
The fact that women should be encouraged to have support by birth partners of their
choice is well recognized (N I CE 2007; Midwives I nformation Resource S ervice
[MI D I RS ] 2008a
). The woman herself is central to all the decisions made about care
during labour and her chosen companion, whether sexual partner, friend or family
member, should understand this. I deally the companion should be involved in
prelabour preparation and decision-making, have participated in compiling a birth
plan and be aware of all the available options.
I f the woman is giving birth in hospital, admission to a labour ward can be an
alienating experience and the company of a supportive companion can help reduce
anxiety. D uring labour, the companion should be made to feel useful and part of the
team by the midwife, as they too may be feeling anxious (Longworth and Kingdon
2010). S uch activities may include massaging the woman's back, offering drinks,
assisting with breathing and relaxation awareness and supporting her decisions
regarding her strategies for working with, or controlling, pain.
I n some cases a midwife will be able to remain with one woman through her entire
labour, but due to the unpredictable workloads and staffing levels this is not always
possible. This can leave the woman feeling unsupported and processed, rather than
cared for and can have profound negative effects on a woman's satisfaction and
memory of the birth (Kirkham 2011). D espite such constraints it is not appropriate to
use the birth partner as a substitute for close observation and a endance by the
midwife. Equally so, the midwife should also recognize the need for the couple to have
some personal space and leave them alone, albeit with the means to summon
assistance should it be required. This would not be acceptable, however, when labour
is well advanced, as being left alone could prove very frightening for the woman and
her partner.
I t would be a mistake to consider that all women have the same requirements,
however, women have varying needs, with some preferring presence and others
preferring complete privacy. The task for the midwife is to provide the individualized
service that ensures that the woman feels safe and supported. D espite the aim to
provide a good outcome for the woman, there is no doubt that a proportion of women
are dissatisfied with the birthing experience and some are positively traumatized by
their experience (Ayers et al 2008).
I t is also important to ensure that support is available to the partner when it is
needed if the woman is in significant pain or a sudden emergency develops and they
are encouraged to take short breaks during a prolonged labour. I f a caesarean section
becomes necessary, the midwife should delegate someone to keep the partner
informed so they are not left feeling abandoned or uncared for.
The concept of continuous support in labour
There is evidence that the presence of the midwife and one-to-one personal a ention
is positively associated with a woman's satisfaction with her care. Kennedy et al (2010)
describe that the presence and demeanour of the midwife can enhance the woman's
trust in her own ability to cope. I n a systematic review by Hodne et al (2011), the
value of continuous support during labour and birth is clearly evident. The review,
consisting of 21 randomized clinical trials, involving over 15 000 women, showed
evidence that women who laboured with continuous support had shorter labours and
were less likely to experience intrapartum interventions. These women were also less
likely to have an epidural or other forms of pain medication, give birth by caesarean
section, ventouse or forceps and consequently appeared more satisfied with their
overall experience of childbirth (Hodne et al 2011). These outcomes have been
further strengthened by the results of S andall et al (2013), who collected data from 13
trials culminating in the birth outcomes of 16 242 women. I t was found that where
women received midwife-led care throughout pregnancy and birth from a small group
of midwives they were less likely to give birth prematurely or require interventions in
labour than those women who received care based on a shared care model or medical
model. Consequently S andall et al (2013) affirm that all women should be offered
midwife-led continuity of care unless they have serious medical or obstetric
complications and women should be encouraged to ask for this option.
The essence of midwifery is to be with woman, providing comfort and support to
women in labour. A lthough the midwife has an important role to play in providing
support and care, there is evidence that a birth partner who is neither from the
woman's social network or a member of the midwifery team, such as a doula, can
provide the most effective continuous support during labour, resulting in less
interventions and pain medication and an increase in positive childbirth experiences
(Hodnett et al 2011).
The physical environment
I n the developed world most births occur in hospital and therefore the atmosphere
and environment of hospital birthing rooms are important (S ullivan and McCormick
2007). The clinical appearance of hospital birthing rooms, coupled with associated
clinical regimes and loss of privacy, can alienate women and lead to feelings of loss of
control (Marshall et al 2011). I n turn, this loss of control can interfere with the normal
physiological process of labour (Walsh 2010a, 2010b).
W hilst there has been an effort by hospitals to provide a less clinical and more
home-from-home environment for birth, there has been some criticism in that such
adaptations create an artificial situation whereby homeliness masks the unchanged
clinical agenda and professional dominance found in traditional labour environments
(Fannon 2003). A lthough evidence is limited, Hodne et al (2009) found that efforts to
make birthing rooms more homely are appreciated by women and can have a positive
effect on them and their care providers. However, such an environment is unlikely on
its own to improve birth outcomes or the birthing experience.
Reducing the risk of infection
I n the latest Confidential Enquiries into Maternal D eaths report, the leading cause of
direct deaths during the triennium 2006–2008, was sepsis, accounting for 26 deaths
(Harper 2011). A s a consequence, the prevention of infection was one of the top 10
recommendations from the report. I n addition, health care-associated infections
(HCA I s) have become the subject of considerable public interest as a consequence of
the rise in methicillin-resistant Staphylococcus aureus (MRS A) andClostridium difficile
(C. difficile). With the introduction of a national strategy to reduce the rates of MRS A
and C. difficile, there is evidence that the rates of both types of infection have more
than halved (N ational Patient S afety A gency [N PS A ] 2007a , 2007b; N ational Audit
Office 2009).
Hand hygiene, the combination of processes including hand washing, the use of
alcohol hand rub and carefully drying and caring for the skin and nails, is considered
to be the single most important measure in preventing the spread of infection. Hand
washing will remove transient microorganisms and render the hands socially clean,
however, evidence suggests that the process of hand washing is poorly performed and
therefore less effective than it otherwise could be. Prior to and immediately following
any direct contact with the woman or baby and their immediate surroundings or after
an exposure risk to any body fluids, effective hand hygiene practices as determined by
WHO (2009) should be followed.
A clean environment is essential if infection rates are to be kept to a minimum and
the midwife has an important role to play in ensuring that all equipment is cleaned
according to local Trust guidelines and that there is adherence to all infection control
measures. Rooms, birthing pools, beds and any equipment used by the midwife
should be effectively cleaned before use.
W hen a woman is admi ed to hospital, invasive procedures should be kept to a
minimum as an intact skin provides an excellent barrier to organisms. I deally, women
should spend as li le time in hospital as determined by their individual needs to
minimize their exposure risk to infection. The fetal membranes should also be
preserved intact unless there is a positive indication for their rupture that would
outweigh the advantage of their protective functions (N I CE 2007). Certain invasive
techniques, such as the performance of vaginal examinations, may be deemed
necessary during labour, however the midwife should ensure that she has a sound
reason before embarking on any procedure. W omen whose labour is prolonged are at
particular risk of infection, often being subjected to a number of invasive procedures
including the administration of intravenous fluids, repeated vaginal examinations,
epidural analgesia and fetal blood sampling, all of which will increase the risk of
infection. By adhering to infection control policies and minimizing interventions when
required, the midwife should reduce the potential risk of infection to the woman and
promote safety.
The midwife is encouraged to use personal protective equipment if she assesses that
there is a risk of transmission of microorganisms to the woman, or the risk of
contamination of her clothing and skin by the woman's body fluids (N I CE 2007). This
poses a difficulty for the midwife as every birth presents a risk of cross-contamination,
but wearing a full gown, face masks and eye goggles can create an artificial barrier
between herself and the labouring woman at a time when a relationship of trust is
vital. Furthermore, face masks and eye goggles provide limited protection from spills
or inhalation of spray. I n most instances, appropriate hand hygiene and the use of
single-use sterile gloves will be sufficient to reduce cross-contamination (NICE 2007).
The midwife's initial physical examination of the woman
The initial examination should include a discussion with the woman about when
labour commenced, whether the membranes have ruptured and the frequency and
strength of the contractions. The midwife should be aware that the woman will be very
conscious of her body and may be unable to concentrate on the conversation or
respond while experiencing a contraction. S ince the woman has embarked on an
intensely energy-demanding process, enquiry should be made about her ability to
sleep and her most recent intake of food. I f she is in early labour and there are no
concerns about the pregnancy, the woman should be advised she can eat and drink as
she wishes, remain mobile and maybe bathe if she would find this relaxing.
Consideration should be given to the woman's social circumstances, including the care
of other children and whether a birthing partner is available and has been contacted.
Past history
Of particular relevance at the onset of a woman's labour are:
• the contents of the birth plan
• her parity and age
• the gestational age and outcomes of previous labours
• the weights and condition of previous babies
• her blood results including grouping, Rhesus factor and haemoglobin
• her attendance at any specialist clinics
• evidence of any known problems: social or physical.
Consent
Prior to touching the woman, a sound explanation of the proposed examination and
their significance should be given. Verbal consent should be obtained and recorded in
the notes (N MC 2008, 2009). The midwife must be aware that a competent woman,
with a capacity to make decisions, is within her rights to refuse any treatment
regardless of the consequences to her and her unborn baby and does not have to give a
reason (DH 2009). S hould the midwife be providing care to a pregnant teenager under
the age of 16 years, it is important to carefully assess whether there is evidence that
she has sufficient understanding in order to give valid consent, i.e. complies with the
Fraser guidelines, previously referred to as being Gillick competent (Gillick v West
Norfolk and Wisbech AHA 1986; GMC 2013).
General assessment
I nitial observations form a baseline for further examinations carried out throughout
labour. Basic observations, including pulse rate, temperature and blood pressure, are
assessed and recorded. The woman's hands and feet are usually examined for signs of
oedema. S light swelling of the feet and ankles is physiological, but pre-tibial oedema
or puffiness of the fingers or face is not.
A detailed abdominal examination including symphysis fundal height and optimum
position for auscultation of the fetal heart, as described in Chapter 10, should be
undertaken and recorded. The abdominal examination may be repeated at intervals in
order to assess descent of the presenting part, whether it be cephalic or breech. This is
measured by the number of fifths palpable above the pelvic brim and should be
recorded on the partogram.
The fetal heart rate should be auscultated for a minimum of 1 minute immediately
after a contraction using a Pinard stethoscope and the rate should be recorded as an
average, in a single figure. The maternal pulse should be palpated to differentiate
between maternal and fetal heart rates (N I CE 2007). A lthough the Pinard stethoscope
is recommended for the initial assessment of the fetal heart, this may not be suitable
for use in women who are markedly obese or unable to remain still during
auscultation. In such circumstances a hand-held Doppler may be used.
A vaginal examination (VE) may also be undertaken to help confirm the onset of
labour and determine the extent of cervical effacement and dilatation (Fig. 16.8), with
some women requesting it when seeking reassurance about the status of their labour.
The procedure, however, is invasive, can be uncomfortable and also poses an infection
risk.
FIG. 16.8 Cervix 4 cm dilated.
Records
The midwife's record of labour is a legal document and must be kept meticulously.
The records may be examined by any court for up to 25 years, or the N ursing and
Midwifery Council's Professional Conduct Commi ee or Health Commi ee, and will
be examined in the audit process of statutory supervision of midwifery or on behalf of
the Clinical N egligence S cheme for Trusts (CN S T) monitoring process. A summary o
good record keeping is provided below (NMC 2009, 2012):
• Records should be as contemporaneous as possible.
• Each entry should be authenticated with the midwife's full signature with the name
printed underneath.
• Records should be comprehensive but concise and consist of the woman's
observations, her physical, psychological and sociological state, and any problem that
arises as well as the midwife's response and any subsequent interventions.
• The records should be kept in chronological order as their accuracy provides the
basis from which clinical improvements, progress or deterioration of the woman or
fetus can be judged.
• The record is shared between the midwife and obstetrician and details of any
consultation with other members of the multiprofessional team should be clearly
documented by the midwife, including the time and nature of the consultation.
• The obstetrician is also responsible to record their findings, timing of visits and any
prescriptions made as the same standards apply to all practitioners.
• The midwife usually enters in the records the summary of labour and initial details
about the health of the baby.
• A midwife must ensure all records are stored securely and should not destroy or
arrange for their destruction.
The partogram or partograph
I n recent years the partogram or partograph has been widely accepted as an effective
means of recording the progress of labour. I t is a chart on which the salient features of
labour are entered in a visual graphic form to provide the opportunity for early
identification of deviations from normal (Fig. 16.9). However, Lavender et al (2008)
found no evidence to support the routine use of the partogram in women who
commenced labour spontaneously at term with regards to maternal and fetal
outcomes in those labours where a partogram was used against those where there was
no partogram. N onetheless, the partogram remains an integral part of intrapartum
record-keeping. The charts are usually designed to allow for recordings at 15-minute
intervals and include:
• fetal heart rate
• maternal temperature, pulse and blood pressure
• frequency and strength of contractions every 10 minutes
• descent of the presenting part
• cervical effacement and dilatation
• colour of amniotic fluid
• degree of caput succedaneum/moulding
• fluid balance
• urine analysis
• drugs administered.
FIG. 16.9 Example of a partogram.
The cervicograph is the diagrammatic representation of the dilatation of the cervix
charted against the hours in labour. S ome initial studies (Friedman 1954; Pearson
1981) demonstrated that the cervical dilatation time of normal labour has a
characteristic sigmoid curve. This curve can be divided into two distinct parts: the
latent phase and the active phase. W omen's progress in labour, however, does not fit
neatly into predetermined criteria therefore rigid parameters of normal progress
should not be adopted (A lbers 1999; Lavender et al 2006). The rate of progress in
labour must be considered in the context of the woman's total wellbeing and choice.
Subsequent care in the first stage of labour
Assessing progress
Physical examination of the cervix is not the only way to assess labour. Midwives can
use a range of skills, including visualization of the purple line, appearing from the
woman's anal margin gradually extending to the nape of the bu ocks (Hobbs 1998;
S hepherd et al 2010), and observing the Rhombus of Michaelis, a kite-shaped area
between the sacrum and ilea which becomes increasing visible as the fetal head
descends in the pelvis (S hepherd et al 2010). I n addition, the midwife should be
vigilant in observing for changes in the woman's breathing, behaviour, noises,
movements and posture alongside changes in the nature of contractions.
Abdominal examination
A n abdominal examination should be repeated by the midwife at intervals throughout
labour in order to assess the length, strength and frequency of contractions and the
descent of the presenting part. Palpation is of benefit prior to undertaking a vaginal
examination, as the findings will assist the midwife to be accurate when defining the
position and station of the head/breech. I t is also useful to record the position of the
fetus contemporaneously during the labour, as this can assist with the analysis of
events should a shoulder dystocia occur (Brydon and Raynor 2012).
Contractions
The frequency, length and strength of the contractions should be noted and recorded
on the partogram, usually at 30 minute intervals. The uterus should always feel softer
between contractions and failure to relax is evidence of hypertonicity. Hypertonicity is
usually defined as a contraction lasting more than 2 minutes (N I CE 2007). The
contraction rate is usually assessed by counting the number of contractions in 10
minutes, over a 20-minute period. Evidence of five contractions or more in 10 minutes
is evidence of tachysystole in spontaneous labour, or hyperstimulation in induced labour
(Chapter 19). A n excessive number of contractions or hypertonicity can result in fetal
compromise as a result of prolonged cord compression or reduction in placental
perfusion with consequent reduction in blood supply to the fetus.
Vaginal examination
A lthough vaginal examinations (VE) have become a routine procedure in labour there
is very li le evidence to support their efficacy. D ixon and Foureur (2010) state that
vaginal examinations are arguably considered to be both an intervention and an
essential clinical assessment tool in labour. Midwives should remember that to women
who have survived sexual abuse, experienced female genital mutilation (FGM), or are
extremely anxious, a vaginal examination can be very distressing and sometimes
impossible. Vaginal examinations are undertaken using aseptic principles and should
be used judiciously when more information is required if this cannot be gleaned from
external observations of women in labour. I deally the same person should perform the
vaginal examinations to be in a be er position to judge any changes. O bservations and
findings as detailed in Box 16.1 should be noted and recorded accordingly by the
midwife.
FIG. 16.10 Diagram to show stations of the fetal head in relation to the pelvic canal.
FIG. 16.11 (A) Diagrams showing descent of the fetal head through the pelvic brim. (B)
Diagrams showing dilatation of the cervix and rotation of the fetal head as felt on vaginal
examination.
Box 16.1
Va gina l e x a m ina t ion obse rva t ion a nd findings
Labia Varicosities/oedema/warts/other lesions
Perineum Scars from previous tears/episiotomies
Vaginal orifice Discharge/liquor/‘show’/bleeding
Liquor Clear/bloodstained/offensive smell (indicating infection)/meconium
staining
Rectum Loaded rectum may be felt on vaginal examination (can impede descent
of presenting part)
Cervix Position of cervix: central/posterior/anterior/lateral
Consistency: hard, soft
Application to the presenting part: loose/well applied
Effacement: length of canal: may be effaced but closed in a
primigravida
Dilatation: Approximate assessment (see Fig. 16.8): 10 cm equates to
full dilatation or when no cervix can be felt (ensure no lips of cervix
remain (Fig. 16.10)
Note in preterm labour, the smaller presenting part may pass through at a
smaller cervical diameter
Membranes Intact/bulging/ruptured
Colour of liquor: clear/bloodstained (liquor/‘show’)/meconium
Following rupture of membranes, midwife needs to check that the
cord has not prolapsed, listen to the fetal heart through contraction
Hindwaters may leak whilst forewaters remain intact
Presenting part (PP): the part of the Identification: cephalic/breech/footling/knee/compound (see Figs 16.31 and
fetus lying over the cervical os 16.32 below)
(96% are cephalic) Level of bony part of PP in relation to the ischial spines, in cm above,
below or at the level of the ischial spines (Fig. 16.11).
The fetus follows the curve of carus therefore it is impossible to judge
the station precisely
Presence of caput succedaneum /moulding/meconium (breech)
Position of presenting part Cephalic presentation:
Sagittal suture: left or right oblique or transverse should rotate to
anteroposterior diameter of the maternal pelvis (Fig. 16.12).
If well flexed the small triangular posterior fontanelle is felt: it has
three sutures leaving it
The anterior fontanelle is diamond-shaped, has a membrane and
four sutures leaving it
Landmarks of the fontanelles give information about the location of
the fetal occiput
Breech presentation:
The sacrum is the diagnostic point in respect of its position with the
maternal pelvis and the ischial spines
Generally, the trend has moved away from routine 4-hourly VE and justification for
each examination should always be recorded. A n explanation of the procedure,
obtaining of verbal consent from the woman and an abdominal examination should
always precede the VE (D H 2009). The woman's bladder should be empty as the
presenting part may be displaced by a full bladder as well as being very uncomfortable
for the woman. I n order to obtain the most information, the woman is usually asked to
lie on her back but the technique can be easily adapted to accommodate other
positions that suit the woman be er. D uring the examination the woman's dignity and
privacy need to be considered. I n order to avoid unnecessary exposure, the woman can
be asked to move and uncover herself when the midwife is ready to commence the
examination. Tap water may be used to cleanse the vagina for this procedure ( NICE
2007). With the combination of external and internal findings, the skilled midwife
should gain a detailed account of the labour and its subsequent progress.
Indications for vaginal examination
There should be valid reasons to undertake a VE in labour, which are to:
• make a positive identification of the presentation
• determine whether the head is engaged in case of doubt
• ascertain whether the forewaters have ruptured, or to rupture them artificially
• exclude cord prolapse after rupture of the forewaters, especially if there is an ill-
fitting presenting part or there are fetal heart rate changes
• assess progress or slow labour
• confirm full dilatation of the cervix (see Fig. 16.12)
FIG. 16.12 Cervix fully dilated.
• confirm the axis of the fetus and presentation of the second twin in a multiple
pregnancy in order to rupture the second amniotic sac, if necessary.
Under no circumstances should a midwife make a vaginal examination if there is
any frank bleeding unless the placenta is positively known to be in the upper uterine
segment.
Assessing the wellbeing of the woman
Assessing the wellbeing of the woman
Maternal observations
Pulse rate
A tachycardia can indicate pain or anxiety and is also associated with pyrexia,
exhaustion and shock. The pulse rate should be recorded hourly (N I CE 2007). I f the
rate increases to >100 bpm it may be indicative of anxiety, pain, infection, ketosis or
haemorrhage. The pulse should also be assessed and recorded at any time that there is
concern about fetal wellbeing or if there is uncertainty about whether the maternal
rather than the fetal pulse is being recorded (NICE 2007).
Temperature
A rise in temperature can be indicative of infection or dehydration. The temperature
should be recorded 4-hourly (N I CE 2007) and additionally when there is a clinical
indication.
Blood pressure
Hypotension may be caused by the woman being in the supine position, by shock or as
a result of vasodilation associated with epidural anaesthesia. Hypertension is an
indicator of pre-eclampsia and in cases where a woman has pre-eclampsia or essential
hypertension during pregnancy, labour may further elevate the blood pressure.
Blood pressure should be measured every 4 hours (N I CE 2007) and additionally
when there is a clinical indication. I t is usual practice to monitor the blood pressure at
5-minute intervals for 20 minutes following the administration of an epidural
anaesthetic and following the administration of any bolus dose.
Fluid balance and urinalysis
A record should be kept of all urine passed in order to ensure that the bladder is being
emptied. I f an intravenous infusion is in progress, the fluids administered must be
recorded accurately. I t is particularly important to note how much fluid remains if a
bag is changed when only partially used.
A trace of protein may be a contaminant following rupture of the membranes or a
sign of a urinary tract infection, but more significant proteinuria may indicate pre-
eclampsia. Urine passed during labour should be tested for ketones and protein.
Ketones may occur in normal labour and a low level is very common and is not usually
thought to be significant.
Cleanliness and comfort
Enemas and perineal shaving
There is no evidence to support the routine procedure of administering enemas or
undertaking perineal shave to women in labour. However, if a woman reports
constipation, or the midwife detects that the rectum is full on vaginal examination, or
if the woman feels there would be benefit, an enema or glycerine suppositories can be
offered. S ometimes for cultural reasons women will shave their own genital/perineal
areas.
Bath or shower
I mmersion in a warm bath or birthing pool can be an effective form of pain relief for
labouring women that facilitates increased mobility with no increased incidence of
adverse outcome for the woman or fetus (D a S ilva et al 2009). The midwife should
invite the woman who is mobile to have a bath or shower whenever she wishes during
labour.
Clothing
I t is entirely up to the individual woman what she wears in labour. I f in hospital she
may prefer to wear the loose gown offered or she may feel more comfortable wearing
her own choice of clothing. A s long as she is aware that the garment may become wet
and bloodstained and that she may require more than one, there is no reason to
restrict her choice.
Position and mobility
There are physical benefits if the woman maintains an upright position, including a
shorter labour and a reduction in the need for analgesia (Lawrence et al 2009), fewer
episiotomies and fewer abnormal fetal heart rate pa erns (Gupta et al 2012). O ther
benefits include increasing the woman's sense of control (Coppen 2005), thus
contributing to a positive birth experience. Lying on the bed during labour or birth
does li le to enhance the physiological birth process and has disadvantages, including
a risk of aorto-caval compression and reduced interspinous diameter of the pelvic
outlet, increased pain and slower descent of the presenting part.
The need to provide a continuous tracing of the fetal heart can inhibit maternal
mobility and in some cases, such as with women who are significantly obese, have pre-
existing mobility problems or have an epidural in situ, this cannot be avoided. D espite
this, the majority of women, including some obese women, will be able to maintain an
upright position, retain a degree of mobility and achieve birth away from a birthing
bed if supported in doing so. A key factor in encouraging different labour positions
and mobility is the environment (Royal College of Midwives [RCM] 2012a ). The
birthing room should contain equipment such as beanbags, birthing balls and chairs
(A lbers 2007) and the midwife should be proactive in encouraging the woman to
remain active and to change her position. A lthough women should be encouraged to
move and adopt whatever position they find most comfortable (N I CE 2007), the
midwife should be aware that the woman's choice of birth position may be influenced
by what she thinks is expected of her rather than what is actually more comfortable.
Cultures where women are constrained and limited in their posture and positioning
during labour are in fact the exception rather than the rule. Many cultures use
movement, dance, physical contact and massage to encourage and sustain the process
of labour. Henley-Einion (2007) discusses the value of the Five Rhythms method.
Movements described as flowing, staccato, chaos, lyrical and stillness, which are a
combination of expressive movements rather than a set of routine exercises, are
employed to provide dance and the music defines, guides, inspires and prompts the
body. Such a strategy would be a fitting one to use during the birthing process.
Pressure ulcer prevention
A pressure ulcer (decubitus ulcer) is a localized injury to the skin and underlying tissue
that arises when an area of skin is placed under pressure. W here women have pre-
existing mobility problems or an epidural in progress, they will be at increased risk of
developing pressure ulcers during labour. I n 2010 alone there were around 100 reports
of women who had developed a pressure ulcer while in a maternity ward (N PS A 2010).
A ll maternity areas should therefore have guidelines for the prevention of pressure
ulcers and the midwife must take great care to ensure that the condition of the
woman's skin is observed and described in the notes with details documented in the
records at 2-hourly intervals.
Nutrition in labour
I t has been estimated that in established labour a woman requires a calorie intake of
121 kcal/hour and that 47 kcal/hr is required to prevent ketosis (Hall Moran and D ykes
2006). Most women will be able to draw on glucose stores to provide energy but if
insufficient carbohydrate is available energy will be obtained from body fat and this
will release ketones, resulting in ketoacidosis.
D ietary care in labour is a controversial issue due to the dearth of good-quality
evidence and as a result there is no universal consensus on management. Hospital
policies are usually based on the need to restrict food intake in order to prevent gastric
aspiration. However, the number of women experiencing gastric aspiration is
extremely low and there is no evidence to support the view that starvation will
guarantee an empty stomach or prevent gastric acidity (N I CE 2007). S tarvation in
labour can also have psychosocial effects as the provision of food and drink can
provide comfort and reassurance, whilst the denial can be seen as authoritarian,
stressful and intimidating, which can increase feelings of apprehension (RCM 2012b).
For many women in normal labour a low residue, low fat diet and freely available
fluids will be appropriate. A s there is evidence that the desire to eat is more common
in women in early labour (S ingata et al 2010) and most women do not want to eat in
active labour, it is important that the woman is not encouraged to eat if she has no
desire to do so.
Bladder care
A lthough frequent bladder emptying during labour is recommended, there is no
evidence to support any particular regime of intervention. I t is therefore reasonable to
consider that the bladder should be emptied at least 4-hourly or more frequently if it is
palpable abdominally. There is some evidence that infrequent bladder emptying in
labour is associated with an increased risk of urinary incontinence in the postpartum
period (Birch et al 2009). A full bladder may increase pain, reduce efficiency of uterine
contractions and delay descent of the presenting part (Simkin and Ancheta 2011).
The woman's sensation to micturate during labour may be reduced by pressure of
the presenting part during its descent through the pelvis, or by an effective epidural
block. In all cases of delay in labour, the midwife should ascertain whether the bladder
is full and encourage the woman to void regularly. W here possible the woman should
be encouraged to use the toilet, and if this is not possible, the midwife should provide
privacy and ensure maximum comfort by placing the bedpan on the chair, stool or bed
and encouraging the woman to adopt a leaning forwards position. The sound or feel of
water can also help to trigger the micturition reflex. I f the bladder is incompletely
emptied or the woman is unable to void for some hours, it may become necessary to
introduce a catheter into the bladder. A s the risk of infection is increased with the use
of retaining catheters, it is generally recommended that an ‘in-out’ catheter is used.
Medicine records
Midwives have an exemption from requiring a prescription for specific medicines used
in the care of women in physiological labour. I n the UK, N HS Trusts also have locally
agreed patient group directions to which the midwife should adhere, providing
guidance as to which medicines are preferred and what doses and frequency should be
used within that Trust. I f the midwife is practising outside the area in which she has
notified her intention to practise, she should consult the supervisor of midwives
regarding any ma ers relating to the supply, administration, storage or surrender of
controlled drugs or medicines (NMC 2010, 2012).
A s well as being entered on the partogram, doses of drugs are recorded on the
prescription sheet, in the summary of labour and, in the case of controlled drugs, in
the Controlled Drugs Register.
Assessing the wellbeing of the fetus
The aim of fetal monitoring in labour is to maintain wellbeing, detect fetal hypoxia
and initiate appropriate intervention before the fetus becomes asphyxiated and
neurological damage occurs. D espite the widespread practice of both intermi ent and
continuous fetal monitoring, there are no statistical differences in the rates of cerebral
palsy, infant mortality or other standard measures of neonatal wellbeing with either
form of monitoring (A lfirevic et al 2013). N I CE (2007)recommend that in all low-risk
established labours, intermi ent auscultation should be practised. The midwife should
discuss the recommendations for fetal monitoring and the available evidence with the
woman in order that she can make an informed decision about how her baby's
wellbeing will be monitored during labour.
Intermittent auscultation
I ntermi ent auscultation involves listening to the fetal heart rate at intervals using a
Pinard stethoscope or a hand-held D oppler. The Pinard stethoscope will simply
amplify the actual heart sound so that it can be heard and counted. However, it may be
difficult to use when the woman is in certain positions, such as all-fours or squa ing,
and as the sound cannot be heard by the woman, this method may be less reassuring
for her. The hand-held Doppler uses ultrasound to detect movement, either of the fetal
heart muscle or valves, which are converted into a sound that can be heard and
counted, such that the woman and her partner can also hear the fetal heart. I t should
be recognized that as the D oppler converts movement into sound it is possible for the
maternal pulse to be detected and be mistaken for the fetal pulse. For this reason it is
recommended that the Pinard stethoscope should be used to check the fetal heart
when any concern arises (Medicines and Healthcare Products Regulatory A gency
[MHPRA ] 2010 ) and that the maternal pulse is also counted (N I CE 2007). The normal
fetal heart will have a rate of 110–160 bpm and there should be no audible
decelerations (NICE 2007). I f at any time a fetal heart rate abnormality is suspected or
there is any concern about fetal wellbeing, such as following the detection of
meconium staining of the liquor, electronic fetal monitoring (EFM) should be
commenced following discussion with the woman and her companion (NICE 2007).
The current guidance is for intermi ent auscultations to be performed in the active
first stage of labour at least every 15 minutes for a full minute immediately following a
contraction (N I CE 2007). A s with any observation, every recording should be
documented in the labour records. I n order to demonstrate compliance with the
recommendation regarding the timing of auscultations, it is helpful at least once to
provide a description in the intrapartum records of how and when auscultation is
being performed.
Continuous electronic fetal monitoring
A n admission cardiotocograph (CTG) isnot recommended in low-risk labour (NICE
2007) . D evane et al (2012) confirmed that such traces do not provide any benefit in
terms of reducing perinatal morbidity or mortality but can increase the rate of
caesarean section by approximately 20%.
Continuous electronic fetal monitoring (EFM) is recommended for any labour where
there are risks to fetal wellbeing, including the use of oxytocin and epidural analgesia
(N I CE 2007; A fors and Chandraharan 2011). W hilst EFM will detectsuspect pathology,
as changes such as tachycardia or bradycardia can be seen, it has low specificity for
identifying between the acidotic fetus and the fetus that is not compromised
(S chiermeier et al 2008). Electronic fetal monitoring can detect changes in the pa ern
of the fetal heart that could indicate hypoxia but cannot provide a diagnosis as the
CTG is a highly sensitive tool but the condition it is designed to detect is of low
prevalence. This results in a high false-positive rate and a poor positive predictive
value; consequently, EFM has shown an increase in the rate of operative and assisted
birth without demonstrating a reduction in perinatal mortality, or the incidence of
cerebral palsy (A yres-de-Campos and Bernades 2010). For this reason, in the absence
of a persistent bradycardia, any evidence of pathology should be further investigated
by fetal blood sampling if this is feasible, otherwise birth should be expedited (NICE
2007). D ecisions about the indications for fetal blood sampling and mode of birth will
be made by an obstetrician.
Good practice points
• On admission an abdominal palpation should be performed to determine the
optimal area for listening to the fetal heart.
• A Pinard or fetal stethoscope should be used at the initial assessment to establish
the real sound of the fetal heart. Intermittent auscultation should be continued
throughout established labour unless there is a reason for EFM.
• The maternal pulse should be palpated and recorded at the start of EFM and at any
time that the trace is recommenced. If there is doubt about whether the maternal or
fetal heart is being monitored, the maternal pulse should be palpated to differentiate
between the two heart rates (NICE 2007).
• The term fetal distress should be avoided when describing the EFM trace as it can
cause alarm to the woman and her companion(s) and is not helpful in the analysis of
the trace.
• The trace should be systematically assessed and categorized and the findings
described in the notes at least hourly. In maternity units where a fresh eyes approach
has been adopted it is usual for this to take place every two hours.
• The CTG monitor clock should be periodically checked for accuracy.
• Significant events should be noted on the CTG, such as VE and mode of birth.
• Each clinician who is asked to review the CTG should sign the trace at the time of the
review.
• EFM is not a substitute for, and should not interfere with, continuous care and
support during labour (MIDIRS 2008a).
• Although EFM can interfere with maternal positioning, for most women it should be
possible for the labour to be experienced out of bed and/or with the woman in an
upright position.
• All staff who interpret CTG traces should receive up-to-date training and assessment
(NICE 2007), and to fulfil CNST (2013) requirements, this should be every 6 months.
• When discontinued, the CTG trace should be systematically assessed, classified and
the findings recorded on the trace which should be stored safely in the appropriate
portion of the woman's records.
Interpretation of the cardiotocograph
W hen interpreting a CTG it is useful to perform a systematic assessment, identifying
any existing risk factors for hypoxia, the reason for EFM and the stage of the labour.
This will assist in the overall analysis of the CTG trace. The trace is then assessed to
identify whether its features are reassuring, non-reassuring or abnormal, as shown in Box
16.2 (NICE 2007).
Box 16.2
C la ssifica t ion of t he fe t a l he a rt ra t e fe a t ure s
Source: NICE 2007
The four features of a CTG trace are:
Baseline rate
This is the mean level of the fetal heart rate between contractions, excluding
accelerations and decelerations. A rising baseline rate may be of concern even if it
remains within the normal range, if other non-reassuring or abnormal features are
present.
Baseline variability
This is the degree to which the baseline varies over the period of a minute. The baseline
variability is under the influence of the autonomic nervous system and this produces
an irregular jagged appearance on the CTG trace. However, if repeated accelerations
are seen on a trace with reduced variability, the variability should not be assessed as
non-reassuring.
Decelerations
These are reflected as a fall in the baseline rate of at least 15 bpm for at least 15
seconds. True uniform decelerations, usually referred to as early, are rare and benign,
and are therefore not significant. Most decelerations in labour are variable, which
means they are variable in presentation and appearance. There are two types of
variable decelerations, typical and atypical, and it is important to distinguish between
them.
Typical variable decelerations
Typical variable decelerations occur in response to intermi ent cord compression and
are commonly seen during the second stage of labour. They are quick to recover to the
normal baseline, have normal variability, last less than 2 minutes and have evidence of
shouldering, which is a normal physiological response to intermi ent cord
compression.
Atypical variable decelerations
These decelerations can be an indicator of hypoxia and have some or all of the
following features:
• Loss of acceleration (shouldering) before and after deceleration
• Delayed recovery back to baseline
• Late component/biphasic deceleration
• Rebound tachycardia – caused by catecholamine release in response to stress
• Loss of variability/change in baseline rate.
Late decelerations
These decelerations are uncommon and are usually considered to be indicative of fetal
hypoxia. The main features being:
• Reduced variability
• Repetitive and uniform shape
• Begin at or after the peak of the contraction
• Their lowest point is 20 seconds or more after the peak of contractions.
Accelerations
These particular features reflect an elevation in the baseline rate of 15 bpm for 15
seconds or more. The significance of the absence of accelerations in an otherwise
normal trace is uncertain.
Overall classification of the fetal heart rate features
A ll four features of the fetal heart rate pa ern are assessed and an overall
classification of normal, suspicious or pathological is determined according to how many
features are described as reassuring, non-reassuring and abnormal, as identified in Box
16.3.
Box 16.3
O ve ra ll cla ssifica t ion of t he fe t a l he a rt t ra ce
Normal: All four features are classified as reassuring
(please note comment about accelerations in Box 16.2)
Suspicious: One feature is classified as non-reassuring and the remaining features are reassuring
Pathological: Two or more features are classified as non-reassuring or one or more classified as abnormal
Source: NICE 2007
I t is important to record the classification of the trace at each assessment as the
actions required will be informed by this.
Normal
I f no other indication for CTG, discontinue and commence intermi ent auscultation
every 15 minutes (Fig. 16.13).
FIG. 16.13 Normal CTG with reassuring features (i.e. baseline variability, presence of
accelerations and no decelerations here).
Suspicious
The trace should continue and the possible causes be considered. The woman's
position should also be changed to the left lateral, her pulse and blood pressure
assessed and fluids administered if appropriate. I f the trace reverts to normal and
there is no other indication for the CTG it could be discontinued; however review by
an obstetrician may be required.
S hould the trace remain suspicious, the appropriate level obstetrician should be
consulted. Fetal blood sampling may be required (Fig. 16.14).
FIG. 16.14 Suspicious CTG with presence of one non-reassuring feature (i.e. typical variable
decelerations).
Pathological
The woman's position should be changed to the left lateral, her pulse and blood
pressure assessed and fluids administered if appropriate. I f there is a bradycardia in a
hospital se ing the emergency call bell should be used to summon assistance and
referral to a Registrar or Consultant should be made immediately.
Fetal blood sampling or the need to expedite the birth may be necessary. I f fetal
blood sampling is performed this should be prior to the administration of pethidine,
epidural or syntocinon, should the trace remain pathological (Fig. 16.15).
FIG. 16.15 Pathological CTG with abnormal features (i.e. atypical variable decelerations: note
the biphasic pattern or W effect of the decelerations).
Fetal blood sampling
Maternity units that use electronic fetal monitoring should have 24 hours access to
fetal blood sampling (FBS ) facilities. W hen the fetal heart rate pa ern is suspicious or
pathological and fetal acidosis is suspected, then FBS should always be undertaken
(N I CE 2007) (Fig. 16.16). The procedure involves a small sample of blood being taken
from the scalp of the fetal head with the woman in the left lateral position as the
lithotomy position is more distressing for both the woman and fetus, causing supine
hypotension which can increase fetal hypoxia. I f the CTG trace is bradycardic or
significantly pathological with no prospect of spontaneous birth, time should not be
wasted performing a FBS. This would be the clinical decision of a senior obstetrician.
FIG. 16.16 Fetal blood sampling. Access to fetal scalp via amnioscope passed through the
cervix.
A normal fetal blood sample result should be repeated no more than an hour later if
the trace remains pathological, or earlier if the heart rate pa ern deteriorates. A fetal
blood sample result of <7.25 should be repeated no more than 30 minutes later,
whereas one that is <7.20 indicates that the baby requires immediate birth (NICE
2007).
Women's control of pain during labour
The relationship between the woman and the midwife is important and can also
impact on how the woman perceives the pain of labour. Time, waiting and following
the woman are important elements of care. The idea of patience and supporting the
woman on her journey, giving meaning and sense to the pain of labour, is paramount.
The issue of pain during labour should be woman-centred, not medically oriented.
A clear differentiation must be made between the traditional goal of pain relief and
the control of pain in labour. Leap and Anderson (2008) proposed that midwives adopt
one of two paradigms: the pain relief model and the working with pain model. I n the pain
relief model, midwives present a menu of pain-relieving options to the woman, but
while this approach has the best of intentions, it inevitably undermines the woman's
confidence in herself and her body to give birth without the aid of medication.
However, in the working with pain model it is expected that most women in labour will
experience some degree of pain that is fundamental to a physiological labour. Pain of
normal labour is positive and has a purpose, and if this philosophy is embraced,
midwives and women can work together to ensure labour is an enabling and
ultimately uplifting experience.
I t is appreciated that emotions such as fear, confidence and also cognition affect the
person's perception of pain (Leap and A nderson 2008; Mander 2011). More than any
other type of sensation, pain can be modified by past experience, anxiety, emotion and
suggestion. Lack of food, rest and sleep also impact on the woman's perception of
pain. The midwife must take into account not only the level or extent of the woman's
pain, but also all other subjective or illusory aspects that may be contributing to the
experience, and also to realize the importance of her own a itude to intrapartum pain
relief, as this may be informed by the medical model.
The role of pain in labour is an important one. For some women it provides the
dominant negative memory of the birth whilst for others it is viewed as empowering,
bestowing a sense of triumphant achievement. A s the pain of labour affects women in
different ways, so then must the response of the midwife be tailored to the individual
needs of the woman.
The physiology of pain
Pain stimulus and pain sensation
Unlike most pain, the pain experienced in labour is not caused by a pathological
process or trauma and instead is the result of an interaction between physiological and
psychological factors (A bushaikha and O weis 2005). The discomfort or pain of labour
is caused by the descent of the fetal head further into the pelvis. I t is also caused by
pressure on the cervix and the stretching of the vaginal walls and pelvic floor muscles,
as descent of the presenting part occurs. The large uterine muscle contracts more
strongly, more frequently and for a longer duration as labour progresses. This also
increases the discomfort felt by the woman. I t is not suitable to use pain-relieving
measures used in other medical circumstances, as the purpose is not to stop or impair
the birth process (or contractions), but to facilitate the labour progress normally, with
the descent and rotation of the presenting part.
Pain is caused by a stimulus that may cause, or be on the verge of causing, tissue
damage. Pain sensation may therefore be distinguished from other sensations,
although emotions such as fear and anxiety are also experienced at the same time,
thereby affecting the person's perception of pain. I t must also be remembered that a
painful stimulus may also induce such changes by the sympathetic nervous system as
increased heart rate, a rise in blood pressure, release of adrenaline (epinephrine) into
the bloodstream and an increase in blood glucose levels. There is also a decrease in
gastric motility and a reduction in the blood supply to the skin, causing sweating.
Thus, stimuli that cause pain result in a sensory incident or occurrence.
Pain transmission
The pain pathway or ascending sensory tract originates in the sensory nerve endings at
the site of trauma. The impulse travels along the sensory nerves to the dorsal root
ganglion of the relevant spinal nerve and into the posterior horn of the spinal cord.
This is known as the first neuron. The second neuron arises in the posterior horn, crosses
over within the spinal cord (the sensory decussation) and transmits the impulse via the
medulla oblongata, pons varolii and the mid-brain to the thalamus. From here, it travels
along the third neuron to the sensory cortex (Fig. 16.17).
FIG. 16.17 The sensory pathway showing the structures involved in the appreciation of pain.
I n cases of acute pain, sensations are transmi ed along Aδ fibres, which are large
diameter nerve fibres. This type of pain is perceived as being a pricking pain that is
readily localized by the sufferer. The pathway for chronic pain is slightly different as the
nerve fibres involved are of smaller diameter and are called C fibres. Chronic pain is
often described as a burning pain that is difficult to localize.
Somatosensory function
Somatic sensation refers to the sensory function of the skin and body walls. This is
moderated by a variety of somatic receptors of which there are particular receptors for
each sensation, such as heat, cold, touch, pressure, etc. O n entering the central
nervous system, the afferent nerve fibres from somatic receptors form synapses with
interneurons that comprise the specific ascending pathways going to the
somatosensory cortex via the brain stem and the thalamus.
An afferent neuron, with its receptor, makes up a sensory unit. Usually the peripheral
end of an afferent neuron branches into many receptors. The receptors whose
stimulation gives rise to pain are situated in the peripheries of small unmyelinated or
slightly myelinated afferent neurons. These receptors are known as nociceptors because
they detect injury (noci, being the Latin word for ‘harm’, ‘injury’). The primary
afferents coming from nociceptors form synapses with interneurons after entering the
central nervous system. S ubstance P is a neurotransmitter that is liberated at some of
these synapses when there is a pain impulse that facilitates information about pain
which is then transmitted to the higher centres.
The stretching of the muscles and ligaments of the pelvic cavity and the pressure of
the descending fetus during the birthing process causes pain in labour to varying
degrees (Fig. 16.18). This sensation is transmi ed by afferent or visceral sensory
neurons, visceral pain being caused by the stretching or irritation of the viscera.
A fferent neurons convey both autonomic sympathetic and parasympathetic fibres.
Pain fibres from the skin and the viscera run adjacent to each other in the
spinothalamic tract. Therefore pain from an internal organ may be perceived or felt as if
it was coming from a skin area supplied by the same section or part of the spinal cord:
for example, pain from the uterus may be perceived or felt by the woman as being in
her back or labia. W hen this sort of pain occurs or is experienced, it is commonly
called referred pain.
FIG. 16.18 Pain pathways in labour showing the sites at which pain may be intercepted by local
anaesthetic techniques.
Martini et al (2011) suggest that the level of pain experienced can be
disproportionate to the amount of painful stimuli due to the facilitation resulting from
glutamate and substance P release. This effect can be one reason why women's
perception of pain associated with childbirth differs so widely.
Endorphins and enkephalins
Endorphins are described as being opiate-like peptides, or neuropeptides, which are
produced naturally by the body at neural synapses at various points in the central
nervous system pathways. They modulate the transmission of pain perception in these
areas. Endorphins are found in the limbic system, hypothalamus and reticular
formation (Martini et al 2011). They bind to the presynaptic membrane, inhibiting the
release of substance P, and therefore inhibit the transmission of pain. Enkephalins are
also neuropeptides that have the ability to inhibit neurotransmi ers along the
pathway of pain transmission, thereby reducing it. These act like a natural pain
relieving substance.
Theories of pain
Theories of pain include specificity, pa ern, affect and psychological/behavioural
theory (Mander 2011), however these are not always applicable to the pain experienced
i n childbirth. The most widely used and accepted theory is the gate-control theory of
Melzack and Wall (1965), who established that gentle stimulation actually inhibits the
sensation of pain. The gate-control theory declares that a neural or spinal gating
mechanism occurs in the substantia gelatinosa of the dorsal horns of the spinal cord.
The nerve impulses received by nociceptors, the receptors for pain in the skin and
tissue of the body, are affected by the gating mechanism. I t is the position of the gate
that determines whether or not the nerve impulses travel freely to the medulla and the
thalamus, thereby transmi ing the sensory impulse or message to the sensory cortex.
I f the gate is closed, pain is blocked and does not become part of the conscious
thought. I f the gate is open, the impulses and messages pass through and are
transmitted freely (Fig. 16.18), resulting in pain being experienced.
Physiological responses to pain in labour
Pain of labour is associated with an increased respiratory rate. This may cause a decrease
in the Paco2 level, with a corresponding increase in the pH and a subsequent fall in the
fetal Paco2 ensues. This may be suspected by the presence of late decelerations on the
CTG if continuous monitoring is being employed during labour. The acid–base
equilibrium of the system may be altered by hyperventilation and breathing exercises.
A lkalosis may then affect the diffusion of oxygen across the placenta, leading to a
degree of fetal hypoxia.
Cardiac output increases during the first and second stages of labour up to an extent
of 20% and 50%, respectively. This increase is caused by the return of uterine blood to
the maternal circulation, which constitutes about 250–300 ml with each contraction.
Pain, apprehension and fear may also cause a sympathetic response, thereby
producing a greater cardiac output.
Both the respiratory and cardiac systems are affected by catecholamine release.
A drenaline (epinephrine), which comprises about 80% of this release, has the effect of
reducing the uterine blood flow, leading to a potential reduction in uterine activity.
Non-pharmacological methods for pain control in labour
I ncreasingly, non-pharmacological methods are being used by women during labour.
I n addition to the methods described below, there is some evidence that hypnosis,
massage, acupuncture and acupressure reduce pain or decrease the need for
pharmacological analgesia during labour (Tiran 2010a).
The midwife needs to be mindful that to administer any complementary
therapy/alternative therapy to a woman in labour it is both essential and a professional
requirement that an approved course of training is undertaken to be deemed
knowledgeable and competent to practise such a skill. (NMC 2010, 2012)
Aromatherapy
A romatherapy is the use of essential oils for a range of purposes, for example to
induce relaxation, reduction of pain or nausea and vomiting. These oils may be
massaged into the skin, inhaled through diffusers or oil burners, or used in
conjunction with hydrotherapy. This particular complementary therapy has become
popular among childbearing women and midwives, with many maternity units in the
UK providing this service for women during labour and birth (S mith et al 2011). Zahra
and Leila (2013) conducted a randomized controlled trial (RCT) in I ran with women
randomly assigned to either massage only or aromatherapy massage with lavender oil.
Pain intensity was significantly lower in the aromatherapy massage group and first
and second stages of labour were shorter. There were, however, only 30 women
assigned to each group. Furthermore, the systematic review conducted by S mith et al
(2011) on the efficacy of aromatherapy for pain management was also too small to
draw any significant conclusions and thus there remains a need for more research in
this area.
Homeopathy
Homeopathy uses small doses of natural medicines to stimulate the body's own
physiological response to heal itself (I darius 2010). Homeopathic remedies are
prepared from plant extracts and from minerals. Professional advice is recommended
during pregnancy as the holistic approach of this method entails a consideration of all
the facets and the requirements of the individual. Aconite may be used to relieve fear
and anxiety and Kali Carbonate to alleviate back pain during labour (S teen and Calvert
2006).
Hydrotherapy
I mmersion in water during labour as a means of analgesia has been used for many
years. Clue and Burns (2009) cite that the effectiveness of hydrotherapy is due to
heat-relieving muscle spasm, and therefore pain, and hydrokinesis eliminates the
effects of gravity and also the discomfort and strain on the pelvis. Two studies
comparing immersion in water during labour with land labour found that those
immersed in water had significantly reduced duration of labour ( Zanetti-Dallenbach
et al 2007; Thoni et al 2010). Clue and Burns (2009) found that immersion in water in
the first stage of labour reduces the use of epidural/spinal analgesia and no evidence
of an increase in adverse effects on fetus/neonate or the woman. Water immersion is
usually highly rated by both women and midwives, and the calming atmosphere of a
pool room can benefit everyone as the woman appears less anxious and therefore feels
less pain (Benjoya Miller 2006).
Music therapy
A s well as at home, many birthing rooms are equipped with radio or CD apparatus
and this is often a useful means to help women relax, be entertained and find some
distraction during the early stages of labour. Many types of music are available for
relaxation, some of which are specifically for childbirth. Henley-Einion (2007) recounts
that music can have a positive effect on the woman's body, mind and spirit by
providing empowerment and creating an enabling effect.
Transcutaneous electrical nerve stimulation (TENS)
Transcutaneous electrical nerve stimulation (TEN S ) is a widely used and well-
appreciated method of pain relief. TEN S stimulates the production of natural
endorphins and enkephalins and impedes incoming pain stimuli. I t consists of a small
device that distributes low intensity electrical charges across the skin which is thought
to prevent pain signals from the uterus, vagina and cervix arriving at the brain (de
Ferrer 2006). The body's own pain relievers, the endorphins, are then released. TEN S
works by stimulating low threshold afferent fibres, such as the fibres of touch
receptors which inhibit neurons in the pain pathways. A s pathways activated by the
touch receptors add a synaptic input into the pain pathways, the individual may
massage a painful area to relieve the pain which is how TENS functions.
The apparatus consists of four electrodes and four flexes that connect these to the
TEN S unit, which has controls to alter the frequency and the intensity of the impulse
(Fig. 16.19). The electrodes are positioned at the level of T10 and L1 on the woman's
back and have been found to be effective in reducing pain during the first stage of
labour. The remaining electrodes are placed between S 2 and S 4 and provide control of
pain during the second stage of labour. The woman can use a boost control bu on to
convey high intensity and high frequency pa erns of stimulation of the dermatomes
during the uterine contraction to provide additional relief, thus enhancing control over
the birth process.
FIG. 16.19 TENS electrode positioning for use during labour.
TENS is considered to be more effective when started in early labour (Juman Blincoe
2007). However, D owswell et al (2011) found that women using TEN s were less likely
to rate their pain as severe and overall they did not find any overwhelming evidence
that TENs significantly reduces pain in labour.
Pharmacological methods for pain control
Inhalation analgesia
A premixed gas made up of 50% nitrous oxide (N2O ) and 50% oxygen (O2)
administered via the Entonox apparatus is the most commonly used inhalation
analgesia in labour. N itrous oxide (also known as laughing gas), like many other forms
of analgesia, acts by limiting the neuronal and synaptic transmission within the
central nervous system. Evidence shows that N2O induces opioid peptide release in the
periaqueductal grey area of the mid-brain leading to the activation of the descending
inhibitory pathways, resulting in modulation of the pain/nociceptive processing in the
spinal cord (Fujinaga and Maze 2002). The mixture of gases is stable at normal
temperature, but separates below −7 °C. I n many large obstetric units the gas is stored
in a bank and piped to each birthing room or is available in cylinders. Midwives
a ending women at home births are responsible for the safe storage of the gas
cylinders which should be on their side, rather than upright. This is because nitrous
oxide is heavier than oxygen and the horizontal position reduces the risk of
administering a severely hypoxic mixture. The cylinders must be brought into a warm
room if they have been exposed to cold temperatures, and the gases remixed by
inverting the cylinder at least three times before use.
Entonox apparatus is usually manufactured by the British O xygen Company (BO C)
Both the apparatus and the cylinder are made so that they do not fit on to other
equipment. These fit together by a pin index system. The cylinder is blue with a blue
and white shoulder. The one-way valve opens on inspiration and the woman should be
advised that optimal analgesia is obtained by closely applying the lips around the
mouthpiece or firmly applying the mask to the face. The gases take effect within 20
seconds and it is important that the woman uses it before a contraction commences.
The maximum efficacy of the gases occurs after about 45–50 seconds which should
coincide with the height of the contraction, providing maximum relief for the woman.
This method of pain control is useful in that the woman is able to administer it herself,
but its effectiveness is determined by the woman's ability to use the equipment as
advised. A study by Teimoori et al (2011) showed that nitrous oxide and oxygen
provided be er analgesia and had more beneficial effects when compared to
pethidine.
Exposure to high levels of nitrous oxide can cause teratogenic and other side-effects
such as infertility among midwives and other staff. I t is important that scavenging
equipment to extract expired gases is installed in all birthing rooms to reduce such
effects on staff (RCM 2012c).
Opiate drugs
Opiate drugs are frequently used during childbirth because of their powerful analgesic
properties. The action of these drugs lies in their ability to bind with receptor sites
which are mainly found in the substantia gelatinosa of the dorsal horn of the spinal
cord (A nderson 2011). O thers are located in the midbrain, thalamus and
hypothalamus.
In the UK three systemic opioids are commonly used for pain relief in labour:
• pethidine (meperidine in the USA)
• diamorphine
• meptazinol (Meptid).
A ll have similar pain-relieving properties, but li le evidence exists in relation to
their effectiveness, maternal satisfaction of their use or their effect on the
fetus/neonate in labour (Ullman et al 2010). There are numerous side-effects of opiate
drugs and the extent to which they are experienced is influenced by the woman's
metabolism of the drug, the degree and speed of transfer of the drug and metabolites
from maternal to fetal circulation and the ability of the fetus to process and excrete
both. Common side-effects of opiate drugs include:
• nausea and vomiting
• delayed emptying of the stomach
• drowsiness or sedation in the woman which may impair decision making
• reduction in fetal heart rate variability and depression of the baby's respiratory
centre at birth
• a sleepy baby affecting the establishment of breastfeeding.
A n anti-emetic agent is sometimes given to the woman at the same time to reduce
the feeling of nausea. I t is therefore important to ensure that the woman is fully
informed during pregnancy of the effects of these drugs so that she can make
informed decisions about methods of pain control.
Pethidine
Pethidine is a synthetic compound acting on the receptors in the body and is the most
frequently used systemic narcotic analgesic in the UK. I t is usually administered
intramuscularly in doses of 50–150 mg, depending on the woman's size, and takes
about 20 minutes to have an effect. Pethidine can be administered intravenously for a
faster effect and some maternity units use a machine to enable the woman to control
the administration: known as patient-controlled analgesia (PCA). S ome reports show
that opiates, especially pethidine, slow down the process of labour and are not
significantly effective in relieving labour pain, as often sedation is confused with
analgesia (Anderson 2011).
Diamorphine
D iamorphine has been found to provide effective analgesia for up to 4 hours in labour
with the usual dose being 5 mg. I t is more rapidly metabolized, accounting for its
greater speed of effectiveness and consequently it is eliminated more readily from
maternal and neonatal plasma (Fernando and J ones 2009). D iamorphine is used far
less commonly than other opiates in labour, even though some claim it gives be er
pain relief and hence more comparative studies are needed (J ones et al 2012). I t is
possible that the lack of use of diamorphine in labour might be due to fears of its
potentially addictive nature.
Meptazinol
Meptazinol is usually given in doses of 100–150 mg intramuscularly. I t is fast-acting
and is effective for about 4 hours. This opiate provides similar pain relief to pethidine
and like other opiates, meptazinol is also associated with an increased incidence of
nausea and vomiting (Ullman et al 2010).
Regional (epidural) analgesia
Epidurals are effective in relieving pain in labour and may be requested by women at
any point during the first stage of labour. W omen who have used other methods of
pain relief on experiencing strong contractions may decide to request an epidural
when labour is well advanced. This makes explanation of the benefits and risks of
epidural analgesia during pregnancy even more important. The pain relief from an
epidural is obtained by blocking the conduction of impulses along sensory nerves as
they enter the spinal cord. I t is an invasive procedure that requires informed consent
from the woman and an experienced (obstetric) anaesthetist to initiate under strict
aseptic conditions.
A n intravenous infusion of crystalloid fluids is commenced prior to siting the
epidural. The need for preloading has reduced since low-dose epidural blockades have
been used, reducing the risk of hypotension (N I CE 2007). The woman is either
positioned in the left lateral position to reduce the risk of supine hypotension or in a
si ing position to flex the spine, in an effort to separate the vertebrae, thus facilitating
the management of the procedure. The fetal heart rate and the woman's blood
pressure must be recorded throughout the procedure.
The skin is first cleansed followed by administration of local anaesthetic into the
epidural space of the lumbar region, usually between L2 and L3, before the
anaesthetist cautiously inserts a Tuohy needle (usually 16G) that has centimetre
marking and a bevelled end to aid the insertion and positioning of a fine catheter, into
the epidural space (Fig. 16.20). To locate the epidural space, the needle is first
advanced until resistance of the ligamentum flavum is encountered. At this point a
syringe is a ached to the Tuohy needle and inserted further until it enters the
epidural space. This is recognized by the loss of resistance when pressure is applied to
the plunger of the syringe or loss of resistance to saline (Hawkins 2010). I t is
particularly important that the woman remains still at this stage as the subarachnoid
space is only a few millimetres deeper and any slight movement could result in the
Tuohy needle puncturing the meninges and causing a dural tap. S maller gauge needles
are used for spinal anaesthesia reducing the risk of dural tap and have the advantage
of relieving pain rapidly (Hawkins 2010).
FIG. 16.20 Sagittal section of the lumbar spine with Tuohy needle in position.
O nce the Tuohy needle is in the epidural space and there is no evidence of any
leakage of blood or cerebrospinal fluid (CS F), a fine catheter is threaded through the
needle and left in situ to facilitate bolus injections or continuous infusion of the local
anaesthetic bupivacaine (marcain). The injection of bupivacaine into the epidural
space bathes the nerves of the corda equina, blocking the autonomic nerve pathways
supplying the uterus. The first dose is given by the anaesthetist to test for effect and
observe for any adverse reactions. The needle is subsequently removed and an
antibacterial filter is a ached to the end of the catheter. The catheter is then secured
to the woman's back with strapping and a syringe pump commenced if there is to be a
continuous infusion.
Continuous infusion of dilute bupivacaine and opioids (usually fentanyl) has
resulted in significant reductions in the amount of local anaesthetic used whilst
ensuring rapid analgesia. I n addition, because of the minimal motor block effect with
this regime, the woman is able to move about more freely and bear down more
effectively in the second stage of labour (A nim-S omuah et al 2011). The Comparative
O bstetric Mobile Epidural Trial (CO MET) S tudy Group UK (2001) found that low-dose
infusion epidurals resulted in a lower incidence of instrumental vaginal births
compared with traditional bolus epidurals.
Observations and care by the midwife
Each midwife is personally responsible for ensuring that they are competent to care
for women who have epidural analgesia, including topping up the epidural block as
specifically prescribed by the anaesthetist, being aware of the possible complications
and their immediate treatment.
A fter the administration of the first dose of bupivacaine and subsequent top-up
doses of local anaesthetic the blood pressure and pulse should be measured and
recorded every 5 minutes for 15 minutes and then every 30 minutes (N I CE 2007).
Temperature should also be recorded regularly. The woman may adopt any position
she finds comfortable avoiding aorto-caval compression and encouraged to change
position regularly to avoid soft tissue damage. The fetal heart is usually monitored
electronically.
The spread of the block should be assessed hourly by the midwife using a cold
object or ethyl chloride spray (NICE 2007). The sensation to void urine may be reduced
so the midwife must ensure that the woman is encouraged to empty her bladder
regularly to avoid postnatal urinary retention. S imilarly the woman may not be as
sensitive to feeling uterine contractions or the desire to bear down in the second stage
of labour. This is due to the pelvic floor muscles being relaxed and affecting rotation of
the fetal presenting part. The midwife therefore needs to be observant of these
physiological changes.
Complications of epidural analgesia
The use of low-dose bupivacaine solutions for analgesia in labour has limited the risks
of hypotension and local anaesthetic toxicity. N evertheless, potential complications of
epidurals still exist and these with their treatment are detailed in Box 16.4.
Box 16.4
C om plica t ions of e pidura l a na lge sia
Complication Cause Treatment
Hypotensive Affects the sympathetic nervous system Assist woman into left lateral position,
incident by causing vasodilation and a fall in administer oxygen, call anaesthetist, rapidly
blood pressure infuse Hartmann's solution intravenously.
Epinephrine, a vasopressor, may be given to
raise the blood pressure
Dural puncture Lowering of pressure/leakage of Epidural injection of 10–20 ml of maternal blood (a
and cerebrospinal fluid causing a blood patch), to seal the puncture and relieve the
consequent stretching of brain tissue headache
headache
Loss of bladder Poor intrapartum bladder care Catheterization of the bladder
sensation
Total spinal Induction of a high nerve block/injection of Stop epidural and employ immediate
leading to bupivacaine into a vein resuscitation procedures
respiratory
arrest
Local Over infusion of local anaesthetic or too Stop epidural and employ immediate
anaesthetic rapid administration resuscitation procedures
toxicity
leading to
cardiac
arrest
Fetal Maternal hypotension or local analgesic Stop epidural and assist woman into left lateral
compromise toxicity position
Increase in Reduced muscle tone of the pelvic floor Consider low dose infusion epidural
assisted Delay pushing if fetal condition is satisfactory
vaginal
births
Neurological Any of the above causes Serious damage extremely rare; weakness/sensory
sequelae loss is uncommon and soon resolves
Long-term Common problem throughout childbirth Encourage mobility during labour so that
backache due to the hormones of pregnancy pressure on the back is given relief
softening the ligaments, BUT no
evidence to suggest that epidurals
cause long-term backache
Source: NICE 2007; Hawkins 2010; Anim-Somuah et al 2011
First stage of labour: vaginal breech at term
This section considers the physiology and intrapartum care in the first stage of labour
of those term pregnancies presenting by the breech. I n addition, the controversies
surrounding the evidence of breech birth and the effect on women's choice for labour
and birth are explored.
Incidence of breech presentation
Breech presentation involves a longitudinal lie of the fetus, with the bu ocks in the
lower pole of the maternal uterus. The presenting diameter is the bitrochanteric
(10 cm) and the denominator is the sacrum. A s pregnancy progresses, the incidence of
breech presentation reduces: being around 15% at 28–32 weeks to around 3–4% by
term as a result of spontaneous version (MI D I RS 2008b ). I t is worth considering,
therefore, that a breech presentation at term is not an abnormality, it is just unusual
and so a normal labour and spontaneous vaginal birth should not be excluded.
A lthough in Western childbirth culture a breech birth has the status of an emergency,
in many parts of the world a vaginal breech birth is part of normal practice (Burvill
2005). This used to be the case in the UK for most community midwives during the last
century (A llison 1996). Following the Peel Report (Maternity A dvisory Commi ee
1970) that gave rise to the transfer of childbirth from the home to the hospital
environment, such skills of the midwife regarding vaginal breech births have been
eroded as midwifery became subsumed into a medico-technocratic model, where
obstetric intervention prevails.
S ince the early 1990s, there has been much sociopolitical influence in the UK, aimed
at improving childbirth choices and quality of maternity services for women. This has
provided the opportunity for midwives to re-examine their role in providing a more
holistic model of maternity care (D H 1993, 2004a, 2004b, 2007, 2008a, 2008b, 2010a,
2010b). The consequential reduction in junior doctors' hours (D H et al 2002) provided
further opportunities for N HS Trusts to embrace collaborative working between
health professionals (DH 2001), leading to a redefining of roles and responsibilities for
midwives and their medical colleagues.
The clearly documented accounts from Cronk (1998a, 1998b), Reed (1999, 2003) and
Evans (2007, 2012a, 2012b) provide first-hand detail of how midwives can support
women with a breech presentation to give birth naturally other than by caesarean
section and are an inspiration to other midwives seeking to develop or re-establish
skills in this area. However, not all breeches can, or should be, born vaginally.
Types of breech presentation and position
There are six positions for a breech presentation, illustrated in Figs 16.21–16.26.
FIG. 16.21 Right sacroposterior.
FIG. 16.22 Left sacroposterior.
FIG. 16.23 Right sacrolateral.
FIG. 16.24 Left sacrolateral.
FIG. 16.25 Right sacroanterior.
FIG. 16.26 Left sacroanterior.
FIGS 16.21–16.26 Six positions in a breech presentation.
Breech with extended legs (frank breech)
The breech presents with the hips flexed and legs extended on the abdomen (Fig.
16.27). This type is particularly common in primigravidae whose efficient uterine
muscle tone inhibits flexion of the legs and free turning of the mobile fetus.
Consequently, this type of breech constitutes 70% of all breech presentations.
FIG. 16.27 Frank breech.
Complete breech
The fetal a itude is one of complete flexion (Fig. 16.28) with hips and knees both
flexed and the feet tucked in beside the buttocks.
FIG. 16.28 Complete breech.
Footling breech
O ne or both feet present due to the fact that neither hip is fully flexed (Fig. 16.29). The
feet are lower than the bu ocks, distinguishing it from the complete breech. This type
of breech is rare.
FIG. 16.29 Footling breech.
Knee presentation
This breech type is particularly rare and presents with one or both hips extended, with
the knees flexed (Fig. 16.30).
FIG. 16.30 Knee presentation.
Causes of breech presentation
O ften there is no identifiable cause, but the following situations favour breech
presentation:
• Extended legs
• Preterm labour
• Multiple pregnancy
• Polyhydramnios
• Hydrocephaly
• Uterine abnormalities such as a septum or a fibroid
• Placenta praevia
Diagnosis of breech presentation
In pregnancy
The woman may inform the midwife that she can feel something very hard and
uncomfortable under her ribs that makes breathing uncomfortable at times. I f the
fetal feet are in the lower pole of the uterus, the woman is likely to experience some
very hard kicks on her bladder. The use of ultrasound examination may be used to
confirm a breech presentation where there is some uncertainty, however a decision on
subsequent care, such as undertaking an external cephalic version (ECV), is usually
deferred until nearer term. S ome women may also a empt the use of moxibustion
from 34 weeks' gestation to reduce the need for ECV (Tiran 2010b; Smith 2013).
Abdominal palpation
I n primigravidae, diagnosis is more difficult because of the woman's firm abdominal
muscles. The lie will be longitudinal with a soft presenting part felt in the lower part of
the uterus. The head can usually be felt in the fundus as a round hard mass, which the
midwife may be able to move independently of the back by balloting it with one or
both hands. I f the legs are extended, the feet may prevent such movement of the head.
W hen the breech is anterior and the fetus well flexed it may be difficult to locate the
head. However, the woman may complain of discomfort under her ribs, especially at
night, owing to pressure of the head on the diaphragm, thus contributing to the
diagnosis.
Auscultation
Prior to the breech passing through the pelvic brim, the fetal heart will be heard most
clearly above the umbilicus. W hen the legs are extended, the breech descends into the
pelvis easily such that the fetal heart is heard at a lower level.
During labour
Abdominal examination
A previously unsuspected breech presentation may not be diagnosed until the woman
is in established labour. I f the legs are extended, the breech may feel like a head on
abdominal palpation and also on vaginal examination should the cervix be less than
3 cm dilated and the breech is high.
Vaginal examination
The breech feels soft and irregular with no sutures palpable. O n occasion the sacrum
may be mistaken for a hard head and the bu ocks for caput succedaneum. I n
addition, the anus may be felt and should the membranes have already ruptured, fresh
meconium on the examining finger is diagnostic. I f the legs are extended (Fig. 16.31)
the external genitalia are very obvious, however, as these become oedematous, a
swollen vulva can be mistaken for a scrotum.
FIG. 16.31 No feet felt: the legs are extended.
FIG. 16.32 Feet felt: complete breech presentation.
FIGS 16.31–16.32 Vaginal touch pictures of left sacrolateral position.
I f a foot is felt (Fig. 16.32) the midwife should differentiate from the hand. Toes are
all the same length, are shorter than fingers and the big toe cannot be opposed to
other toes. The foot is at right-angles to the leg and the heel has no equivalent in the
hand.
Mode of birth: the evidence
The evidence regarding the safest mode for breech babies to be born has been
somewhat controversial and misleading, with the randomized multicentre Term
Breech Trial conducted byHannah et al (2000) concluding the safest way to give birth
was by planned caesarean section. This has had a major impact on the choices offered
to women who may be presenting with a breech towards the end of their pregnancy
regarding mode of birth, leading to a consequential increase in planned caesarean
sections. By 2004 doubts had been cast on Hannah et al's (2000) research, with
questions being raised over the validity and ethical basis of using a RCT for such a
study and further research distrusting the results and recommendations (A larab et al
2004; Háheim et al 2004; Kotaska 2004; Ulander et al 2004; Pradham et al 2005;
Glezerman 2006; Fahy 2011). Furthermore, the two-year follow-up study by W hyte et al
(2004) and Hannah et al (2004) did not show any differences in long-term outcomes
between planned caesarean section or planned vaginal breech births.
Two further prospective trials undertaken by Goffinet et al (2006) and Maier et al
(2011) clearly found that where planned vaginal breech birth is common practice and
when strict criteria are met before and during labour, vaginal breech birth at term can
still be a safe option. For a successful outcome, the evidence indicates that the most
important factor is the presence of an experienced health professional, be it a midwife
or obstetrician, facilitating the birth. A s approximately one-third of all breech
presentations are undiagnosed until labour and there is no evidence to support a
caesarean section at this late stage, unless there is another clinical indication, it is
important that midwives and obstetricians are competent to support vaginal breech
birth. Consequently, the RCO G (2006) recommended that the most experienced
available practitioner should be present at a vaginal breech birth and that all
maternity units have guidelines in place, including structured simulated training for
all staff who may encounter vaginal breech births.
Place of birth
Vaginal birth should be presented to the woman as the norm for breech presentation
(MIDIRS 2008b) provided there are no contraindications or complications. The woman
should also be informed that there is an increase in the risk to the mother associated
with Caesarean section births (Chapter 21). I f a vaginal breech birth is planned for the
home environment it is important that the midwife is competent to facilitate the birth
and has clear lines of communication and support from her colleagues, including the
S upervisor of Midwives, with a second midwife being present for the birth itself (NMC
2008, 2012). However, according to N I CE (2007), a breech is considered to be a
malpresentation indicative of risk, and recommends the labour and birth should be
planned to take place in an obstetric unit. O utside of the hospital environment, any
decision to transfer the woman from the home should be made promptly taking into
consideration the time it would take to complete. A n action plan for the labour and
birth should be made with the woman that includes specifying those situations where
midwives would make the decision to transfer to hospital, namely where there is a lack
of progress or fetal compromise.
Posture for labour and birth
W hen women labour instinctively, without interruption or direction, they rarely
choose to labour in a semi-recumbent position. I n the campaign for normal birth, the
RCM currently endorses an upright position for breech labour and birth as this aids
descent of the presenting part, assisting the normal physiology of labour as well as
reducing the risk of aorto-caval compression with subsequent improvement in
placental blood flow (RCM 2005) (Chapter 17). However, as the upright position has
not been fully evaluated, the RCO G (2006) still recommends the woman to be in a
dorsal position for the actual birth.
Care in labour
Basic care during the first stage of labour is the same as those labours where the
presentation is cephalic: minimizing intervention and enabling the normal physiology
to progress. The breech with extended legs fits the cervix quite well, but with a less
well applied presenting part as in the complete breech there is a tendency for the
membranes to rupture early, increasing the risk of cord prolapse ( Chapter 22). S hould
this occur, the midwife must undertake a vaginal examination to exclude cord prolapse
and assess the fetal heart rate. I t is not uncommon to find meconium staining of the
amniotic fluid liquour with a breech presentation due to the compression of the fetal
abdomen, and for this reason is not always a sign of fetal compromise.
Prelabour rupture of fetal membranes at term (PROM)
Prelabour rupture of membranes (PRO M) at term (>37 weeks) complicates between 8
and 10% of all pregnancies and most women with PRO M will labour spontaneously
within 24 hours (N I CE 2007). Following PRO M with no signs of labour, regardless of
whether or not liquor is draining, digital examination should be avoided owing to an
increased risk of ascending infection (N I CE 2007; N I CE 2013). I f there is doubt about
whether the membranes have ruptured, a sterile speculum examination can be
performed in order to observe whether there is pooling of liquor in the posterior fornix
of the vagina (N I CE 2013). I f there are no facilities for this, the woman can be
encouraged to wear a sanitary pad for an hour or two in order for the midwife to re-
assess for signs of any liquor before a definite diagnosis can be made. The taking of
low vaginal swabs is not recommended ( N I CE 2007). I nitial assessment of the woman
should include observation of her pulse, respiration rate, blood pressure, temperature,
oxygen saturation and urinalysis. A n abdominal examination should be undertaken
and the fetal heart auscultated.
Following PRO M the risk of serious neonatal infection is increased from 0.5% to 1%,
compared with women whose membranes remain intact, and the woman should be
advised of this (N I CE 2007). I n view of this, and in the absence of any clinical
indication for immediate induction, such as Group B S treptococcus, maternal infection
or meconium staining of the liquor, it is usual practice to advise the woman that if she
does not go into spontaneous labour within 24 hours, labour should be induced after
PROM (NICE 2007) (see Chapter 19). W omen should be given adequate information to
decide between expectant management and active management of labour following
PRO M. Hospital admission, in the absence of any other concerns, is not required
whilst waiting for induction to take place.
Until the induction is commenced or if expectant management beyond 24 hours is
chosen by the woman the following recommendations regarding advice to women and
subsequent care should be followed (NICE 2007):
• Bathing or showering are not associated with an increase in infection, but having
sexual intercourse may be.
• Body temperature should be recorded every 4 hours during waking hours and any
change in the colour or smell of the vaginal loss should be reported to the midwife
immediately.
• Fetal movements should be observed.
• In the absence of any risk indicators and with satisfactory evidence of fetal
movements and a normal fetal heart rate, there is no reason for a CTG to be
performed.
• Low vaginal swabs and blood samples to assess maternal C-reactive protein should
not be taken.
Preterm prelabour rupture of the membranes (PPROM)
Preterm prelabour rupture of the membranes (PPRO M) occurs before 37 completed
weeks' gestation, where the fetal membranes rupture without the onset of
spontaneous uterine activity and the consequential cervical dilatation. I t is discussed
in Chapter 12.
The responsibilities of the midwife
The midwife has an important enabling and facilitating role to support the woman
during childbirth. I t is vital that shared decision-making takes place between women
and their caregivers at all times (Hodne et al 2012). A ccurate and detailed records of
all care given during the first stage of labour, including the careful administration and
monitoring of any medicines, is essential to the provision of quality care. These in turn
will provide a good basis from which proper decisions may be made concerning the
progress and the needs of the woman to optimize her labour experience and eventual
birth outcome.
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Further reading
Downe S. Normal childbirth: evidence and debate. 2nd edn. Churchill Livingstone:
London; 2008.
This text explores contemporary issues in maternity care. It includes thought-provoking
chapters by Nicky Leap and Tricia Anderson on ‘the role of pain in normal birth’, Soo
Downe et al's chapters on ‘rethinking risk and safety in maternity care’ and on ‘the
early pushing urge’..
McCormick C, Cairns A. Reducing unnecessary caesarean section by external
cephalic version. Marshall JE, Raynor MD. Advancing skills in midwifery practice.
Elsevier, Churchill Livingstone: Edinburgh; 2010:47–55.
This chapter examines the rationale for the procedure of external cephalic version
(ECV). It discusses why and how midwives and obstetricians should acquire
competency in such a skill to improve a woman's choice in achieving a vaginal birth
should their baby be presenting by the breech..
National Institute for Health and Clinical Excellence NICE. Intrapartum care: care
of healthy women and their babies during childbirth. CG 55. NICE: London; 2007.
This document contains evidence-based information for intrapartum care of women with
uncomplicated pregnancies. The intention of the guidelines are to standardise
practices among maternity units in the UK..
Walsh D. Normal labour and birth: a guide for midwives. 2nd edn. Routledge:
London; 2012.
This textbook examines care during normal labour and birth, including excellent
evidence-based guidance to normalize childbirth..
Useful websites
Royal College of Midwives. www.rcm.org.uk.
National Childbirth Trust. www.nct.org.uk.
Association of Radical Midwives. www.midwifery.org.uk.
Midwives Information and Resource Service. www.midirs.org.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
C H AP T E R 1 7
Physiology and care during the transition
and second stage phases of labour
Soo Downe, Jayne E Marshall
CHAPTER CONTENTS
The nature of the transition and second stage phases of labour 368
Uterine action 368
Soft tissue displacement 369
Recognition of the commencement of the second stage of labour 369
Presumptive evidence 369
Confirmatory evidence 370
Phases and duration of the second stage 370
The latent phase 370
The active phase 370
Duration of the second stage 370
Maternal response to transition and the second stage 370
Pushing 370
Position 371
Maternal and fetal condition 373
The mechanism of normal labour (cephalic presentation) 373
Main movements of the fetus 373
Midwifery care in transition and the second stage 374
Care of the parents 374
Observations during the second stage 376
Maternal comfort 377
Preparation for the birth 377
Birth of the baby 377
Vaginal breech birth at term 380
Mechanism of right sacro-anterior position 380
Undiagnosed breech presentation 381
Types of breech birth 381
Position for breech birth 381
Facilitating a vaginal breech birth in an upright/kneeling position 382
Potential complications of breech birth 387
Professional responsibilities and term breech birth 387
Record-keeping 387
Conclusion 388
References 389
Further reading 392
Useful websites 393
When labour moves to the phase of active maternal pushing, the whole
tempo of activity changes. The change in nature of uterine activity can lead
women to express confusion and loss of control. Intense physical effort and
exertion is needed as the baby is finally pushed towards its birth. The
woman, her supporting companions and her midwife all require stamina and
courage. Excitement and expectation mount as the birth becomes imminent.
A positive outcome will depend upon mutual respect and trust between all
involved professional groups, and between those groups and the labouring
woman and her companions. A woman will never forget a midwife who
positively supports her capacity to give birth to her baby, as shown in
Diane's story (see Box 17.7).
The chapter aims to:
• consider the nature of the transition and second stage phases of labour
• describe the usual sequence of events during these stages
• summarize signs of transition and of the expulsive phase of labour
• discuss the care of the mother, father and birth companions
• review the observations that should be carried out at this time
• discuss the physiology of birth and the role of the midwife when the term fetus is
presenting by the breech.
The first section of this chapter is focused on labour where the presentation is
cephalic. The special situation of the breech presentation at term is described in
the second half of the chapter.
The nature of the transition and second stage phases of
labour
The second stage of labour has traditionally been regarded as the phase between full
dilatation of the cervical os, and the birth of the baby. However, the physiological
reality of stages and phases of labour has been questioned (Walsh 2010; Zhang et al
2010). S ee Box 17.1 for examples of other controversial issues at this point in labour.
Most midwives and labouring women are aware of a transitional period between the
period of cervical dilatation, and the time when active maternal pushing efforts begin.
This is typically characterized by maternal restlessness, discomfort, desire for pain
relief, a sense that the process is never-ending, and demands to a endants to end the
whole process. A ppropriate midwifery care encompasses both knowledge of the usual
physiological processes of this phase and of the mechanism of birth, and insight into
the needs and choices of each individual labouring woman.
Box 17.1
E x a m ple s of a re a s of cont rove rsy in la bour t ra nsit ion
a nd se cond st a ge
D iscussion about the nature of normal physiological labour and birth has
taken place for at least the last 50 years, with an increase in publications in
this area over the last decade or so (Montgomery 1958; Crawford 1983;
D owne 1994, 2004, 2006, 2008; Gould 2000; Anderson 2003 D owne et al 2013;
Hannah et al 2013). These debates include:
• The utility of dividing labour into standard ‘phases’ or ‘stages’.
• The need or otherwise for regular vaginal examinations to assess the
progress of labour.
• The nature of transition.
• The nature and impact of the early pushing urge.
• Pushing in the context of epidural analgesia.
• The efficacy of signs of progress such as the anal cleft line and the
appearance of the rhomboid of Michaelis.
• The significance, and optimum management, of the tight nuchal cord at
the time of birth.
• The physiological limits to the length of the second stage of labour.
• Long-term outcome for the neonate relating to childbirth interventions.
The physiological changes are a continuation of the same forces that occurred in the
earlier hours of labour, but activity is accelerated. This acceleration, however, does not
occur abruptly. S ome women may experience an urge to push before the cervical os is
fully dilated, and others may experience a lull before the onset of strong expulsive
second stage contractions. This la er phenomenon has been termed the resting phase
of the second stage of labour. The formal onset of the second stage of labour is
traditionally confirmed with a vaginal examination to check for full dilatation of the
cervical os. However, a finding of full cervical dilatation may occur some time after this
stage has in fact been reached, and maternal behavioral changes may be a good
indication that expulsive contractions are occurring (Baker and Kenner 1993; Dahlen
et al 2013; Downe et al 2013).
Uterine action
Contractions become stronger and longer but may be less frequent, allowing both
mother and fetus regular recovery periods. The membranes often rupture
spontaneously towards the end of the first stage or during transition to the second
stage. The consequent drainage of liquor allows the presenting part, either the hard,
round fetal head or the bu ocks, to be directly applied to the vaginal tissues. This
pressure aids distension. Fetal axis pressure increases flexion of the presenting part,
resulting in smaller presenting diameters, more rapid progress and less trauma to
both mother and fetus. I f the mother is upright during this time, these processes are
optimized.
The contractions become expulsive as the fetus descends further into the vagina.
Pressure from the presenting part stimulates nerve receptors in the pelvic floor. This
phenomenon is termed the ‘Ferguson reflex’. A s a consequence, the woman experiences
the need to push. This reflex may initially be controlled to a limited extent but
becomes increasingly compulsive, overwhelming and involuntary. The mother's
response is to employ her secondary powers of expulsion by contracting her
abdominal muscles and diaphragm.
Soft tissue displacement
A s the fetal head descends, the soft tissues of the pelvis become displaced. A nteriorly,
the bladder is pushed upwards into the abdomen where it is at less risk of injury
during fetal descent. This results in the stretching and thinning of the urethra so that
its lumen is reduced. Posteriorly, the rectum becomes fla ened into the sacral curve
and the pressure of the advancing head expels any residual faecal ma er. The levator
ani muscles dilate, thin out and are displaced laterally, and the perineal body is
fla ened, stretched and thinned. The fetal head becomes visible at the vulva,
advancing with each contraction and receding between contractions until crowning
takes place. The head is then born. The shoulders and body follow with the next
contraction, accompanied by a gush of amniotic fluid and sometimes of blood. The
second stage culminates in the birth of the baby.
Recognition of the commencement of the second stage of
labour
Progress from the first to the second stage is not always clinically apparent.
Presumptive evidence
Expulsive uterine contractions
S ome women feel a strong desire to push before full dilatation occurs. Traditionally, it
has been assumed that an early urge to push will lead to maternal exhaustion and/or
cervical oedema or trauma. More recent research indicates that the early pushing urge
may in fact be experienced by a significant minority of women, and that, in certain
circumstances, spontaneous early pushing may be physiological (Petersen and
Besuner 1997; Roberts and Hanson 2007; D owne et al 2008; Borrelli et al 2013). I t is not
clear whether these findings are influenced by factors such as maternal or fetal
position, or parity, and there is not enough evidence to date to determine the optimum
response to the early pushing urge. The midwife needs to work with each individual
woman in the context of each labour to determine the best approach in that specific
case.
Rupture of the forewaters
Rupture of the forewaters may occur at any time during labour.
Dilatation and gaping of the anus
D eep engagement of the presenting part may produce this sign during the la er part
of the first stage.
Anal cleft line
S ome midwives have reported observing this line (also called ‘the purple line’) as a
pigmented mark in the cleft of the bu ocks which gradually ascends the anal cleft as
the labour progresses (Hobbs 1998; Wickham 2007). There is some observational
evidence from one study that this sign appears in the majority of women during
labour, and that it is somewhat correlated to both cervical dilatation and position of
the fetal head (Shepherd et al 2010). The efficacy of this observation in practice in large
populations of women remains to be tested formally.
Appearance of the rhomboid of Michaelis
This is sometimes noted when a woman is in a position where her back is visible. I t
presents as a dome-shaped curve in the lower back, and is held to indicate the
posterior displacement of the sacrum and coccyx as the fetal occiput moves into the
maternal sacral curve (Sutton and Scott 1996). This seems to lead the labouring woman
to arch her back, push her bu ocks forward and throw her arms back to grasp any
fixed object she can find. S u on and S co (1996) hypothesize that this is a
physiological response, since it causes a lengthening and straightening of the curve of
Carus, optimizing the fetal passage through the birth canal.
Upper abdominal pressure and epidural analgesia
I t has been observed anecdotally that women who have an epidural in situ often have
a sense of discomfort under the ribs towards the end of the first stage of labour. This
seems to coincide with full cervical dilatation. The efficacy of these observations in
predicting the onset of the anatomical second stage of labour remains to be
researched.
Show
This is the loss of bloodstained mucus which often accompanies rapid dilatation of the
cervical os towards the end of the first stage of labour. I t must be distinguished from
frank fresh blood loss caused by partial separation of the placenta or a ruptured vasa
praevia.
Appearance of the presenting part
Excessive moulding of the fetal head may result in the formation of a large caput
succedaneum which can protrude through the cervix prior to full dilatation of the os.
Very occasionally, a baby presenting by the vertex may be visible at the perineum at
the same time as remaining cervix. This is more common in women of high parity.
S imilarly a breech presentation may be visible when the cervical os is only 7–8 cm
dilated.
Confirmatory evidence
I n many midwifery se ings, it is held that a vaginal examination must be undertaken
to confirm full dilatation of the cervical os. This is both to ensure that a woman is not
pushing too early, and to provide a baseline for timing the length of the second stage
of labour. However, in some maternity se ings, individual midwives do not always
undertake this, unless there are observable maternal and/or fetal signs that the labour
is not progressing as anticipated. Enkin et al (2000) noted that vaginal assessment of
cervical dilatation is largely unevaluated, and a recent Cochrane review concludes that
this lack of evidence persists (D owne et al 2013). D espite this, regular vaginal
examinations are undertaken by most midwives and obstetricians, and expected by
many women. W hether the midwife undertakes an examination or not, she should
record all the signs she observes and all the measurements she takes, and she should
advise and support the labouring woman on the basis of accurate observation and
assessment of progress.
Phases and duration of the second stage
Two distinct phases in second stage progress have been recognized in some women.
These are the latent phase, during which descent and rotation occur, and the active
phase, with descent and the urge to push.
The latent phase
I n some women, full dilatation of the cervical os is recorded, but the presenting part
may not yet have reached the pelvic outlet. W omen in this situation may not
experience a strong expulsive urge until the head has descended sufficiently to exert
pressure on the rectum and perineal tissues. There is evidence from a study
undertaken half a century ago that active pushing during the latent phase does not
achieve much, apart from exhausting and discouraging the mother (Benyon 1990).
More recent concerns over the impact of epidural analgesia on spontaneous birth have
led to an increasing interest in the so-called passive second stage of labour, in which
active pushing efforts are delayed until fetal descent and rotation have occurred
(S impson and J ames 2005; N I CE 2007; Brancato et al 2008; Gillesby et al 2010). I t is
hypothesized that the prolongation of second stage progress when epidural analgesia
is used is due to the relaxation effect of epidural analgesia on the pelvic floor muscles,
meaning that the fetal presenting part does not encounter the necessary resistant force
from the pelvic floor to bring about the normal rotation process. This tends to be
particularly evident in nulliparous women. Passive descent of the fetus can continue
with good midwifery support for the woman until the head is visible at the vulva, or
until the woman feels a spontaneous desire to push.
The active phase
Most women without epidural analgesia will experience a compulsive urge to push, or
bear down, once the fetal head has rotated and started to descend. The phase of labour
that involves active bearing down is termed the active second stage of labour.
Duration of the second stage
There is no good evidence about the absolute time limits of physiological labour
(Downe 2004; N I CE 2007; Zhang et al 2010). Most researchers who have examined this
area have shown that, for healthy women and babies, the second stage of labour can
last for up to three hours or so before the risk of maternal and/or fetal compromise
begins to increase (A lbers 1999; A llen et al 2009). I n the presence of regular
contractions, maternal and fetal wellbeing, and progressive descent, considerable
variation between women is to be expected. W hile many maternity units do currently
impose standardized limits on the second stage beyond which medical help should be
called, these are not based on good evidence.
Maternal response to transition and the second stage
Pushing
Traditionally, if the maternal urge to push occurs before confirmation of full dilatation
of the cervical os, or the appearance of a visible vertex, the mother has been
encouraged to avoid active pushing. This has been done to conserve maternal effort
and allow the vaginal tissues to stretch passively. Techniques to avoid active pushing
efforts in this situation include position change, often to the left lateral, using
controlled breathing, inhalation analgesia, or even narcotic or epidural pain relief
(D owne et al 2008). However, when mother and baby are well and labour has
progressed spontaneously, anecdotally, an increasing number of midwives have
adopted the practice of supporting the overwhelming urge to bear down without
confirming full dilatation of the cervical os, while paying close a ention to the
maternal and fetal condition (D owne et al 2008; Borrelli et al 2013). A s stated above,
the optimum response in this situation has not yet been established.
There has been convincing evidence for more than two decades that managed active
pushing in the second stage of labour accompanied by breath holding (the Valsalva
manoeuvre) has adverse consequences (Thomson 1993; A ldrich et al 1995; Enkin et al
2000; Yildirim and Beji 2008; Prins et al 2011). W henever active pushing commences,
the woman should be encouraged to follow her own inclinations in relation to
expulsive effort. Few women need instruction on how to push unless they are using
epidural analgesia (Box 17.2).
Box 17.2
E pidura l a na lge sia a nd spont a ne ous va gina l birt h
Epidural analgesia provides optimal pain relief for women, but its use is
associated with an increase in instrumental births (A nim-S omuah et al
2011). W omen who use epidural analgesia are no more satisfied with their
pain relief than those who do not, and their memories of labour as being
extremely painful and therefore distressing may persist longer than for
women with equal levels of pain in labour who do not receive epidural
analgesia (Waldenstrom and S chy 2009). Techniques for reducing the risk
of instrumental births in this group have included:
• Minimizing the concentration of local anaesthetic (Stoddart et al 1994)
• Letting the block wear off towards the end of labour (Torvaldsen et al
2004)
• Using oxytocin in the second stage of labour (Costley and East 2012)
• Fundal pressure (Verheijen et al 2009)
• Delaying active pushing between the diagnosis of the onset of full
dilatation of the cervix and a fixed point later in the labour (Roberts et al
2004)
• Using different positions (Downe et al 2004; Roberts et al 2005)
• Using combinations of anaesthetic that allow women to mobilize in
labour (COMET Study Group UK 2001).
These techniques have had varying success rates, with most of them
failing to show large differences in outcome.
S pontaneous pushing efforts usually result in maximum pressure being exerted at
the height of a contraction. I n turn, this allows the vaginal muscles to become taut and
prevents bladder supports and the transverse cervical ligaments from being pushed
down in front of the baby's head. I t is believed that this may help to prevent prolapse
and urinary incontinence in later life, although this belief has still not been formally
tested (Benyon 1990).
S ome mothers vocalize loudly as they push. This may aid in coping with the
contractions, so women should feel free to express themselves in this way.
Reassurance and praise will help to boost confidence, enabling the mother to assert
her own control over events. The atmosphere should be calm and the pace unhurried.
Position
I f the woman lies flat on her back, vena caval compression is increased, resulting in
hypotension. This can lead to reduced placental perfusion and diminished fetal
oxygenation (Humphrey et al 1974; Kurz et al 1982). The efficiency of uterine
contractions may also be reduced. The semi-recumbent or supported si ing position,
with the thighs abducted, is the posture most commonly used in Western cultures.
W hile this may afford the midwife good access and a clear view of the perineum, the
woman's weight is on her sacrum, which directs the coccyx forwards and reduces the
pelvic outlet. I n addition, the midwife needs to bend forward and laterally to support
the birth, which may lead to injury.
Left lateral position
This position was widely used in the United Kingdom (UK) in the 20th century,
although it is less common in current practice. The perineum can be clearly viewed
and uterine action is effective, but an assistant may be required to support the right
thigh, which may not be ergonomic. I t provides an alternative for women who find it
difficult to abduct their hips. I t may also aid fetal rotation, especially in the context of
epidural analgesia (Downe et al 2004).
Upright positions: squatting, kneeling, all-fours, standing, using a
birthing ball
A review of studies examining upright versus recumbent positions during the second
stage of labour showed there were clear advantages for women in adopting any
position that was not horizontal, as shown in Figs 17.1 and 17.2 (Gupta et al 2012).
These included reduced duration of second stage labour, fewer assisted births, fewer
episiotomies, reduced severe pain in second stage labour, and fewer abnormal heart
rate pa erns. However, increased rates of perineal damage and of estimated blood
loss >500 ml also occurred. The experimental group included women who used
birthing chairs, a technique known to be associated with increased blood loss (Stewart
and S piby 1989; Turner et al 1988). I t is not clear if this risk accrues to all upright
positions. The ‘upright position’ group in this review included women who were in
supported si ing positions on a bed, and in the lateral position. There are a number of
studies relating to positions and mobility for women using so-called ‘walking
epidurals’, but recent data on the physiology of labour and birth for women in
spontaneous labour who mobilize without the use of pharmacological pain relief do
not seem to exist.
FIG. 17.1 Supported sitting position. After Simkin and Ancheta 2006, with permission from Blackwell
Science.
FIG. 17.2 Using a birthing ball. After Simkin and Ancheta 2006, with permission from Blackwell Science.
Radiological evidence demonstrates an average increase of 1 cm in the transverse
diameter and 2 cm in the anteroposterior diameter of the pelvic outlet when the
squa ing position is adopted. This produces an average 28% increase in the overall
area of the outlet compared with the supine position (Russell 1969). S ome women find
the all-fours position to be the optimum approach for all or part of their labours,
especially in the case of an occipitoposterior position, due to relief of backache
(S tremler et al 2005). I n the case of a breech presentation, anecdotal evidence suggests
that most women will spontaneously adopt an all-fours or forward-leaning position
(see discussion below). I t can, however, be tiring to maintain for a long period of time.
A wide range of other standing and leaning positions can be experimented with to
help the woman cope with her labour (S imkin and A ncheta 2006; S imkin 2010; Royal
College of Midwives 2013). I t is important not to insist on any position as the ‘right’
one. Positive and dramatic effects on labour progress can be achieved by encouraging
the woman to change and adapt her position in response to the way her body feels.
The position the woman may choose to adopt is dictated by several factors:
• The woman's instinctive preference.
• The environment, which should not act as a constraint through lack of privacy or lack
of supports such as cushions and chairs. In a hospital setting, it may help to move the
labour bed from the middle of the room, and to provide other supports such as
cushions and birthing balls, so that the woman can roam from one to another as the
labour dictates. Low lighting and music of her choice may help the woman to see the
room as a safe and secure place. Minimizing unnecessary intrusion by other
members of staff is essential.
• The midwife's confidence. A full understanding of the mechanism of labour should
enable the midwife to adapt to any position that the woman wishes to adopt,
ensuring in the process that the postures adopted by the midwife are protective of
her own health (and, specifically, of her back). One way of minimizing damage to the
back is to refrain from placing the woman in a low supported sitting position with
her feet resting on the midwife's hip. Minimizing vaginal examinations in labour will
also reduce the risk of back injury. If the woman has an epidural in situ it is essential
that help is called when the woman needs to be moved, and that ergonomic lifting
positions are used.
Maternal and fetal condition
I f the woman has had analgesia, or if there is any concern about her wellbeing or that
of her baby, then more frequent or continuous monitoring may limit the choices
available to her. However, there are often creative solutions to these situations, and
good midwifery care involves finding these solutions where possible (RCM 2013).
The mechanism of normal labour (cephalic presentation)
A s the fetus descends, soft tissue and bony structures exert pressures that lead to
descent through the birth canal by a series of movements. Collectively, these
movements are called the mechanism of labour. There is a mechanism for every fetal
presentation and position that can lead to a vaginal birth. Knowledge and recognition
of the normal mechanism enables the midwife to anticipate the next step in the
process of descent. Understanding and constant monitoring of these movements can
help to ensure that normal progress is recognized, that the woman gives birth safely
and positively, or that early assistance can be sought should any problems occur. The
fetal presentation, position, and size relative to that of the woman will govern the exact
mechanism as the fetus responds to external pressures. Principles common to all
mechanisms are:
• descent takes place
• whichever part leads and first meets the resistance of the pelvic floor will rotate
forwards until it comes under the symphysis pubis
• whatever emerges from the pelvis will pivot around the pubic bone.
I t should be noted that, while the mechanism set out below is the most common, it
is not an invariant blueprint, but a guide: each labour is unique.
D uring the mechanism of normal labour, the fetus turns slightly to take advantage
of the widest available space in each plane of the pelvis. The widest diameter of the
pelvic brim is the transverse: at the pelvic outlet the greatest space lies in the
anteroposterior diameter.
At the onset of labour the most common presentation is the vertex and the most
common position either left or right occipitoanterior; therefore it is this mechanism
which will be described. In this instance:
• the lie is longitudinal
• the presentation is cephalic
• the position is right or left occipitoanterior
• the attitude is one of good flexion
• the denominator is the occiput
• the presenting part is the posterior part of the anterior parietal bone.
Main movements of the fetus
Descent
D escent of the fetal head into the pelvis often begins before the onset of labour. For a
primigravid woman this usually occurs during the la er weeks of pregnancy. I n
multigravid women muscle tone is often more lax and therefore descent and
engagement of the fetal head may not occur until labour actually begins. Throughout
the first stage of labour the contraction and retraction of the uterine muscles reduces
the capacity in the uterus, exerting pressure on the fetus to descend further. Following
rupture of the forewaters and the exertion of maternal effort, progress speeds up.
Flexion
This increases throughout labour. The fetal spine is a ached nearer the posterior part
of the skull; pressure exerted down the fetal axis will be more forcibly transmi ed to
the occiput than the sinciput. The effect is to increase flexion which results in smaller
presenting diameters that will negotiate the pelvis more easily. At the onset of labour
the suboccipito-frontal diameter, which is approximately 10 cm, is presenting. With
greater flexion, the sub-occipitobregmatic diameter, that is, approximately 9.5 cm,
presents. The occiput becomes the leading part.
Internal rotation of the head
D uring a contraction, the leading part is pushed downwards onto the pelvic floor. The
resistance of this muscular diaphragm brings about rotation. A s the contraction fades,
the pelvic floor rebounds, causing the occiput to glide forwards. A s discussed above,
resistance is an important determinant of rotation, as Fig. 17.3 demonstrates. This
explains why rotation is often delayed following epidural analgesia, which causes
relaxation of pelvic floor muscles. The slope of the pelvic floor determines the
direction of rotation. The muscles are hammock-shaped and slope down anteriorly, so
whichever part of the fetus first meets the lateral half of this slope will be directed
forwards and towards the centre. I n a well-flexed vertex presentation the occiput leads,
and rotates anteriorly through of a circle when it meets the pelvic floor. This causes
a slight twist in the neck as the head is no longer in direct alignment with the
shoulders. The anteroposterior diameter of the head now lies in the widest
(anteroposterior) diameter of the pelvic outlet. The occiput slips beneath the sub-
pubic arch and crowning occurs when the head no longer recedes between
contractions and the widest transverse diameter (biparietal) is born. I f flexion is
maintained, the sub-occipitobregmatic diameter, approximately 9.5 cm, distends the
vaginal orifice.
FIG. 17.3 (A) Internal rotation of the head begins. (B) Upon completion, the occiput lies under
the symphysis pubis.
Extension of the head
O nce crowning has occurred, the fetal head can extend, pivoting on the suboccipital
region around the pubic bone. This releases the sinciput, face and chin, which sweep
the perineum, and then are born by a movement of extension, as shown in Fig. 17.4.
FIG. 17.4 (A) Birth of the head. (B) Restitution. (C) External rotation.
Restitution
The twist in the neck of the fetus which resulted from internal rotation is now
corrected by a slight untwisting movement. The occiput moves of a circle towards
the side from which it started.
Internal rotation of the shoulders
The shoulders undergo a similar rotation to that of the head to lie in the widest
diameter of the pelvic outlet, namely anteroposterior. The anterior shoulder is the first
to reach the levator ani muscle and it therefore rotates anteriorly to lie under the
symphysis pubis. This movement can be clearly seen as the head turns at the same
time (external rotation of the head). I t occurs in the same direction as restitution, and
the occiput of the fetal head now lies laterally.
Lateral flexion
The shoulders are usually born sequentially. W hen the woman is in a supported
si ing position, the anterior shoulder is usually born first, although midwives who
encourage women to adopt an upright or kneeling positions have observed that the
posterior shoulder is commonly seen first. I n the former case, the anterior shoulder
slips beneath the sub-pubic arch and the posterior shoulder passes over the perineum.
I n the la er the mechanism is reversed. This enables a smaller diameter to distend the
vaginal orifice than if both shoulders were born simultaneously. The remainder of the
body is born by lateral flexion as the spine bends sideways through the curved birth
canal.
Midwifery care in transition and the second stage
Care of the parents
The woman and her companions will now realize that the birth of the baby is
imminent. They may feel excited and elated but at the same time anxious and
frightened by the dramatic change in pace. They will need frequent explanations of
events. The midwife's calm approach and information about what is happening can
ensure the woman stays in control, and is confident. This is critical at the time of
transition, when events can result in a sensation of panic. The midwife should praise
and congratulate the woman on her hard work, recognizing that she is probably
undertaking the most extreme physical activity she will ever encounter. Birth is an
intimate act which often takes place in a public se ing. The midwife should work hard
to ensure that privacy and dignity are maintained.
Crucially, it is at the time of transition that a maternal request for analgesia may
occur, even if she had stated antenatally that she did not want pain relief in labour.
S uch a request will need to be carefully assessed by the a ending midwife. This is
especially true when a supportive companion is not present. O n the basis of her
knowledge of the woman, the midwife may be able to help her over this transient
phase with good midwifery support, and without utilizing pharmacological analgesia.
The decision for or against pain relief at this stage must be made in partnership with
the woman, recognizing that, particular for a nulliparous woman, a demand for pain
relief may often be an unconscious proxy for a demand for labour support. I n order to
achieve the kind of supportive care that can help a woman over the uncertainties and
distress of transition, it is eminently preferable that the woman should have
continuous support throughout labour (Hodne et al 2012). I deally, the same midwife
or small group of known midwives should a end the woman throughout (McLachlan
et al 2012). A lternatives to pharmacological analgesia include praise and reassurance
about progress, changes in position and scenery, massage and appropriate nutrition.
Complementary therapies and optimal fetal positioning may also be offered if the
midwife is competent to undertake them. Leg cramp is a common occurrence
whichever posture is adopted. I t can be relieved by massaging the calf muscle,
extending the leg and dorsiflexing the foot. These measures may be crucial in re-
energizing a labour that is beginning to flag in the second stage.
The midwife should also have regard to the wellbeing of the woman's partner and
other companions as far as possible. Witnessing labour and birth is not easy,
especially for the woman's partner/birth companions. I ndeed, recent qualitative
research has indicated that birth companions can be profoundly affected by
witnessing traumatic birth, and can even exhibit symptoms that appear to be similar
to those of post-traumatic stress for years after the birth (White 2007; S teen et al 2012).
The a itude of the midwife to the labour, to the woman, and to the partner/birth
companions will have a profound effect on the labour (Halldorsdo ir and Karlsdo ir
1996; Lundgren 2004; El-N emer et al 2006; Thomson and D owne 2008, 2010; Elmir et al
2010; Berg et al 2012), with possible consequences for the mother, her partner and the
family after the birth (Thomson and D owne 2010). I t is crucial to respect the woman
and her partner/birth companions, and to respect the meaning that this birth will have
for them, both on the day, and in the future.
Observations during the second stage
Four factors determine whether the second stage is continuing safely, and these must
be carefully monitored:
• Uterine contractions
• Descent, rotation and flexion of the presenting part
• Fetal condition/suspicious or pathological changes in the fetal heart
• Maternal condition.
Uterine contractions
The strength, length and frequency of contractions should be assessed regularly by
observation of maternal responses, and by uterine palpation during the second stage
of labour. They are usually stronger and longer than during the first stage of labour,
with a shorter resting phase. The posture and position adopted by the woman may
influence the contractions.
Descent, rotation and flexion
I nitially, descent may occur slowly, especially in primigravid women, but it usually
accelerates during the active phase. I t may occur very rapidly in multigravid women. I f
there is a delay in descent on abdominal palpation, despite regular strong contractions
and active maternal pushing, a vaginal examination may be performed with maternal
permission. The purpose is to confirm whether or not internal rotation of the head has
taken place, to assess the station of the presenting part and to determine whether a
caput succedaneum has formed. I f the occiput has rotated anteriorly, the head is well
flexed and caput succedaneum is not excessive it is likely that progress will continue.
I n the absence of good rotation and flexion, and/or a weakening of uterine
contractions, change of position, nutrition and hydration, or use of optimal fetal
positioning techniques maybe helpful (S imkin and A ncheta 2006). Consultation with a
more experienced midwife may provide more suggestions to re-orientate the labour.
However, if there is evidence that either fetal or maternal condition are compromised,
an experienced obstetrician should be consulted.
Fetal condition/suspicious or pathological changes of the fetal heart
I f the membranes are ruptured, the liquor amnii is observed to ensure that it is clear.
W hile thin old meconium staining is not always regarded as a sign of fetal
compromise, thick fresh meconium is ominous, and experienced obstetric advice must
be sought if this sign appears (N I CE 2007). I t may, however, be the only indication of
an undiagnosed breech presentation.
A s the fetus descends, fetal oxygenation may be less efficient owing to either cord or
head compression or to reduced perfusion at the placental site. A well-grown healthy
baby will not be compromised by this transitory hypoxia. I f continuous electronic fetal
monitoring is being undertaken due to risk factors in the mother or baby, it is not
unusual at this stage to see early decelerations of the fetal heart, with a swift return to
the normal baseline after a contraction, and good beat-to-beat variation throughout.
The midwife should learn to recognize the normal changes in fetal heart rate pa erns
during the second stage, both when monitored continuously (where there are specific
risk factors) and when monitored intermi ently. This will minimize the risk of
iatrogenic intervention, and maximize a timely response to fetal compromise if it
occurs. I f the woman is labouring normally, N I CE guidelines recommend that a
Pinard's stethoscope or other hand-held system such as a S onicaid should be used to
monitor the fetal heart intermi ently (N I CE 2007). D uring the second stage this is
usually undertaken immediately after a contraction, with some readings being taken
through a contraction if the woman can tolerate this.
Late decelerations, and a lack of return to the normal baseline, a rising baseline or
diminishing beat-to-beat variation, are signs of concern. W hile it is generally
acknowledged that beat-to-beat variation is hard to identify in intermi ent
monitoring, the other characteristics can be identified. I f these are heard for the first
time in the second stage, they may be due to cord or head compression, which may be
helped by a change in maternal position. However, if they persist, experienced
obstetric aid must be sought. I f the labour is taking place in a unit that is distant from
an obstetric unit, an episiotomy may be considered – with maternal consent – if the
birth is imminent, or midwives who are trained and experienced in ventouse birth may
consider expediting the birth. O therwise, with maternal consent, transfer to an
obstetric unit should take place.
Maternal condition
The midwife's observation includes an appraisal of the woman's ability to cope
emotionally as well as an assessment of her physical wellbeing. This includes close
a ention to what she says, as well as how she behaves, and a swift supportive
response to any indication that she is losing belief in herself to accomplish the birth of
her baby.
Maternal pulse rate is usually recorded half-hourly and blood pressure every few
hours, provided that these remain within normal limits. I f the woman has an epidural
in situ, blood pressure will be monitored more frequently, and continuous electronic
fetal monitoring will probably be in use.
Maternal comfort
A s a result of her exertions the woman usually feels very hot and sticky, and she will
find it soothing to have her face and neck sponged with a cool flannel. Her mouth and
lips may become very dry. S ips of iced water or other fluids are refreshing and a
moisturizing cream can be applied to her lips. Her partner may help with these tasks
as a positive contribution to ease her discomfort.
The bladder is vulnerable to damage, due to compression of the bladder base
between the pelvic brim and the fetal head. The risk is increased if the bladder is
distended. The woman should be encouraged to pass urine at the beginning of the
second stage unless she has recently done so.
Preparation for the birth
O nce active pushing commences, the midwife should prepare for the birth. There is
usually li le urgency if the woman is primigravid, but multigravid women may
progress very rapidly.
The room in which the birth is to take place should be warm with a spotlight
available so that the perineum can be easily observed if necessary. A clean area should
be prepared to receive the baby, and waterproof covers provided to protect the bed
and floor. S terile cord clamps, a clean apron, and sterile gloves are placed to hand. I n
some se ings, sterile gowns are also used. A n oxytocic agent may be prepared, either
for the active management of the third stage if this is acceptable to the woman, or for
use during an emergency. A warm cot and clothes should be prepared for the baby. I n
hospital a heated ma ress may be used; at home, a warm ( not hot) water bo le can be
placed in the cot.
N eonatal resuscitation equipment must be thoroughly checked and readily
accessible.
Birth of the baby
The midwife's skill and judgement are crucial factors in minimizing maternal trauma
and ensuring an optimal birth for both mother and baby. These qualities are refined
by experience but certain basic principles should be applied. They are:
• observation of progress
• prevention of infection
• emotional and physical comfort of the mother
• anticipation of normal events, and support for the normal processes of labour
• recognition of abnormal developments, and appropriate response to them.
D uring the birth, both mother and baby are particularly vulnerable to infection.
W hile there is now evidence that strict antisepsis is unnecessary if the birth is
straightforward (Keane and Thornton 1998; Lumbiganon et al 2004), meticulous
aseptic technique must be observed when preparing sterile surgical equipment that
could be used for invasive techniques, such as episiotomy scissors. S urgical gloves
should be worn during the birth for the protection of both woman and midwife.
Goggles or plain glasses should be available to avoid the risk of ocular contamination
with blood or amniotic fluid.
The equipment that is used during the birth of the baby includes the following
items:
• warm swabbing solution or tap water
• cotton wool and pads
• sterile cord scissors and clamps
• sterile episiotomy scissors (these should be available in case they are needed).
Birth of the head
O nce the birth is imminent, the perineum may be swabbed clean of any mucus should
this be indicated (although no longer a common practice), and a clean pad is placed
under the woman to absorb any faeces or fluids. I f she is not in an upright position a
pad is placed over the rectum on the perineum (but not covering the fourche e) and a
clean towel is placed on or near the woman for receipt of the baby. Throughout these
preparations the midwife observes the progress of the fetus. With each contraction the
head descends. A s it does so the superficial muscles of the pelvic floor can be seen to
stretch, especially the transverse perineal muscles. The head recedes between
contractions, which allows these muscles to thin gradually. The skill of the midwife in
ensuring that the active phase is unhurried helps to safeguard the perineum from
trauma, either observing the gradual advancement of the fetal head or controlling it
with light support from her hand. O ne large study, the HO O P (Hands-O ff Hands
Poised) trial, indicated that, compared with guarding the perineum, a hands-off
technique was associated with slightly more maternal discomfort at 10 days
postnatally (McCandlish et al 1998). The hands-off technique was also associated with
a lower risk of episiotomy, but a higher risk of manual removal of placenta. There is
some debate about the generalizability of this trial to all se ings and positions in
labour. However, account should be taken of these findings in working with individual
women. Most midwives place their fingers lightly on the advancing head to monitor
descent and prevent very rapid crowning and extension, which are believed to result in
perineal laceration (see (Fig. 17.5). Excessive pressure on the head, however, may be
associated with vaginal lacerations. W hatever technique the midwife adopts, it should
be based on the assumption that it is the woman who is giving birth to her baby, and
the midwife is there to add the minimum physical help necessary at any given time.
FIG. 17.5 Supporting the head. (A) Preventing rapid extension. (B) Controlling the crowning. (C)
Easing the perineum to release the face.
O nce the head has crowned, the woman can achieve control by gently blowing or
‘sighing’ out each breath in order to minimize active pushing. Birth of the head in this
way may take two or three contractions but may avoid unnecessary maternal trauma.
The head is born by extension as the face appears at the perineum.
D uring the resting phase before the next contraction the midwife may check that the
cord is not around the baby's neck. I f found, it is usual to slacken it to form a loop
through which the shoulders may pass. I f the cord is very tightly wound around the
neck, it is common practice in the UK to apply two artery forceps approximately 3 cm
apart and to sever the cord between the two clamps (J ackson et al 2007). I n the United
S tates, the so-called ‘somersault manoeuvre’ is often performed, as shown in Fig. 17.6
(Mercer et al 2005, 2007). There has been controversy over early cord cu ing for the
healthy term baby, on the basis that, even if tightly around the neck, the cord is still
supplying oxygen. A dditionally, the blood volume model proposed by Mercer and
S kovgaard (2004) suggests that the loss of blood volume occasioned by clamping and
cu ing the cord before it stops pulsating may be detrimental to the baby. This
hypothesis has been supported by systematic reviews (Hu on and Hassan 2007;
McD onald and Middleton 2008). However, these studies have not controlled for the
possible adverse effects of a tight nuchal cord. I f the cord is cut, the baby should be
born very soon afterwards, as it now has no access to oxygen until it takes its first
breath. For this reason, cu ing of the nuchal cord should always be a last resort, if the
cord cannot be freed or the baby born with the cord intact.
FIG. 17.6 The somersault manoeuvre. From Mercer et al 2005.
I f the cord is clamped, great care must be taken that maternal tissues are not
damaged. Holding a swab over the cord as it is incised will reduce the risk of the
a endants being sprayed with blood during the procedure. O nce severed, the cord
may be unwound from around the neck.
Birth of the shoulders
Restitution and external rotation of the head maximizes the smooth birth of the
shoulders and minimizes the risk of perineal laceration. However, it is not uncommon
for small babies, or for babies of multiparous women, to be born with the shoulders in
the transverse, or even to have a twist in the neck opposite to that expected. W hile the
hands-on technique in the HO O P trial included both perineal support and active birth
of the trunk and shoulders (McCandlish et al 1998) it is not clear which component of
this technique was beneficial for women and babies. I f the position is upright, it is
more common for the shoulders to be left to birth spontaneously with the help of
gravity.
D uring a water birth, it is important not to touch the emerging fetus to avoid
stimulating it to gasp underwater. I f there is a problem with the birth in this
circumstance, the woman should be asked to stand up out of the water before any
manoeuvres are attempted.
I f the midwife does physically aid the birth of the shoulders and trunk, she should
be absolutely sure that restitution has occurred prior to trying to flex the trunk
laterally. O ne shoulder is released at a time to avoid overstretching the perineum. A
hand is placed on each side of the baby's head, over the ears, and gentle downward
traction is applied (Fig. 17.7). This allows the anterior shoulder to slip beneath the
symphysis pubis while the posterior shoulder remains in the vagina. I f the third stage
of labour is to be actively managed, the assistant will now give an intramuscular (I M)
oxytocic drug. W hen the axillary crease is seen, the head and trunk are guided in an
upward curve to allow the posterior shoulder to escape over the perineum. These
manoeuvres are reversed if the mother is in a forward-facing position such as all-fours.
The midwife or mother may now grasp the baby around the chest to aid the birth of
the trunk and lift the baby towards the mother's abdomen. This allows the mother
immediate sighting of her baby and close skin contact, and removes the baby from the
gush of liquor which accompanies release of the body. I f the midwife does not actively
assist, she should be ready to support the head and trunk as the baby emerges. The
time of birth is noted and recorded.
FIG. 17.7 (A) Downward traction releases the anterior shoulder. (B) An upward curve allows the
posterior shoulder to escape.
I f this has not already been done, the cord is severed between two cord clamps
placed close to the umbilicus at whatever time is considered appropriate, with due
a ention to the theories around the blood volume model set out above. The cord
clamp is applied. The baby is dried and placed in the skin-to-skin position with the
mother if she is happy with this (Moore et al 2007; Bystrova et al 2009). A warm cover is
placed over the baby. S wabbing of the eyes and aspiration of mucus during and
immediately following birth are not considered necessary providing the baby's
condition is satisfactory. O ral mucus extractors should not be used because of the
risks of mucus that is contaminated with a virus such as hepatitis or human
immunodeficiency virus (HIV) entering the operator's mouth.
The moment of birth is both joyous and beautiful. The midwife is privileged to
share this unique and intimate experience with the parents.
Vaginal breech birth at term
This section follows on from Chapter 16 regarding the physiology and management of
the first stage of labour for women with term pregnancies where the fetus is
presenting by the breech. The main aim for both chapters is to examine the knowledge
and skills required to effectively facilitate planned vaginal breech births at term in both
home and hospital se ings. I t is important that midwives are conversant with the
controversies surrounding the Term Breech Trial (Hannah et al 2000) and the
subsequent studies and guidance that are available to inform a woman's choice in
mode of breech birth (Goffinet et al 2006; RCO G 2006; N I CE 2007; Maier et al 2011)
(see also Chapter 16). However, many midwives will, occasionally, find themselves in
the situation of diagnosing a breech presentation in transition or the second stage of
labour, sometimes while a ending an out-of-hospital birth. For this reason, all
midwives need to have the skills and knowledge to support the woman in this
situation, to make decisions, work with the normal physiology of the labour if the
birth is proceeding spontaneously, to know how to recognize impending or actual
problems, how when to undertake manoeuvres, and/or to transfer the woman to
obstetric care in a hospital setting.
Mechanism of right sacro-anterior position
S imilar to cephalic presentations that favour the left occipitoanterior position, breech
presentations more commonly adopt the right sacro-anterior position, the mechanism
of which is described below:
• The lie is longitudinal.
• The attitude is one of complete flexion.
• The presentation is breech.
• The position is right sacro-anterior.
• The denominator is the sacrum.
• The presenting part is the anterior (right) buttock.
• The bitrochanteric diameter (10 cm) enters the pelvis in the right oblique diameter of
the maternal pelvic brim.
• The sacrum points to the right ilio-pectineal eminence.
Compaction
D escent takes place with increasing compaction owing to increased flexion of the
limbs.
Internal rotation of the buttocks
The anterior (right) bu ock reaches the pelvic floor first and rotates forward of a
circle along the left side of the maternal pelvis to lie underneath the symphysis pubis.
The bitrochanteric diameter is now in the anterioposterior diameter of the maternal
pelvic outlet.
Lateral flexion of the body
The anterior bu ock escapes under the symphysis pubis, the posterior bu ock sweeps
the perineum and the bu ocks are born by a movement of lateral flexion: also known
as ‘rumping’.
Restitution of the buttocks
The anterior buttock turns slightly to the mother's left side.
Internal rotation of the shoulders
The shoulders enter the brim of the pelvis in the same oblique diameter as the
bu ocks: namely the right oblique diameter. The anterior shoulder rotates forward
of a circle along the left side of the maternal pelvis and escapes under the symphysis
pubis; the posterior shoulder sweeps the perineum and the shoulders are born.
Internal rotation of the head
The fetal head enters the maternal pelvis with the sagi al suture in the transverse
diameter of the pelvic brim. The occiput rotates forwards of a circle along the left
side of the maternal pelvis and the suboccipital region (nape of the neck) impinges on
the undersurface of the symphysis pubis.
External rotation of the head
At the same time the baby's body turns so that it lies parallel with the maternal body.
Birth of the fetal head
The chin, face and sinciput sweep the perineum, and the baby's head is born in a
flexed attitude.
Undiagnosed breech presentation
I t is still not uncommon for a breech presentation to be discovered for the first time
during labour, often towards the end of labour, as the presenting part becomes more
easily identified, or in the presence of fresh meconium. I f the midwife a ends a
woman in labour at home with a breech presentation where a hospital birth had
initially been planned, it is important to remain calm whilst undertaking a careful
assessment of the risk to the woman and baby taking into consideration the parent's
wishes before a decision to transfer to hospital is made. This will depend on the stage
of labour, fetal position and maternal medical and obstetric history. I f the woman is
nearing the second stage of labour and the labour is progressing well, assistance
should be promptly summoned while supporting her to give birth at home. S hould a
decision be made to transfer to hospital, the midwife must alert the hospital of the
transfer and ensure that the paramedics are equipped for neonatal resuscitation. The
fetal heart and maternal condition should be monitored and recorded throughout the
journey to hospital. The midwife must always be prepared for the birth in transit as it
may progress more rapidly than initially anticipated. I n such a situation, the driver
should be asked to stop the ambulance in order for the midwife to assist the birth,
undertaking any necessary manoeuvres safely. I f the baby is likely to be born in
transit, it is useful to take a number of towels/blankets to wrap the baby, encouraging
skin-to-skin contact and early breast feeding to maintain thermoregulation, i.e.
warmth, and reducing the likelihood of hypoglycaemia and hypothermia.
Types of breech birth
Box 17.3 highlights the three types of vaginal breech birth.
Box 17.3
T ype s of bre e ch birt h
Spontaneous The birth occurs with little assistance from the attendant.
Assisted The buttocks are born spontaneously, but some assistance is necessary for the birth of extended
breech legs, arms and the head.
Breech This birth involves manipulating the fetal body by an experienced attendant (usually an
extraction obstetrician) in order to hasten the birth of the baby in an emergency situation, such as fetal
compromise.
Position for breech birth
The woman's position can significantly affect the physiological labour and birth
process and the one that is adopted should ideally be her choice. Many of the existing
texts describing vaginal breech births tend to assume the woman should give birth in
the hospital environment on the bed in a semi-recumbent, adapted lithotomy position
(Chadwick 2002; N dala 2005; Lewis 2011). S uch a position affects the normal
physiological process of labour, and may lead to malposition due to the reduction in
gravitational force on the fetal mechanisms, consequently increasing the need for the
midwife to undertake manoeuvres to assist the birth.
W hile gravity helps to expel the fetus, it is the expulsive contractions and angle of
the pelvis that assist in facilitating a physiological breech birth if the woman adopts an
upright forward-leaning position. Li le assistance from the midwife is needed if these
mechanisms are achieved spontaneously, except in the case of care with the birth of
the after-coming head. Use of the birth pool is generally not advised, as the buoyancy
of the water may work against gravity and thus impede the physiological mechanisms
that effect a spontaneous breech birth. A ‘hands off the breech’ approach is optimal
when the woman either adopts a standing or an ‘all-fours’/leaning forwards position
(Cronk 1998a, 1998b; Reed 2003; Burvill 2005; Royal College of Midwives 2005; Evans
2012a).
W here the mother is on all-fours or leans upon the bed/se ee or on her birth
partner (see Fig. 17.8), the baby's trunk descends through the pelvis at 45o and is able
to move more freely around the curve of Carus of the maternal pelvis. This position
provides an excellent view of the birth process and access to the baby's face as it is
born over the perineum, as well as ample space for the midwife to undertake any
manoeuvres should they be necessary to assist the birth of the baby.
FIG. 17.8 The baby descending in the ‘all-fours’ position.
Facilitating a vaginal breech birth in an upright/kneeling
position
Breech births can be as physiological as any other vaginal birth and a woman who has
chosen to birth vaginally, or discovers in labour that her baby is presenting by the
breech, requires calm support from skilled and confident midwives (Marshall 2010).
The importance of not pushing until the cervix has been confirmed as fully dilated
should be explained to the woman. I n addition, the woman should be aware that other
skilled attendants may need to be called to the birth.
At the start of the expulsive part of the second stage of labour, the woman tends to
make pelvic rocking movements which facilitates the descent of the fetus and corrects
positioning for further progress. A s the woman commences pushing spontaneously,
gradually the anterior bu ock should descend, becoming visible at the introitus of the
vagina, followed by the baby's anus, genitalia and posterior bu ock. The
bitrochanteric diameter is then born with lateral flexion, known as ‘rumping’. W hile
this is occurring, the baby's shoulders are entering the oblique diameter of the
maternal pelvis.
D escent continues, the baby's thighs, popliteal fossa (back of the knee) and lower
legs become visible and the pelvis is eventually born. The baby is then observed to
arch its spine backwards, extending its pelvis causing its lower body to curl round the
maternal symphysis pubis. A s a result, the tension that this places on the baby's legs
assists in their spontaneous release from the introitus, especially when the woman is
in an upright, kneeling position, and the baby is born as far as the umbilicus. At this
point, the woman may spontaneously lower her body so that the baby is si ing on the
floor, further encouraging flexion of the baby. I t is no longer common practice to pull
down a loop of cord to avoid traction of the umbilicus unless there appears to be
constriction of the blood vessels as manipulating the cord or stretching it can induce
spasm of the vessels.
With further descent and continued anticlockwise rotation, the head enters the brim
of the maternal pelvis as the shoulders rotate in the mid-cavity assisted by the pelvic
floor muscles. Evans (2012b) emphasizes that this continued rotation of the baby's
body assists in bringing the arms down using the pelvic floor muscles in a way that is
very similar to the Løvset manoeuvre (used when the birth is delayed should the arms
be extended). The anterior shoulder is released under the symphysis pubis and the
posterior shoulder and arm pass over the perineum. At this point Evans (2012a) refers
to the baby flexing its legs up towards its abdomen and its arms up towards its
shoulders, similar to a sit-up or tummy scrunch. S uch a movement, results in the baby
flexing its head by bringing its chin down onto its chest and pivoting the occiput on
the internal aspect of the symphysis pubis. This stimulates the woman to lower her
body from an upright kneeling position to an all-fours or a knee–chest position,
moving her pelvis round the baby's flexing head. This enables the baby's chin, face,
sinciput and head to smoothly pass over the perineum. The midwife is only required
to support the baby as the head is spontaneously born.
I f a uterotonic is to be given to the woman as part of the third stage of labour
management, it should be withheld until the baby's head is completely born.
The birth of the after-coming head
To avoid any sudden change in fetal intracranial pressure and subsequent cerebral
haemorrhage it is vital the head is born in a steady and gradual fashion and often
some assistance is given at this point. There are three methods used.
Burns Marshall manoeuvre
This particular manoeuvre facilitates movement of the baby's head through the
maternal pelvic outlet, but is only possible when the woman is in a semi-recumbent,
adapted lithotomy position. The baby is allowed to ‘hang’ until the head descends
onto the perineum, when after about one to two minutes the nape of the neck becomes
visible and the suboccipital region is born. The baby's ankles are grasped with
forefinger between the two, maintaining sufficient traction to prevent the neck from
extending and resulting in possible cervical spine fracture (Fig. 17.9A). The feet are
taken up through a 180o arc until the mouth and nose are free of the vulva. This should
be undertaken slowly to prevent sudden changes in pressure to the baby's head and
undue stretching of the perineum. The perineum can be guarded to prevent sudden
escape of the head (Fig. 17.9B). I t is imperative that the midwife observes the baby has
descended sufficiently to ensure that it is the suboccipital region that pivots under the
pubic arch and not the neck to avoid fracture of the cervical vertebra and crushing of
the spinal cord.
FIG. 17.9 Burns Marshall manoeuvre for the after-coming head. (A) Correct grasp around the
fetal ankles. (B) The sub-occipital region pivots 180° under the pubic arch: the mouth and nose
are free of the vulva.
Mauriceau–Smellie–Veit manoeuvre
W hilst the baby's head is facilitated through the same 180o arc as in the Burns
Marshall manoeuvre, the Mauriceau–S mellie–Veit manoeuvre provides more control
with the birth of the head and places less strain on the baby's back. This particular
manoeuvre can be undertaken in a variety of positions that the woman may adopt for
the birth: semi-recumbent, si ing, the adopted lithotomy position or the all-fours
position. A s this manoeuvre facilitates maximum flexion of the baby's head, it can be
used to advantage when the head is extended and descent is delayed. Furthermore, it
allows for slow birthing of the baby's head and thus reduces the risk of intracranial
haemorrhage.
I n an ‘all-fours’ position, the midwife supports the baby's back over her right arm
and flexes the baby's head by tipping the occiput forwards with the middle finger of the
right hand and by gentle pressure on the baby's malar bones (cheek bones) with the
first and ring fingers of the left hand (see Fig. 17.10A ,B). I t is important that the
midwife avoids placing her finger in the baby's mouth to prevent fracture to the jaw or
trauma to the mouth and gums, which can result in the baby having difficulties with
feeding. The vault of the baby's head should be born slowly and gently to facilitate
gradual adaptation of the head to the changing pressures imposed by the birth
process. This should be in a downwards direction following the pelvic curve of Carus.
FIG. 17.10 Mauriceau–Smellie–Veit manoeuvre to assist the birth of the after-coming head in a
breech presentation. (A and B) ‘All-fours’ position demonstrating how the occiput is tipped
forwards to achieve flexion, pivoting downwards under the symphysis pubis to facilitate birth of the
head. (C) In a semi-recumbent/sitting/adapted lithotomy position, showing position of hands and
downward direction of flexion whilst pivoting upwards through a 180° arc under the pubic arch.
I n the semi-recumbent position, the midwife should support the baby on one of her
arms, with her first and ring fingers placed on the baby's malar bones, pulling the jaw
down and increasing flexion. The other hand is placed across the baby's shoulders
with the midwife's middle finger on the occiput to increase flexion. The outer fingers
can apply gentle traction on the baby's shoulders. Maintaining flexion, the head is
drawn out of the vagina until the suboccipital region appears and then the baby's head
is slowly pivoted gently and slowly upwards around the symphysis pubis following the
curve of Carus, delivering the chin and face first (see Fig. 17.10C).
Forceps birth
I f an obstetrician is facilitating the vaginal breech birth, forceps may be applied to the
after-coming head to ensure the birth is controlled.
Manoeuvres to assist the breech birth
If the midwife uses her professional judgement and decides to undertake a manoeuvre
to assist the breech birth, as this will involve making some contact with the woman
she must obtain the woman's consent in order to avoid the legal tort of trespass to the
person (D imond 2006; N ursing and Midwifery Council [N MC] 2008 ). I f the fact that
the baby is presenting by the breech is known before the onset of labour, it is
recommended that the midwife and the woman discuss the reasons for any possible
manoeuvres, including their benefit and risks. The midwife could seek consent to
undertake any necessary manoeuvres prior to the labour.
The following manoeuvres were originally developed to facilitate a breech birth with
the woman positioned on the bed, but can be utilized when the woman is on all fours
or standing. With the benefits of gravity encouraging descent of the fetus in the la er
positions, the likelihood of the midwife needing to adopt such measures is reduced.
N evertheless, as noted above, unexpected breech presentations in late labour still
arise, so it is important that the midwife is both aware of, and skilled, in these
manoeuvres and maintains her competence in these areas.
The birth of extended legs
I f the fetal legs are not born spontaneously, it is likely they are extended, splinting the
baby's body, which impedes lateral flexion of the spine and ultimately delays the birth.
Gentle pressure, as shown in Fig. 17.11, can be applied in the popliteal fossa of one of
the legs to encourage knee flexion. This assists in the birth of the leg by sweeping it to
the side of the abdomen through abducting the hip. This can be repeated for the other
leg if necessary. The knee is a hinge joint which bends in one direction only. I f the
knee is pulled forwards from the abdomen, severe injury to the joint can result.
FIG. 17.11 Assisting the birth of extended leg by applying pressure in the popliteal fossa.
The birth of extended arms: the Løvset manoeuvre
This manoeuvre, which is a combination of rotation and downward traction, is used
when the arms fail to appear during the birth of the baby's trunk and chest as a result
of them being extended above the head. I f the arms are not released then the birth will
be delayed with increasing risk of hypoxia to the baby.
The baby is held at the iliac crests with thumbs over the sacrum and downward
traction is applied whilst the baby is rotated 180° (Fig. 17.12). Care must be taken to
always keep the baby's back towards the woman's front, i.e. the baby's abdomen must
b e uppermost in an all-fours position or the baby's back is uppermost in a semi-
recumbent position. I t is important that the baby is not grasped by the flanks or
abdomen as this may cause intra-abdominal trauma resulting in kidney, liver or spleen
injury.
FIG. 17.12 Correct grasp for the Løvset manoeuvre for extended arms.
To keep the baby's abdomen uppermost should the woman have adopted the all-
fours position, if the baby's right arm is extended the baby should be rotated to the
right by applying downward traction on the pelvic girdle in order to release the arm.
This process is then repeated for the left arm if necessary.
The Løvset manoeuvre creates friction of the baby's posterior arm lying in the sacral
curve against the pubic bone as the shoulder becomes anterior, sweeping the arm in
front of the face (Fig. 17.13). The movement enables the shoulders to enter the
maternal pelvis in the transverse diameter. The anterior arm is then born and the baby
can be rotated back in the opposite direction in order for the other arm to be born. I f
the arm is not born spontaneously, it is usual to splint the humerus with two fingers,
flex the elbow and sweep the arm across the face and downwards across the baby's
chest (‘cat-lick’ manoeuvre).
FIG. 17.13 The Løvset manoeuvre to assist the birth of extended arms.
Delay in the birth of the head
I f the head is trapped in an incompletely dilated cervix, an air channel can be created
to enable the baby to breathe pending intervention. This is done by inserting two
fingers or a S im's speculum in front of the baby's face and holding the vaginal wall
away from the nose. A ny mucus is wiped away and the airways are cleared. A empts
to release the head from the cervix result in high perinatal morbidity and mortality.
S hushan and Younis (1992) have suggested the McRoberts manoeuvre as a method to
facilitate the release of the fetal head. This requires the woman to lie flat on her back,
bringing her knees up to her abdomen, and abducting the hips. More commonly this
manoeuvre is used to relieve shoulder dystocia and is described in detail in Chapter
20.
Posterior rotation of the occiput is rare and usually results from mismanagement. If the
woman is in a semi-recumbent position, the baby's back should always remain
uppermost after the shoulders are born. To assist the birth should the head be in the
occipitoposterior position, the baby's chin and face may pass under the symphysis
pubis as far as the root of the nose and the baby is then lifted up towards the mother's
abdomen to enable the occiput to sweep the perineum.
W hen facilitating the birth of a woman presenting with a breech at term, there are
some important issues for the midwife to consider that are pertinent to the breech
scenario. These have been summarized in the S econd S tage of Labour Checklist, as
detailed in Box 17.4.
Box 17.4
S e cond st a ge of la bour che cklist for va gina l bre e ch
birt h a t t e rm
• Regular fetal heart monitoring undertaken and documented: Continuous
electronic fetal heart monitoring in hospital. Pinard or sonicaid
auscultation following every contraction in the second stage at home
(NICE 2007 recommendations).
• Check for cord prolapse if membranes rupture and buttocks are not
engaged.
• Check for full dilatation before encouraging the woman to push: The
woman may experience a premature urge to push as the fetal body can
pass through the cervix prior to full dilatation: the fetal head could
become entrapped causing asphyxia increasing perinatal morbidity and
mortality.
• The umbilical cord may be loosened gently (rarely required): This may be
undertaken to prevent constriction of blood vessels as the baby's body is
born. In the all-fours position, the condition of the baby can be easily
monitored by observing the chest movements.
• Encourage a physiological birth with minimum handling (hands off the
breech): To allow the baby to be born by gravity and propulsion and
reduce trauma to the baby once the buttocks are distending the vulva.
• Vault of the fetal skull should be born slowly: To avoid rapid
decompression resulting in intracranial haemorrhage.
• Be aware and skilled in manouevres: To assist the birth of the breech if
problems arise with fetal descent and to control the birth of the baby's
head.
• DO NOT PERFORM BREECH EXTRACTION (routine use of
manoeuvres/interventions to expedite birth): This can cause delay and
obstruction, e.g. fetal arms pulled upwards, head extended backwards.
• Care of the baby following birth should include: Appropriate
resuscitation including suction of the oropharynx and inspection of the
vocal cords (if thick meconium), maintaining the baby's body
temperature, early feeding and paediatric assessment for signs of birth
trauma.
• Postnatal examination of the mother: To assess the physical condition,
including any birth trauma and discuss the birth and its outcome whilst
assessing psychological wellbeing.
• Documentation: Is vitally important throughout the labour and birth, to
include specific details of all discussions and referrals and the time they
were initiated. As the breech is born, the time that each stage is reached
and any manoeuvres undertaken should also be recorded. Additionally
documentation should account for immediate condition of the baby,
including any resuscitation measures taken, and the condition of the
mother following the birth.
Potential complications of breech birth
I t is important that midwives are fully aware of the potential complications associated
specifically with vaginal breech births at term, which are listed in Box 17.5. Many of
these can be avoided by having an experienced and skilled a endant assisting at the
birth. I n the latest Centre for Maternal and Child Enquiries (CMA CE) Report o
Perinatal Mortality in 2009 there were eight intrapartum stillbirths at term (CMACE
2011): however, the mode of birth or place of birth were not articulated.
Box 17.5
P ot e nt ia l com plica t ions of bre e ch birt h
Potential fetal/neonatal complication Associated cause
Congenital abnormality, e.g. hydrocephaly. A cause for the presentation.
Mechanism of the birth itself poses risks.
Congenital dislocation of the hip (↑ Usually a complication of the presentation and not the birth
frank/extended breech). process.
Fetal asphyxia. Umbilical cord prolapse (↑ preterm labour/footling breech/ill-
fitting presenting part).
Cord compression.
Premature placental separation due to uterine retraction
once the baby's body has been born.
Intracranial haemorrhage. Rapid decompression of the fetal skull causing tearing of the
dura mater lining the brain and other major blood vessels.
Superficial tissue damage/bruising and Pressure on the cervix / prolapsed foot that lies in the vagina or
oedema of baby's genitalia, feet. at the vulva for some time.
Fractures of the femur, humerus, clavicle Incorrect or excessive handling during the birth.
and spine/spinal cord damage.
Dislocation of the hip, shoulder, neck.
Brachial nerve paralysis (Erb's palsy).
Soft tissue damage/rupture to baby's liver, Abdominal area is roughly squeezed.
kidneys, spleen and adrenal glands.
Dislocation of fetal jaw/soft tissue damage to Baby's mouth incorrectly being used to create traction rather
mouth and gums/feeding difficulties. than the malar bones (cheekbones) in the Mauriceau–
Smellie–Veit manoeuvre.
Cold injury/thermal shock and Ambient temperature too cool and baby loses heat during
hypoglycaemia. completion of the birth process.
Potential maternal complication Associated cause
Urethral, vaginal and perineal trauma. Rapid birth of the baby's head.
Effects of anaesthesia (local, regional general), Risks of operative procedures.
infection, haemorrhage, thromboembolic
disorders etc.
Psychological distress, affecting attachment to Unexpected vaginal breech birth with lack of time to discuss
baby, feeding difficulties and traumatic options.
stress disorder.
Professional responsibilities and term breech birth
A s an autonomous, accountable practitioner, the midwife has responsibility to
maintain skills in normal physiological birth in relation to breech presentations at
term in order to offer women real choice regarding mode of birth. This includes being
familiar with the current evidence and re-developing the skills midwives once had to
facilitate vaginal breech births at term where there are no contraindications. I t is
therefore essential that these skills are seen as part of the normal physiological birth
process rather than viewed as a rare maternity ‘emergency’.
Record-keeping
I t is the responsibility of the midwife assisting the birth to complete the labour record.
This should include details of any drugs administered, of the duration and progress of
labour, of the reason for performing an episiotomy, and of perineal repair. This
information is recorded on the mother's notes (paper and/or computerized) and may
be duplicated on her domiciliary record as well as in the birth register in some sites.
D etails of the baby's condition, including A pgar score, are also recorded. I n some
areas extra charts and monitoring processes are being introduced to respond to a
range of imperatives. I t is the professional responsibility of the midwife to remember
that the primary purpose of record keeping is to ensure effective delivery and
handover of care for each mother and baby, not to protect staff or the organization
from the risk of litigation. A s the N ursing and Midwifery Council Midwives Rules and
S tandards state: ‘you must make sure the needs of the woman or baby are the primary focus
of your practice’ (N MC 2012: 15). Midwives need to balance the need for complete and
accurate record-keeping with the need to maintain a focus on the woman and her fetus
and birth companions. I f demands to complete duplicate or unnecessary records
hinder this central activity, the midwife should bring the situation to the a ention of
her manager and/or supervisor of midwives. S ee Box 17.6 for other current dilemmas
in practice as midwives negotiate around the various requirements of undertaking
their vocation, being a professional, being an employee and practising competently
and ethically.
Box 17.6
D ile m m a s of pra ct ice
• The contrast between the current evidence base and actual practices.
• The contrast between knowledge gained from experience (empirical
knowledge) and that gained from evidence (authoritative knowledge).
• The problem of using guidelines and clinical risk assessments based on
population evidence for individual women/babies.
• Balancing maternal choice, institutional demands, and midwifery
expertise.
N ew developments such as the A ll Wales Clinical Pathway for N ormal Labour NHS(
Wales 2006), which uses exception reporting, provide alternative approaches to record-
keeping that may be useful for practitioners in the future. A ll data in the UK are
subject to the Data Protection Act 1998.
O fficial notification of the birth must be completed within 36 hours. This may be
undertaken by anyone present at the birth but is usually carried out by the midwife.
The notification is sent to the Chief Medical O fficer in the health district in which the
baby was born.
Conclusion
The processes of transition and of second stage labour are likely to be very physically
and emotionally intense, particularly for the woman, but also for her partner and other
birth companions. I f maternal behaviour and instinct are respected, in the context of
skilled and watchful waiting, the vast majority of labours will progress physiologically.
The skill of the midwife is to support the woman effectively, to guide her when her
spirits or the labour are flagging, and to enable her to accomplish her birth safely and
in triumph. D iane's story in Box 17.7 provides a personal account of how important
this is for women.
Box 17.7
D ia ne 's birt h st ory
The birth of my first baby should have been one of the happiest days of my life.
I nstead, I felt I had failed; I was mentally and physically traumatized. Five years
on, when I was eventually pregnant again, my fears started creeping back, and I
considered having a caesarean section. I was referred to the local caseload
midwifery team. W hen my midwife came to visit, I told her that my first birth had
left me traumatized, confused and scared about everything. This was my big turn
around: after talking to her I realized I did not want a caesarean section, and I
started to feel confident about giving birth naturally.
The big day arrived. I was over the moon that I had started my labour
naturally. After a few hours my midwife came to my house, just to check how
everything was going. Eventually, we decided it was time to go to the hospital.
W hen I arrived they organized an epidural for me, which I had discussed, and
which was in my birth plan. I was ge ing excited, knowing I was going to meet
my baby soon. M y midwife supported me and encouraged me on everything I
decided. She was there for me all the time, keeping me focused and positive about
my birth. After about 3 hours, I started pushing hard with contractions. The
epidural wore off enough for me to turn around on to my knees with my body
upright, and I could feel the baby drop down. I gave it my all for two pushes, and
out popped the head. I controlled my breathing, pushing slowly, and my beautiful
baby girl came out. The midwife brought her through my legs so I could see her
and that's when my husband cut her cord, which was memorable and
overwhelming for him. I was the happiest person, I had the biggest smile on my
face: to me this was a beautiful birth. Thanks to the wonderful midwives – it goes
to show that with the right help and guidance you can overcome your fears and
anxieties with positive thinking.
Clear, comprehensive, proportionate record-keeping is essential. W hile much
practice in this area is still not based on formal evidence (see Box 17.8), new
observations about normal birth are beginning to be recorded, which will form the
basis for future research.
Box 17.8
E x a m ple s of a re a s in ne e d of re se a rch in t ra nsit ion
a nd se cond st a ge la bour
• The areas of controversy, as set out in Box 17.1.
• The nature of physiological fetal heart patterns, and variation and
significance of variation in normal fetal heart tones and rhythms as heard
with a Pinard's stethoscope.
• The physiological variation in mechanisms and patterns of labour in
settings where no restrictions on positioning or length of labour are
imposed as a matter of routine.
• Evaluation of maternal behaviours and other non-invasive techniques to
assess progress in labour.
• The short-, medium- and long-term epigenetic consequences of
physiological labour and birth for the mother and her baby.
• The optimum approach to supporting women who experience the early
pushing urge.
• Tools and technologies (including e- and m-technologies) to enhance
personalized approaches to tailoring maternity care provision for the
specific needs and choices of individual women.
Key issues in the management of the second stage of labour are summarized in Box
17.9.
Box 17.9
K e y issue s in t he m a na ge m e nt of t he se cond st a ge of
la bour
• The transition and second stage phases of labour are emotionally intense
and physically hard.
• The majority of labours will progress physiologically.
• Maternal behaviour is usually a good indication of progress during this
time.
• The core midwifery skill is to support the woman in the context of a
sound knowledge of the physiology and the mechanisms of this phase of
labour.
• Support should be unobtrusive.
• The woman is the central player.
• Clear, comprehensive record keeping is essential.
• There are many gaps in the research evidence in this area.
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Further reading
Davis E. Heart and hands: a midwife's guide to pregnancy and birth. 5th edn. Ten
Speed Press: New York; 2012.
This is a manual of midwifery based on the skills and experiences gained by lay
midwives working in America. If offers unique tips and insights..
Evans J. Breech birth: what are my options?. AIMS: Taunton; 2005.
An informative and empowering text that discusses the major issues surrounding breech
birth and explains the options for women and midwives to consider that are reinforced
by the inclusion of poignant personal birth stories..
Floyd-Davis R, Sargent CF. Childbirth and authoritative knowledge: cross-cultural
perspectives. University of California Press: California; 1997.
A seminal work, which explores how authority is given to certain kinds of knowledge,
and how the knowledge and expertise of women and of less dominant cultures is not
privileged, even in the area of childbirth, and even in the face of the evidence..
International Mother Baby Childbirth Initiative. [Available at] www.imbci.org/
[(accessed 5 March 2013)] .
This international campaign is modelled on the Baby Friendly Initiative, and is based
on 10 key steps which are believed to promote optimal births for mother and baby. The
site includes inspirational material, and updates from demonstration sites across the
world..
Leap N, Hunter B. The midwife's tale: an oral history from handywoman to
professional midwife. Scarlet Press: London; 1993.
This is an historical account of trained midwives and laywomen practising in the 1950s.
The stories of their experiences and responsibilities while attending women in labour
are fascinating. The final chapter offers some accounts of labours from the point of
view of women themselves..
Marshall JE. Facilitating vaginal breech at term. Marshall JE, Raynor MD.
Advancing skills in midwifery practice. Churchill Livingstone/Elsevier:
Edinburgh; 2010:89–102.
This chapter considers the midwife's professional, legal and ethical responsibilities in
facilitating vaginal breech births at term within both the hospital and home
environment..
Royal College of Midwives Campaign for Normal Birth. [Online. Available at]
www.rcmnormalbirth.org.uk/ [(accessed 5 March 2013)] .
The campaign was set up by the Royal College of Midwives to inspire and support
normal birth practice in the midwifery profession. It is a web-based initiative, using
real stories and midwives’ experiences, underpinned with a sound evidence base. The
site includes top tips to maximize physiological childbirth. There are some excellent
videos showing different positions, and how to help women to adopt them..
Walsh D. Evidence based care for normal labour and birth. Routledge: London; 2007.
A clearly written overview of both formal and informal evidence that effectively
integrates narrative, evidence and experiential learning..
Useful websites
Campaign for Normal Birth. www.rcmnormalbirth.org.uk.
[The Breech Birth Network] www.breechbirth.org.uk.
Midwifery Matters. [(Association of Radical Midwives)] www.midwifery.co.uk.
C H AP T E R 1 8
Physiology and care during the third stage
of labour
Cecily Begley
CHAPTER CONTENTS
Physiological processes 396
Separation and descent of the placenta 396
Caring for a woman in the third stage of labour 398
Expectant (or physiological) care during the third stage of labour (EMTSL) 398
Active management of the third stage of labour (AMTSL) 400
Is the timing of uterotonic administration, cord clamping and/or CCT clinically
important in influencing the incidence of PPH? 403
Evidence for active versus expectant management 403
Asepsis 404
Cord blood sampling 404
Completion of the third stage 404
Blood loss estimation 404
Examination of placenta and membranes 404
Immediate care 405
Record-keeping 406
Transfer from the birth room 406
Complications of the third stage 406
Postpartum haemorrhage 406
Primary postpartum haemorrhage 412
Secondary postpartum haemorrhage 413
Care after a postpartum haemorrhage 414
Conclusion 414
References 414
Further reading 416
Useful website 416
The third stage of labour is a time of profound relief for most women,
following on the exertions of labour and birth. During this stage, mother,
baby and father come together as a family unit for the first time; parents
explore and become familiar with their newborn, marvel at their baby's
behaviour and relax. The physical mechanisms of birth continue almost
unnoticed, and the placenta and membranes are expelled. Until the third
stage is complete, continued vigilance on the part of the midwife is essential
to ensure that postpartum haemorrhage (PPH) is prevented or treated early,
and that the placenta and membranes are born intact. PPH is ranked among
the top four major causes of maternal death globally (World Health
Organization [WHO] 2012). Although the majority (99%) of deaths reported
occur in developing countries, the risk of PPH should not be underestimated
for any birth, and PPH is at present the sixth leading cause of direct
maternal death in the United Kingdom (UK) (Centre for Maternal and Child
Enquiries [CMACE] 2011). Maternal mortality rates in high resource
countries are relatively low when compared to low resource countries;
however, maternal morbidity is similar in significance and rates of PPH are
increasing world-wide (Knight et al 2009). To facilitate a healthy, enjoyable
outcome for mother and baby, good antenatal health plus preparation,
coupled with skilled, evidence-based practice of the midwife are crucial.
The chapter aims to:
• describe the normal physiological mechanism of placental separation, descent and
expulsion, including factors that facilitate haemostasis
• present evidence on the types, use and side-effects of uterotonic drugs in active
management of the third stage
• discuss the evidence relating to timing of clamping the umbilical cord, and controlled
cord traction
• describe the risk factors most commonly associated with PPH and discuss the current
evidence-based management strategies for prevention and treatment
• discuss the midwife's care of the mother and family unit, during and immediately after
separation and expulsion of the placenta and membranes.
Physiological processes
The third stage can be defined as the period from the birth of the baby to complete
expulsion of the placenta and membranes. I t involves the development of the
relationship between mother, baby and father, the separation, descent and expulsion
of the placenta and membranes, the control of haemorrhage from the placenta site,
and sometimes, the initiation of breast-feeding. A lthough traditionally labour is
divided into three distinct component parts to aid comprehension, it should be viewed
as one continuous process. With this in mind, it is important to understand that the
physiology of the third stage depends, in part, on what has happened during
pregnancy as well as during the first and second stage of labour, and on the woman's
basic level of health and wellbeing. The midwife's knowledge and evidence-based
skills play a crucial role in ensuring that the care received by the woman works with,
not against, physiological processes.
The placenta may shear off during the final expulsive contractions accompanying
the birth of the baby or remain adherent for some time. The third stage usually lasts
between 5 and 15 minutes, but any period up to 1 hour may be considered normal.
Separation and descent of the placenta
Mechanical factors
The unique characteristic of uterine muscle lies in its power of retraction. D uring the
second stage of labour, the uterine cavity progressively empties as the baby moves
down, enabling the retraction process to accelerate. Thus, by the beginning of the
third stage, the placental site has already diminished in area by about 75% (Baldock
and D ixon 2006). A s this occurs, the placenta becomes compressed and the blood in
the intervillous spaces is forced back into the spongy layer of the decidua basalis.
Retraction of the oblique uterine muscle fibres exerts pressure on the blood vessels so
that blood does not drain back into the maternal system. The vessels during this
process become tense and congested. With the next contraction the distended veins
burst and a small amount of blood seeps in between the thin septa of the spongy layer
and the placental surface, stripping it from its a achment (Fig. 18.1). A s the surface
area for placental a achment reduces, the relatively non-elastic placenta begins to
detach from the uterine wall.
FIG. 18.1 The placental site during separation. (A) Uterus and placenta before separation. (B)
Separation begins. (C) Separation is almost complete.
The majority of placentas are situated on the anterior or posterior wall of the uterus,
and separation usually starts from the lower pole of the placenta and moves gradually
upwards (Herman et al 2002). Fundal placentas separate first at both poles, followed
by the fundal part. The length of the third stage may be approximately 2 minutes
shorter when the placenta is located at the fundus (A ltay et al 2007). I f separation
begins centrally, a retroplacental clot is formed ( Fig. 18.2). This further aids separation
by exerting pressure at the midpoint of placental a achment so that the increased
weight helps to strip the adherent lateral borders and peel the membranes off the
uterine wall so that the clot thus formed becomes enclosed in a membranous bag as
the placenta descends, fetal surface first. This process of separation (first described by
S chul e) is associated with more complete shearing of both placenta and membranes
and less fluid blood loss (Fig. 18.3A). I f the placenta begins to detach unevenly at one
of its lateral borders, the blood escapes so that separation is unaided by the formation
of a retroplacental clot. The placenta descends, slipping sideways, maternal surface
first. This process (first described by Ma hews D uncan in the nineteenth century)
takes longer and is associated with ragged, incomplete expulsion of the membranes
and a higher fluid blood loss (Fig. 18.3B).
FIG. 18.2 The mechanism of placental separation. (A) Uterine wall is partially retracted, but not
sufficiently to cause placental separation. (B) Further contraction and retraction thicken the
uterine wall, reduce the placental site and aid placental separation. (C) Complete separation and
formation of the retroplacental clot. Note: The thin lower segment has collapsed like a concertina
following the birth of the baby.
FIG. 18.3 Expulsion of the placenta. (A) Schultze method. (B) Matthews Duncan method.
O nce separation has occurred the uterus contracts strongly, forcing placenta and
membranes to fall into the lower uterine segment (Fig. 18.4), and finally, into the
vagina.
FIG. 18.4 Third stage: placenta in lower uterine segment.
Haemostasis
The normal volume of blood flow through the placental site is 500–800 ml/min, but
this is considerably reduced once the baby is born and the placental site on the uterine
wall has diminished (Baldock and D ixon 2006). At placental separation, blood flow has
to be arrested swiftly, or serious haemorrhage can occur. The interplay of four factors
within the normal physiological processes that control bleeding are critical in
minimizing blood loss and preventing maternal morbidity or mortality. They are:
1. Retraction of the oblique uterine muscle fibres in the upper uterine segment
through which the tortuous blood vessels intertwine – the resultant thickening of
the muscles exerts pressure on the torn vessels, acting as clamps, and preventing
haemorrhage (see Fig. 18.1). It is the absence of oblique fibres in the lower uterine
segment that explains the greatly increased blood loss usually accompanying
placental separation in placenta praevia.
2. The presence of vigorous uterine contraction following separation – this brings the
walls into apposition so that further pressure is exerted on the placental site.
3. The achievement of haemostasis – there is a transitory activation of the coagulation
and fibrinolytic systems during, and immediately following, placental separation. It
is believed that this protective response is especially active at the placental site so
that clot formation in the torn vessels is intensified. Following separation, the
placental site is rapidly covered by a fibrin mesh utilizing 5–10% of circulating
fibrinogen.
4. Breast-feeding – the release of oxytocin from the posterior pituitary in response to
skin-to-skin contact between mother and baby, and the baby's nuzzling at the
breast, causes uterine contractions.
Caring for a woman in the third stage of labour
Two methods of care may be used during the third stage, expectant (physiological)
care or active management. I t is ultimately the woman's decision as to how she would,
ideally, like her birth plan to be followed in the third stage. S he may have
philosophical, religious or cultural beliefs that influence her decision. The a ending
midwife may also have views, based on evidence, as to the ideal method of care for
each particular woman. Midwives should ensure that, in order to facilitate informed
decision-making by the woman, adequate time for deliberation and questions is made
available, where possible, during the course of her routine antenatal consultations.
The best available research information on care during the third stage of labour
should be offered in an objective manner (Begley et al 2011), supported by wri en
information on possible care options for the woman in keeping with the se ing in
which she intends to birth. I nformation on types of uterotonics, explanation of their
different routes of administration, benefits, risks and side-effects involved, and timing
and method of placental birth or delivery should be given.
The midwife's care of the mother should be based on an understanding of the
normal physiological processes at work, including having access to as much
information as possible about the woman's pregnancy and labour history. Progress of
the first and second stages of labour are likely to impact on management of the third
stage of labour and should not be reviewed in isolation. The midwife's actions can
make the third stage a wonderful, relaxing time of birth and can reduce the risks of
haemorrhage, infection, retained placenta and shock, any of which may increase
maternal morbidity and even result in death. A mother's ability to withstand
complications in the third stage depends, to a large degree, upon her general health
and the avoidance of debilitating, predisposing problems, such as anaemia, ketosis,
exhaustion and prolonged hypotonic uterine action. Factors that may influence the
risk of haemorrhage are discussed in more detail later.
D etailed, accurate, wri en (contemporaneous wherever possible) documentation is
extremely important in all aspects of care, particularly in areas where evidence-based
information is relied upon to assess whether due care has been delivered. I n the case
of third stage management, two examples might be: where a woman requests
expectant (physiological) management of the third stage of labour (EMTS L), the
midwife should clarify the circumstances in which this decision may be reversed (e.g.
if severe bleeding should occur); where a woman requests active management
(A MTS L), the midwife should clarify the circumstances in which this decision may be
reversed (e.g., if the baby requires a ention and the placenta separates before a
uterotonic has been given). The woman's preference for care must be recorded in her
notes antenatally, and a record of the discussion may be signed by the woman. I t
would be prudent for midwives to notify their supervisor of midwives (S oM), clinical
manager or the a ending medical practitioner if any of the woman's requests are
contrary to local guidelines.
Expectant (or physiological) care during the third stage of
labour (EMTSL)
I n expectant management, the normal, physiological mechanisms of labour are
supported and no routine actions (such as administration of a uterotonic drug, or
clamping of the umbilical cord) are carried out. A study of the reported actions of 27
expert midwives (who used EMTS L in at least 30% of births, and had recorded PPH
rates of less than 4%) identified the key actions that they believed led to success when
using EMTS L Begley
( et al 2012). A synthesis of these actions, some of which are
supported by other research also, provides the following instructions for best practice
when using EMTSL:
1. Maintain a calm, quiet, warm environment. Use warmed sheets or blankets to wrap
mother and baby together, skin-to-skin. This close contact, and the baby's eventual
nuzzling at the breast, will stimulate oxytocin release, which may shorten the third
stage and increase breast-feeding on discharge (Marín Gabriel et al 2010).
2. Maintain the woman in a comfortable, semi-upright position (at least a 45° angle) to
encourage placental separation by maintaining a gentle downward weight.
3. Facilitate this time of parent–baby discovery and attachment by keeping quiet,
observing from a distance and not interfering with the physiological processes.
4. Watch and wait. Take cues from the woman's behaviour; if she is alert and happy,
examining the baby and talking, she is not bleeding excessively or in need of any
intervention. Reassurance can also be obtained from discretely checking the
woman's pulse if there is any anxiety in, for example, a prolonged third stage.
5. Signs of placental separation:
▪ The woman may fidget, make a face, or state that she has a contraction.
▪ A large ‘gush’ of blood may follow, indicating partial or complete separation of
the placenta. It usually ceases after 10–20 seconds, especially if the placenta has
separated completely and the uterus has contracted well. This gush is larger than
that seen when a uterotonic is given routinely, and midwives need to develop an
understanding of this physiological blood loss and not rush to administer
oxytocic treatment unnecessarily.
6. Signs of placental descent:
▪ The woman may wriggle, change position, or complain of pressure, or a pain, in
her back or bottom.
▪ The cord may lengthen and/or the walls of the vulva may bulge as the placenta
descends.
▪ The uterus becomes hard, round and mobile (Fig. 18.5). This can be seen visually,
or by the fact that the baby, resting on the mother's abdomen, has moved
downwards. It is inadvisable to touch or manipulate the uterus at this stage, as
this can prevent full contraction, disturb the fibrin mesh, and cause excessive
bleeding. If there is concern that the uterus may be filling up with blood (a
concealed haemorrhage), a gentle hand placed on the fundus will detect if there
is a large, soft, uncontracted uterus.
FIG. 18.5 Fundal height relative to the umbilicus and symphysis pubis.
7. Birthing the placenta:
▪ Gravity should be used during the birth of the placenta by encouraging a truly
upright position: sitting on a birthing stool, standing up in the birthing pool or
on the birthing mat, walking out to the toilet, sitting on the toilet, kneeling
upright or squatting over a bedpan. A basin, bin bag or disposable sheet can be
placed strategically over, or in, the pan of the toilet to receive the placenta. It
should be noted that such positions increase visible blood loss (Gupta and
Nikodem 2002).
▪ Maternal effort can be used to expedite expulsion, and most women will push the
placenta out as soon as they feel pressure, with little effort.
▪ The cord should be left unclamped until pulsation ceases (McDonald et al 2013),
or until after the birth of the placenta, unless the mother wishes it to be cut
earlier. Any mild resuscitation of the baby can be done at the site of birth, with
the benefit of continued oxygen flow to the baby through the umbilical cord.
▪ If the placenta is definitely separated and is sitting just inside the vagina (i.e., the
insertion of the cord can be seen at the vulva, or the cord has lengthened and the
vulval walls are bulging) the midwife may ease gently on the cord to help lift out
the placenta. This is not controlled cord traction as no force is used, the placenta
is separated and has left the uterus, therefore no counter-pressure is required on
the abdomen as there is no risk of uterine inversion. Controlled cord traction
should NEVER be used in the absence of a well contracted uterus following uterotonic
administration.
▪ Trailing membranes should be teased out gently, by turning the placenta around
and twisting them into a ‘rope’, thus stripping the ends gently from the uterine
wall.
8. At any time, a uterotonic may be administered to control haemorrhage, or if uterine
tone is poor following placental birth. It is preferable to withhold administration
until the placenta is delivered, if possible, to avoid the risk of a retained placenta
when the uterus contracts strongly in response to the treatment.
This spontaneous process can take from 10 minutes to 1 hour to complete, with a
median of 13 minutes (Begley 1990). I f the placenta remains undelivered for a
prolonged period, the risk of bleeding becomes greater because the uterus cannot
contract down fully while the bulk of the placenta is in situ. D ombrowski et al (1995)
found that the frequency of haemorrhage increased between 10 minutes and 40
minutes after the birth of the baby. However, patience and confidence not to interfere
unnecessarily are required on the part of the midwife to secure a successful
conclusion. Early a achment of the baby to the breast may enhance these
physiological changes by stimulating the reflex release of oxytocin from the posterior
lobe of the pituitary gland, which helps to secure good uterine action.
Active management of the third stage of labour (AMTSL)
A n active management policy usually includes the routine prophylactic administration
of a uterotonic agent, either intravenously, intramuscularly or (occasionally) orally, as
a precautionary measure aimed at reducing the risk of postpartum haemorrhage. I t is
applied regardless of the assessed obstetric risk status of the woman, and is usually
undertaken in conjunction with clamping of the umbilical cord shortly after birth of
the baby and delivery of the placenta by the use of controlled cord traction. I n
situations where women may also be assessed as being at higher risk for PPH (e.g.
multiple birth), a prophylactic infusion of larger doses of uterotonics diluted in
intravenous solutions may be administered over several hours following the birth.
This would also be considered to be part of an active management policy, as would
routine uterine massage following delivery of the placenta in some countries (Jangsten
et al 2011), although there is no evidence to support this practice once an oxytocic has
been given (Hofmeyer et al 2013).
A ctive management in the third stage is the policy of third stage labour
management most widely practised throughout the developed world. Like all
interventions performed, skill in assisting the delivery of the placenta and membranes
is extremely important to prevent complications. W hether women should routinely
receive uterotonic drugs, have the umbilical cord clamped or be given assistance with
placental delivery has been the subject of a great deal of debate and many research
trials. These three aspects are considered separately here.
Administration of uterotonics
Uterotonics (also known as oxytocics, or ecbolics), are drugs (e.g. S yntometrine,
S yntocinon, ergometrine and prostaglandins) that stimulate the smooth muscle of the
uterus to contract. They may be administered with crowning of the baby's head, at the
birth of the anterior shoulder of the baby, after the birth of the baby but prior to
placental expulsion, or following the birth, or delivery, of the placenta and
membranes.
In practice, one of the following uterotonic drugs is usually used.
Intravenous ergometrine 0.25–0.5 mg
This drug acts within 45 seconds, and is particularly useful in securing a rapid
contraction where hypotonic uterine action results in haemorrhage. I f a doctor is not
present in such an emergency, a midwife may give the injection, if it is within his/her
scope of practice. There is no evidence for the continued routine use of intravenous
ergometrine, which is associated with an increased risk of retained placenta
(Prendiville et al 1988; Begley 1990), so this drug is more often used to treat a PPH
rather than as a prophylactic drug. I f an intravenous cannula is not already in situ, any
difficulty encountered in locating a vein or sudden movement by the woman may
result in failed venepuncture or at least a delay in administration. Ergometrine can
cause headache, nausea, vomiting and an increase in blood pressure (Begley 1990) and
it is contraindicated where there is a history of hypertensive disorder or cardiac
disease (D yer et al 2010). To decrease the chance of nausea and vomiting when the
woman has had a caesarean section under epidural, it is advisable not to use
ergometrine on its own (Balki and Carvalho 2005).
Combined ergometrine and oxytocin (a commonly used brand is Syntometrine)
A 1 ml ampoule contains 5 I U of oxytocin and 0.5 mg ergometrine and is administered
by i.m. injection. The oxytocin acts within min, and the ergometrine within 6–7 min
(Fig. 18.6). Their combined action results in a rapid uterine contraction enhanced by a
stronger, more sustained contraction lasting several hours. I t can be administered as
the anterior shoulder of the baby is born, or after the birth of the baby. The use of
combined ergometrine/oxytocin or any ergometrine-based drug is associated with
side-effects such as elevation of blood pressure, nausea and vomiting ( Begley 1990).
The most recent report on maternal deaths from the Centre for Maternal and Child
Enquiries in the UK states that ‘S yntometrine should be avoided as a routine drug
completely’ (CMACE 2011: 69).
FIG. 18.6 The rapid action of oxytocin in comparison with ergometrine.
CAUTION: N o more than two doses of ergometrine 0.5 mg should be given, due to
its side-effects.
Oxytocin
O xytocin (a commonly used brand is S yntocinon) is a synthetic form of the natural
oxytocin produced in the posterior pituitary, and is safe to use in a wider context than
combined ergometrine/oxytocin agents. I t can be administered as an intravenous and
or intramuscular injection. However, an intravenous bolus of oxytocin can cause
profound, fatal hypotension, especially in the presence of cardiovascular compromise.
The recommendation of the Confidential Enquiry in Maternal D eaths Lewis ( and D rife
2001: 21) is that ‘when given as an intravenous bolus the drug should be given slowly
in a dose of not more than 5 IU’.
Research evidence to date suggests that oxytocin is an effective uterotonic choice
where routine prophylactic management of the third stage of labour is practised (Khan
et al 1995; Co er et al 2001; Choy et al 2002), more specifically in women who
experience a blood loss exceeding 1000 ml. Two Cochrane reviews have suggested that
it is probably be er to use oxytocin rather than ergometrine, due to the side-effects of
ergot (Cotter et al 2001; Liabsuetrakul et al 2007).
Carbetocin, originally developed for veterinary use and not widely employed for
prophylactic use in management of the third stage, is a long-acting synthetic oxytocin
analogue which can be administered as a single-dose 100 mg injection. Carbetocin has
been shown in some trials to be as effective as oxytocin in preventing PPH (Reyes et al
2011; Su et al 2012); however, it does require refrigeration for stability.
Prostaglandins
The use of prostaglandins for third stage management has up until now been more
often associated with the treatment of postpartum haemorrhage than with
prophylaxis. This may be partly due to prostaglandin agents being more expensive and
associated with side-effects, such as diarrhoea (A nderson and Etches 2007) and
cardiovascular complications of increased stroke volume and heart rate (van S elm et al
1995).
In more recent years, a great deal of research time and investment has been invested
in seeking alternate ways of implementing strategies to reduce the risk of PPH.
Misoprostol (a prostaglandin E1 analogue) was first used to treat gastric ulcers, but
when its potential as a uterotonic agent was discovered, optimism regarding its
suitability in low resource se ings was high. I t is cheap, not prone to loss of potency,
does not need to be sterile or refrigerated and can be administered vaginally, orally or
rectally, negating the need for syringes. Misoprostol orally or sublingually (400–
600 µg) appears to be a useful drug to prevent PPH, but is not as effective as
Syntocinon (N g et al 2007; Tunçalp et al 2012) and has unpleasant side-effects, such as
severe shivering and higher temperature, both of which are transient but unacceptable
to some women. I ts use appears to be no more likely than S yntocinon to necessitate
manual removal of the placenta. Even though the recommendation of the latest
Cochrane review is that misoprostol should not replace other uterotonics, the authors
suggest that it may be useful in circumstances where nothing else is available
(Tunçalp et al 2012).
Clamping of the umbilical cord
This may, necessarily, be carried out following birth of the baby's head if the cord is
tightly around the neck; however, it is preferable, and usually possible, to loosen the
loop and slip it over the baby's head, then allow the baby's body to slip out beside the
loop. I f the cord is looped several times around the neck it will be possible to gently
tighten one, or more, of the loops of cord and then ease a looser loop over the baby's
head. I n this way, the baby's oxygen supply is not cut off prematurely, which could be
very detrimental to their condition. I f this is not successful, the midwife can be ready
to clamp and cut the cord just as the woman starts a contraction, so that the oxygen
supply is cut off only just before the birth.
Early clamping of the cord, as part of active management of the third stage of labour
(A MTS L), is normally applied in the first 30 seconds to 3 minutes after birth,
regardless of whether or not cord pulsation has ceased. I t has been suggested that this
practice may have the following effects:
• It may reduce the volume of blood returning to the fetus by an amount between 75
and 125 ml (van Rheenen and Brabin 2004; Farrar et al 2011), which is 30–40% of total
potential blood volume (Farrar et al 2011).
• It may prematurely interrupt the respiratory function of the placenta in maintaining
O2 levels and combating acidosis in the early moments of life. This may be of
particular importance in a baby who is slow to breathe.
• It may result in lower neonatal bilirubin levels, although the effect on the incidence
of clinical jaundice is unclear (McDonald et al 2013).
• It may increase the likelihood of fetomaternal transfusion as a larger volume of
blood remains in the placenta. Venous pressure is further increased as retraction
continues and may be sufficiently high to rupture surface placental vessels, thus
facilitating the transfer of fetal cells into the maternal system; this may be a critical
factor where the mother's blood group is Rhesus negative (see Chapter 10).
• It results in the truncated umbilical vessels containing a quantity of clotted blood,
which provides an ideal medium for bacterial growth; as this is near to, and has a
patent opening into, the baby's abdomen there is potential for systemic infection
(Mercer et al 2006).
• Heavier placental weight has also been associated with early cord clamping (Newton
et al 1961), which may cause difficulty with delivery of the placenta, particularly when
the cervix has contracted following administration of a uterotonic.
Proponents of late clamping suggest that no action be taken until cord pulsation
ceases or the placenta has been completely delivered, thus allowing the physiological
processes to take place without intervention. S uggested advantages of late clamping
include:
• The route to the low resistance placental circulation remains patent, which provides
the newborn with a safety valve for any raised systemic blood pressure. This may be
critical when the baby is preterm or asphyxiated, as raised pulmonary and central
venous pressures may exacerbate the difficulties in initiating respiration and
accompanying circulatory adaptation (Dunn 1985).
• The transfusion of the full quota of placental blood to the newborn. This may
constitute as much as 30–40% of the circulating volume (Farrar et al 2011), depending
on when the cord is clamped and at what level the baby is held prior to clamping and
may therefore be important in maintaining haematocrit levels.
• The neonatal effects associated with increased placental transfusion include higher
mean birth weight by 87–116 g (Farrar et al 2011) and higher neonatal haematocrit
accompanied by an increase in the incidence of jaundice in term (McDonald et al
2013) and preterm babies (Rabe et al 2012). There is growing evidence that delaying
cord clamping confers improved iron status in infants up to 6 months post-birth
(Chaparro et al 2006; Mercer 2006; Hutton and Hassan 2007; Rabe et al 2012;
McDonald et al 2013).
• Delayed cord clamping in preterm babies (until at least 30–120 seconds) is associated
with babies requiring fewer transfusions, and having a lower risk of developing
necrotizing enterocolitis or intraventricular haemorrhage (Rabe et al 2012).
• Delayed cord clamping may decrease the risk of fetomaternal transfusion, which is
important in women with Rhesus-negative blood (Wiberg et al 2008).
Given the benefits of delayed cord clamping and the documented harms caused by
early clamping, many centres have now stopped using early cord clamping as part of
their active management package (Afaifel and Weeks 2012).
The actual action to take when clamping the cord early is to place one clamp (usually
a disposable plastic one) close to the baby's navel end. Care should be taken to apply
the clamp 3–4 cm clear of the abdominal wall, to avoid pinching the skin or clamping a
portion of gut, which, in rare instances, may be in the cord. A greater length of cord is
left when umbilical vessels are needed for transfusion, for example in preterm babies
and cases of Rhesus haemolytic disease. The second clamp is placed closer to the
placental end of the cord, with approximately 2–4 cm between them. The cord between
the two clamps is then cut, while shielding personnel from blood spurts with a gloved
hand. The baby may then be placed on the mother's abdomen, put to the breast or be
more closely examined on a warmed cot if resuscitation is required.
There is very li le evidence concerning how much, if any, of a uterotonic agent the
baby receives following birth, through an intact cord. I n five documented cases of
accidental administration of an adult dose of S yntometrine to a newborn infant, no
long-term adverse effects were reported (W hitfield and S alfield 1980). I f the cord is
clamped and cut soon after birth, the midwife should release the second clamp and
drain blood from the maternal end of the cord to simulate placental–fetal transfusion,
as this may reduce maternal blood loss up to 77 ml and shorten the third stage by up
to 3 minutes (Soltani et al 2011).
Delivery of the placenta and membranes
Controlled cord traction (CCT)
Recent research has shown that this manoeuvre has no effect on severe haemorrhage
(>1000 ml) and li le, if any, effect on mild PPH (>500 ml) in both high (Deneux-
Tharaux et al 2013) and low income se ings (Gülmezoglu et al 2012). I t does, however,
shorten the third stage of labour by 6 minutes (Gülmezoglu et al 2012). This means
that, in developing countries in particular, oxytocin can be given by healthcare
workers, without the need to train them in safe utilization of CCT (G ülmezoglu et al
2012), providing that they are taught to avoid manipulating the uterus or pulling on
the cord.
I f CCT is to be used successfully, the principles of placental separation described at
the beginning of this chapter should be clearly understood. Before proceeding, the
midwife should check:
• that a uterotonic drug has been administered
• that it has been given time to act
• that the uterus is well contracted
• that counter-traction is applied
• that signs of placental separation and descent are present.
At the beginning of the third stage, a strong uterine contraction results in the
fundus being palpable below the umbilicus (see Fig. 18.5). I t feels broad as the
placenta is still in the upper segment. A s the placenta separates and falls into the
lower uterine segment there is a small fresh blood loss, the cord lengthens, and the
fundus becomes rounder, smaller and more mobile as it rises in the abdomen above
the level of the placenta.
I t is important not to manipulate the uterus in any way as this may precipitate
incoordinate action. N o further step should be taken until a strong contraction is
palpable. I f tension is applied to the umbilical cord without this contraction, uterine
inversion may occur. This is an acute obstetric emergency with life-threatening
implications for the mother (see Chapter 22), and was implicated in one maternal
death in the UK in the period 2006–2008 (CMACE 2011).
O nce the uterus is found to be contracted, one hand is placed above the level of the
symphysis pubis with the palm facing towards the umbilicus, exerting pressure in an
upwards direction. This is counter-traction. The other hand, firmly grasping the cord,
applies traction in a downward and backward direction following the line of the birth
canal (Fig. 18.7). S ome resistance may be felt but it is important to apply steady
tension by pulling the cord firmly and maintaining the pressure. Jerky movements and
force should be avoided. The aim is to complete the action as one continuous, smooth,
controlled movement. However, it is only possible to exert this tension for a short time
as it may be an uncomfortable procedure for the mother and the midwife's hand will
tire.
FIG. 18.7 Controlled cord traction.
D ownward traction on the cord must be released before uterine counter-traction is
relaxed as sudden withdrawal of counter-traction while tension is still being applied to
the cord may also facilitate uterine inversion. I f the manoeuvre is not immediately
successful there should be a pause before the uterine contraction is again checked and
a further a empt is made. S hould the uterus relax, tension is temporarily released
until a good contraction is again palpable. O nce the placenta is visible it may be
cupped in the hands to ease pressure on the friable membranes. A gentle upward and
downward movement or twisting action will help to coax out the membranes and
increase the chances of delivering them intact. A rtery forceps may be applied to
gradually ease the membranes out of the vagina. This process should not be hurried;
great care should be taken to avoid tearing the membranes.
Is the timing of uterotonic administration, cord clamping
and/or CCT clinically important in influencing the
incidence of PPH?
A lthough active management leads to reduced risk of PPH, it is important to establish
which of the components of this package lead(s) to this reduction. Given the
difficulties of adhering to an active management policy, the absence of uterotonics in
low resource countries, and the preferences of some women for physiological
management, it is important to explore practice behaviours to clarify whether or not
the policy, as it is currently practised, should continue.
W hether oxytocin is administered before or after the placenta is expelled does not
appear to make any significant difference to the incidence of PPH (blood loss >500 ml
and >1000 ml), maternal hypotension, retained placenta, length of third stage, mean
blood loss, maternal haemoglobin, need for maternal blood transfusion or therapeutic
uterotonics (Soltani et al 2010).
S imilarly, CCT has no effect on severe haemorrhage (>1000 ml) and li le, if any,
effect on mild PPH (>500 ml) (Gülmezoglu et al 2012). Given the emerging evidence on
the benefits of delaying cord clamping (McD onald et al 2013), it is now reasonable to
suggest an active management package that includes cord clamping after 3 minutes,
followed by administration of oxytocin (either before or after the birth of the placenta)
and either maternal effort or controlled cord traction to expel the placenta once
separation occurs. A s A MTS L has not been implemented in that first 3 or more
minutes, the principles of care described for expectant care during the third stage
should be followed in that period.
Evidence for active versus expectant management
There is an increasing amount of appropriate, rigorously conducted research evidence
available that suggests that the prophylactic administration of a uterotonic
significantly reduces the risk of PPH, results in a lower mean blood loss, fewer blood
transfusions are required and there is a reduced need for therapeutic uterotonics
(Begley et al 2011). I t has also been highlighted by the widely ranging ‘risk status’ of
women included in several studies that it is in fact very difficult to define a group of
women who are not at risk for PPH. However, women truly at ‘low risk’ for PPH do no
appear to suffer undue harm from EMTSL (Begley et al 2011; Dixon et al 2011), and this
should remain an option for care (N I CE [N ational I nstitute for Health and Clinica
Excellence] 2007). Midwifery students should be given the opportunity to assist at
births using EMTS L, to learn and develop their skills, as ‘knowledge of physiological
management of the third stage of labour is considered a basic midwifery competency’
by the International Confederation of Midwives (ICM 2008).
I t should be noted that the care pathway, whether active or expectant, is reliant on
all components of the pathway being carried out as recommended. For example, if
management is expectant, then the introduction of a uterotonic drug, cord clamping or
pulling on the cord will disrupt the intended sequence of the care process leading to
what is often described as a fragmented approach. O nce the sequence of the processes
is altered, the clinician should commit to completing the process. That is, if the
protocol for expectant management is interrupted the clinician should proceed to
completing the process with an active management approach. This practice has been
shown to reduce the incidence of PPH significantly in a birth centre se ing (Patterson
2005).
Asepsis
The need for asepsis is even greater now than in the preceding stages of labour.
Laceration and bruising of the cervix, vagina, perineum and vulva provide a route for
the entry of microorganisms. At the placental site, a raw surface provides an ideal
medium for infection. Strict attention to the prevention of infection is therefore vital.
Cord blood sampling
This may be required for a variety of conditions:
• when the mother's blood group is Rhesus negative or as a precautionary measure if
the mother's Rhesus type is unknown;
• when atypical maternal antibodies have been found during an antenatal screening
test;
• where a haemoglobinopathy is suspected (e.g. sickle cell disease);
• ‘when there has been concern about the baby either in labour or immediately
following birth’ (NICE 2007:231).
The sample should be taken as soon as possible from the fetal surface of the
placenta where the blood vessels are congested and easily visible. I f the cord has not
been clamped prior to placental birth the fetal vessels will not be congested, but a
sample of sufficient volume may still be easily obtained, or can be taken by syringe
prior to birth of the placenta. I n the case of paired cord blood sampling being required
for reasons outlined by N I CE (2007), blood will be obtained from the umbilical cord.
To achieve this, an additional clamp will need to be applied resulting in double-
clamping of the cord. The appropriate containers should be used for any
investigations requested. These may include the baby's blood group, Rhesus type,
haemoglobin estimation, serum bilirubin level, cord blood analysis for acid base
status, Coombs' test or electrophoresis. Maternal blood for Kleihauer testing can be
taken upon completion of the third stage.
Completion of the third stage
O nce the placenta has spontaneously birthed, or has been delivered, the midwife must
first check that the uterus is well contracted and fresh blood loss is minimal. Careful
inspection of the perineum and lower vagina is important. A strong light is directed
onto the perineum in order to assess trauma accurately prior to instigating repair. This
should be carried out as gently as possible as the tissues are often bruised and
oedematous. I f perineal suturing (see Chapter 15) is required it should be carried out
as expediently as possible to prevent unnecessary blood loss, increased risk of oedema
at the site of trauma and perhaps unnecessary re-infiltration of additional local
anaesthetics.
Blood loss estimation
Blood loss is difficult to measure and is frequently underestimated (D uthie et al 1990;
Prastertcharoensuk et al 2000). A ccount must be taken of blood that has soaked into
linen and swabs as well as measurable fluid loss and clot formation. The site of the
blood loss does not necessarily alter the impact in terms of potential debility for
affected women. Brandt (1966) believes that women can withstand perhaps a 1000–
1500 ml blood loss. However, any further blood loss may not be tolerated so readily.
W omen who undergo elective caesarean section will for the most part have been
adequately prepared. W omen who undergo emergency caesarean section or vaginal
birth who are dehydrated or anaemic may not withstand sudden large volumes of
blood loss.
I n his study of the importance and difficulties of precise estimation of PPH,Brandt
(1967) calculated that 20% of women lose >500 ml of blood after a vaginal birth. I t was
estimated that 3940 ml of circulating blood volume were required to maintain the
central venous pressure at 10 cmH2O . Most measurement techniques are not
sufficiently sensitive to detect a rapid volume change in the immediate se ing when
decisions need to be made.
Note: I t should also be remembered that any amount of blood loss that causes a
physical deterioration such as feeling faint, sudden onset of tachycardia, altered
respirations or drop in blood pressure should be immediately investigated.
Examination of placenta and membranes
This should be performed as soon after birth as practicable so that, if there is doubt
about their completeness, further action may be taken before the woman leaves the
birth room or the midwife leaves the home. A thorough inspection must be carried out
in order to make sure that no part of the placenta or membranes has been retained.
The membranes are the most difficult to examine as they become torn during the birth
or delivery and may be ragged. Every a empt should be made to piece them together
to give an overall picture of completeness. This is easier to see if the placenta is held
by the cord, allowing the membranes to hang. The hole through which the baby was
born can then usually be identified and a hand can be spread out inside the
membranes to aid inspection (Fig. 18.8). The placenta should then be laid on a flat
surface and both placental surfaces minutely examined in a good light. The amnion
should be peeled from the chorion right up to the umbilical cord, which allows the
chorion to be fully viewed.
FIG. 18.8 Examination of the membranes.
A ny clots on the maternal surface need to be removed and kept for measuring.
Broken fragments of cotyledon must be carefully replaced before an accurate
assessment is possible.
The lobes of a complete placenta fit neatly together without any gaps, the edges
forming a uniform circle. Blood vessels should not radiate beyond the placental edge.
I f they do, this denotes a succenturiate lobe, which has developed separately from the
main placenta (see Chapter 6). W hen such a lobe is visible there is no cause for
concern, but if the tissue has been retained the vessels will end abruptly at a hole in
the membrane. I f there is any suspicion that the placenta or membranes are
incomplete, they must be kept for inspection and a doctor informed immediately in
case a PPH occurs or there is the possibility that a surgical intervention may be
required.
Upon completion of the examination, the midwife should return her a ention to the
mother. The empty uterus should be firmly contracted and below the level of the
umbilicus. I f the fundus has risen in the abdomen a blood clot may be present. This
should be expelled while the uterus is in a state of contraction by pressing the fundus
gently in a downward and backward direction – with due regard to the risk of
inversion and acute discomfort to the woman. Force should never be used.
Immediate care
I t is advisable for mother and baby to remain in the midwife's care for at least 1 hour
after birth, regardless of the birth se ing. Much of this time will be spent in clearing
up and completion of records but careful observation of mother and infant is very
important. I f an epidural catheter is in situ it is usually removed and checked at this
time. Early physiological observations including ensuring a well-contracted uterus,
assessment of vaginal blood loss and a gentle inspection of the genital tract to inspect
for trauma should be undertaken (NICE 2007).
The woman should be encouraged to pass urine because a full bladder may impede
uterine contraction. S he may not actually feel an urge to do so, especially if she has
passed urine immediately prior to giving birth or an effective epidural has been in
progress, but she should be asked to try. Uterine contraction and blood loss should be
checked on several occasions during this first hour. O nce basic procedures to ensure
the woman's and baby's safety and comfort have been completed, the woman may be
offered a light meal such as tea and toast.
Most women intending to breastfeed will wish to put their babies to the breast
during these early moments of contact. This is especially advantageous, as babies are
usually very alert at this time and their sucking reflex is particularly strong. There is
also evidence to suggest that women who breastfeed soon after birth successfully
breastfeed for a longer period of time (Salariya et al 1979). A n additional benefit lies in
the reflex release of oxytocin from the posterior lobe of the pituitary gland, which
stimulates the uterus to contract. This may result in the mother experiencing a sudden
fresh blood loss as the uterus empties and she should be pre-warned and reassured
that it is a normal response. The desire to feed a newborn baby is a warm, loving and
instinctive response. W hile breastfeeding should be actively encouraged, a formula
feed should be available for those who do not wish to breastfeed.
Record-keeping
A complete and accurate account of the labour, including the documentation of the
administration of all medicines, physical examination and observations, is the
midwife's responsibility. This should also include details of examination of the
placenta, membranes and cord with a ention drawn to any abnormalities. The volume
of blood loss is particularly important. This record not only provides information that
may be critical in the future care of both mother and infant but is a legal document
that may be used as evidence of the care given. S ignatures are therefore essential, with
cosignatories where necessary. I n the UK, many mothers now carry their own notes
related to pregnancy and details of the birth. The completed records are a vital
communication link between the midwife responsible for the birth and other
caregivers, particularly those who take over care and provide ongoing community
support services once the woman returns home.
I t is usually the midwife who completes the birth notification form. Timely
notification and referral may prevent delay in a woman receiving appropriate
assistance should she need it.
Transfer from the birth room
The midwife is responsible for seeing that all observations are made and recorded
prior to transfer of mother and baby to the postnatal ward, or home, or before the
midwife leaves the home following the birth.
The postnatal ward midwife should verify these details prior to transfer of mother
and baby. Following a domiciliary birth, the midwife should leave details of a
telephone number where she may be contacted should the parents feel any cause for
concern.
Complications of the third stage
Postpartum haemorrhage
Primary postpartum haemorrhage is defined as bleeding from the genital tract in
excess of 500 ml at any time following the baby's birth up to 24 hours postpartum
(W HO 2003). A loss of 500–999 ml in a healthy woman is considered a mild PPH, and
severe haemorrhage is deemed to be a loss of greater than 1000 ml (Bloomfield and
Gordon 1990).
Postpartum haemorrhage (PPH) is one of the most alarming and serious
emergencies a midwife may face and can occur following both traumatic and
straightforward births. I t is always a stressful experience for the woman and any
support persons present and may undermine her confidence, influence her a itude to
future childbearing and delay her recovery. A lthough the maternal mortality rate
(MMR) in developed countries such as those of Western Europe, Australasia, N orth
A merica and J apan is quoted as approximately 7, 6, 16 and 7 per 100 000 live births
respectively (Hogan et al 2010), the reported MMR for lower resource countries is
much higher; for example, southern A sia with 323 per 100 000 live births, and sub-
S aharan A frica (west) with 629 per 100 000 live births (Hogan et al 2010). A significant
number of the deaths recorded were due to PPH, often in the absence of a trained
health professional. The midwife is often the first, and may be the only, professional
person present when a haemorrhage occurs, so her prompt, competent action will be
crucial in controlling blood loss and reducing the risk of maternal morbidity or even
death.
Primary postpartum haemorrhage
Fluid loss is extremely difficult to measure with any degree of accuracy, especially
when a mixture of blood and fluid has soaked into the bed linen and spilled onto the
floor. I t should also be remembered that measurable solidified clots represent only
about half the total fluid loss. With these factors in mind, the best yardstick is that any
blood loss, however small, that adversely affects the mother's condition constitutes a
PPH. Much will therefore depend upon the woman's general wellbeing. I n addition, if
the measured loss reaches 500 ml, it must be treated as a PPH, irrespective of maternal
condition; however, it should be noted that in high income countries, and in a woman
who is otherwise healthy with a high haemoglobin, a blood loss of 500 ml is the
equivalent of a routine blood donation and usually causes no ill effects.
Causes
There are several reasons why a PPH may occur, including atonic uterus, retained
placenta, trauma and blood coagulation disorder.
Atonic uterus
This is a failure of the myometrium at the placental site to contract and retract and to
compress torn blood vessels and control blood loss by a living ligature action. W hen
the placenta is a ached, the volume of blood flow at the placental site is
approximately 500–800 ml/min. Upon separation, the efficient contraction and
retraction of uterine muscle will staunch the flow and prevent a haemorrhage, which
can otherwise ensue with horrifying speed (Box 18.1).
Box 18.1
C a use s of a t onic ut e rine a ct ion
• Incomplete separation of the placenta
• Retained cotyledon, placental fragment or membranes
• Precipitate labour
• Prolonged labour resulting in uterine inertia
• Polyhydramnios or multiple pregnancy causing overdistension of uterine
muscle
• Placenta praevia
• Placental abruption
• General anaesthesia especially halothane or cyclopropane
• Episiotomy or perineal trauma
• Induction or augmentation of labour with oxytocin
• A full bladder
• Aetiology unknown
Incomplete placental separation
I f the placenta remains fully adherent to the uterine wall, it is unlikely to cause
bleeding. However, once separation has begun, maternal vessels are torn. I f placental
tissue remains partially embedded in the spongy decidua, efficient contraction and
retraction are interrupted.
Retained placenta, cotyledon, placental fragment or membranes
These will similarly impede efficient uterine action (Sosa et al 2009).
Precipitate labour
W hen the uterus has contracted vigorously and frequently, resulting in a duration of
labour that is less than 1 hour, then the muscle may have insufficient opportunity to
retract.
Prolonged labour
I n a labour where the active phase lasts >12 hours uterine inertia (sluggishness) may
result from muscle exhaustion (Chapter 19).
Polyhydramnios, macrosomia or multiple pregnancy
The myometrium becomes excessively stretched and therefore less efficient (S osa et al
2009).
Placenta praevia
The placental site is partly or wholly in the lower segment where the thinner muscle
layer contains few oblique fibres: this results in poor control of bleeding.
Placental abruption
Blood may have seeped between the muscle fibres, interfering with effective action. At
its most severe this results in a Couvelaire uterus (Chapter 12).
Induction or augmentation of labour with oxytocin
I n some circumstances, the use of oxytocin during labour may result in
hyperstimulation of the uterus and cause a precipitate, expulsive birth of the baby
(S osa et al 2009; Grotegut et al 2011). I n this instance the uterus may still be
responding in a stimulated, but ineffective manner in terms of contracting the empty
uterus. I n the case of induction or augmentation of labour, that continues over a
prolonged period without establishing efficient uterine contractions, physical and
emotional fatigue of the mother, and uterine fatigue or inertia may occur. This inertia
inhibits the uterine muscle from providing strong, sustained contraction and
retraction of the empty uterus that aids in the prevention of a postpartum
haemorrhage.
Episiotomy, and need for perineal sutures
Blood loss from perineal trauma, in addition to even a normal blood loss from the
uterus, can together equal a mild PPH (S osa et al 2009). Poeschmann et al (1991) have
shown that an episiotomy can cause up to 30% of postpartum blood loss.
General anaesthesia
A naesthetic agents may cause uterine relaxation, in particular the volatile inhalational
agents, for example halothane.
Mismanagement of the third stage of labour
‘Fundus fiddling’ or manipulation of the uterus may precipitate arrhythmic
contractions so that the placenta only partially separates and retraction is lost.
A full bladder
I f the bladder is full, its proximity to the uterus in the abdomen on completion of the
second stage may interfere with uterine action. This also constitutes mismanagement.
Aetiology unknown
A precipitating cause may never be discovered.
There are in addition a number of factors that do not directly cause a PPH, but do
increase the likelihood of excessive bleeding (Box 18.2).
Box 18.2
P re disposing fa ct ors t ha t m ight incre a se t he risks of
post pa rt um ha e m orrha ge
• Previous history of postpartum haemorrhage or retained placenta
• Presence of fibroids
• Maternal anaemia
• Ketoacidosis
• Multiple pregnancy
• HIV/AIDS
• Caesarean section
Previous history of PPH or retained placenta
There may be a risk of recurrence in subsequent pregnancies, depending on the cause
of the PPH in the previousbirth. A detailed obstetric history taken at the first
antenatal visit will ensure that optimum care can be given.
Fibroids (fibromyomata)
These are normally benign tumours consisting of muscle and fibrous tissue, which
may impede efficient uterine action.
Anaemia
W omen who enter labour with reduced haemoglobin concentration (below 10 g/dl)
may feel a greater effect of any subsequent blood loss, however small. Moderate to
severe anaemia (<9 g/dl) is associated with an increase in third stage blood loss and
risk of postpartum haemorrhage (Kavle et al 2008; Soltan et al 2012).
HIV/AIDS
W omen who have HI V/A I D S are often in a state of severe immunosuppression, which
lowers the platelet count to such a degree that even a relatively minor blood loss may
cause severe morbidity or death.
Ketosis
The influence of ketosis upon uterine action is still unclear. Foulkes and D umoulin
(1983) demonstrated that, in a series of 3500 women, 40% had ketonuria at some time
during labour. They reported that if labour progressed well, this did not appear to
jeopardize either the fetal or maternal condition. However, there was a significant
relationship between ketosis and the need for oxytocin augmentation, instrumental
delivery and PPH when labour lasted more than 12 hours. Correction of ketosis is
therefore advisable and can be facilitated by ensuring women have an adequate intake
of fluids and light solid nourishment as tolerated throughout labour. There is no
evidence to suggest restriction of food or fluids is necessary during the normal course
of labour (Singata et al 2010).
Caesarean section
I t should be noted that, of the five women who died of postpartum haemorrhage in
the UK in the period 2006–2008, four of them had had a caesarean section (the fifth
concealed her pregnancy and died alone at home) (CMA CE 2011 ). The report noted
that in three of the four women (75%), a lack of routine observation of vital signs in the
postoperative period, or failure on the part of staff to notice that bleeding was
occurring, were key failures in care. Postoperative observations need to be recorded
regularly, using a modified early obstetric warning score (MEO W S ) chart, and
abnormal findings acted upon (CMACE 2011).
Signs of PPH
Signs may be obvious, such as:
• visible bleeding
• maternal collapse.
However, more subtle signs may present, such as:
• pallor
• rising pulse rate
• falling blood pressure
• altered level of consciousness; the mother may become restless or drowsy
• an enlarged uterus as it fills with blood or blood clot; it feels ‘boggy’ on palpation
(i.e. soft and distended and lacking tone); there may be little or no visible loss of
blood.
Prophylaxis
By using the above list, it is possible for the midwife to apply some preventive
screening in an a empt to identify women who may be at greater risk and to recognize
causative factors. D uring the antenatal period a thorough and accurate history of
previous obstetric experiences will identify possible risk factors. A rrangements for
birth can be discussed with the woman, and the necessity for birth to take place in a
unit where facilities for dealing with emergencies are available can be explained. The
early detection and treatment of anaemia will help ensure that women enter labour
with a haemoglobin level, ideally, in excess of 10 g/dl. The midwife should check that
blood tests, if needed, are taken regularly and the results recorded and explained to
the woman. I f necessary, action can be taken to restore the haemoglobin level before
birth. W omen more prone to anaemia should be closely monitored, e.g. those with
multiple pregnancies.
D uring labour, good management practices during the first and second stages are
important to prevent prolonged labour and ketoacidosis. A mother should not enter
the second or third stage with a full bladder. A MTS L is recommended for all women at
high risk of PPH, and will reduce blood loss for women of mixed risk (B egley et al
2011). Two units of cross-matched blood should be kept available for any woman
known to have a placenta praevia or other major predisposing risk factors for PPH.
Treatment of PPH
W hatever the stage of labour or crisis that may occur, the midwife should adhere to
the underlying principle of always reassuring the woman and her support persons by
continually relaying appropriate information and involving them in decision-making.
Three basic principles of care should be applied immediately upon observation of
excessive bleeding, using the mnemonic ABC:
1. Call for medical Aid.
2. Stop the Bleeding by rubbing up a contraction, giving a uterotonic and emptying the
uterus.
3. ResusCitate the mother as necessary.
Call for medical aid
This is an important initial step so that help is on the way whatever transpires. I f the
bleeding is brought under control before the doctor arrives, then no action by the
doctor will be needed. However, the woman's condition can deteriorate very rapidly, in
which case medical assistance will be required urgently. I f the mother is at home or in
a midwife-led unit, the emergency department of the closest obstetric unit should be
contacted and, depending on the policy of the region, an obstetric emergency team
summoned or ambulance transfer arranged.
Stop the bleeding
The initial action is always the same, regardless of whether bleeding occurs with the
placenta in situ or later.
Rub up a contraction
The fundus is first felt gently with the fingertips to assess its consistency. I f it is soft
and relaxed, the fundus is massaged with a smooth, circular motion, applying no
undue pressure. When a contraction occurs, the hand is held still.
Give a uterotonic to sustain the contraction
I n many instances, oxytocin 5 units or 10 units, or combined ergometrine/oxytocin
1 ml, has already been administered and this may be repeated. A lternatively,
ergometrine 0.25–0.5 mg may be injected intravenously (in the absence of
contraindications), and will be effective within 45 seconds; vomiting may occur
immediately. N o more than two doses of ergometrine should be given (including any
dose of combined ergometrine/oxytocin), as it may cause pulmonary hypertension.
S everal reports have described the dramatic haemostatic effects of prostaglandins
used in cases of uterine atony. Misoprostol (Cytotec) or carboprost (Hemabate) are the
most common prostaglandin drugs used to increase uterine contractility for the
treatment of PPH. However, the side-effects (nausea, vomiting, pyrexia, hypertension,
diarrhoea) associated with these drugs can make their use limited (A nderson and
Etches 2007).
The baby may be put to the breast to enhance the physiological secretion of oxytocin
from the posterior lobe of the pituitary gland, thus stimulating a contraction.
Empty the uterus
O nce the midwife is satisfied that it is well contracted, she should ensure that the
uterus is emptied. I f the placenta is still in the uterus, it should be delivered; if it has
been expelled, any clots should be expressed by firm but gentle pressure on the
fundus.
Resuscitate the mother
A n intravenous infusion should be commenced while peripheral veins are easily
negotiated. This will provide a route for an oxytocin infusion or fluid replacement. A s
an emergency measure, the mother's legs may be lifted up in order to allow blood to
drain from them into the central circulation. However, the foot of the bed should not
be raised as this encourages pooling of blood in the uterus, which prevents the uterus
contracting.
I t is usually expedient to catheterize the bladder to ensure that a full bladder is not
impeding uterine contraction and thus precipitating further bleeding, and to minimize
trauma should an operative procedure be necessary.
O n no account must a woman in a collapsed condition be moved prior to
resuscitation and stabilization.
The flow chart in Fig. 18.9 briefly sets out the possible courses of action that may be
taken depending on whether or not bleeding persists. I f the above measures are
successful in controlling any further loss, administration of oxytocin, 40 units in 1 litre
of intravenous solution (e.g. Hartmann's or saline) infused slowly over 8–12 hours, will
ensure continued uterine contraction. This will help to minimize the risk of
recurrence. Before the infusion is connected, 10 ml of blood should be withdrawn for
haemoglobin estimation and for cross-matching compatible blood. I f bleeding
continues uncontrolled, the choice of further action will depend largely upon whether
the placenta remains undelivered.
FIG. 18.9 Management of primary PPH.
Placenta delivered
I f the uterus is atonic following birth of the placenta, light fundal pressure may be
used to expel residual clots while a contraction is present. I f an effective contraction is
not maintained, 40 units of S yntocinon in 1 litre of intravenous fluid should be started.
The placenta and membranes must be re-examined for completeness because retained
fragments are often responsible for uterine atony and may need to be removed
manually, under anaesthetic.
Bimanual compression
I f bleeding continues, bimanual compression of the uterus may be necessary in order
to apply pressure to the placental site. I t is desirable for an intravenous infusion to be
in progress. The fingers of one hand are inserted into the vagina like a cone; the hand
is formed into a fist and placed into the anterior vaginal fornix, the elbow resting on
the bed. The other hand is placed behind the uterus abdominally, the fingers pointing
towards the cervix. The uterus is brought forwards and compressed between the palm
of the hand positioned abdominally and the fist in the vagina ( Fig. 18.10). I f bleeding
persists, a clo ing disorder must be excluded before exploration of the vagina and
uterus is performed under a general anaesthetic. Compression balloons may also be
used to provide pressure on the placental site and if bleeding continues, ligation of the
uterine arteries or hysterectomy may be considered.
FIG. 18.10 Bimanual compression of the uterus.
Placenta undelivered
The placenta may be partially or wholly adherent.
Partially adherent
W hen the uterus is well contracted, an a empt should be made to deliver the placenta
by applying CCT. I f this is unsuccessful a doctor will be required to remove it
manually.
Wholly adherent
Bleeding does not usually occur if the placenta is completely adherent. However, the
longer the placenta remains in situ the greater is the risk of partial separation, which
may give rise to profuse haemorrhage.
Retained placenta
This diagnosis is reached when the placenta remains undelivered after a specified
period of time (usually 1 hour following the baby's birth). The conventional treatment
is to separate the placenta from the uterine wall digitally, effecting a manual removal.
Breaking of the cord
This is a not unusual occurrence during completion of the third stage of labour. Before
further action, it is crucial to check that the uterus remains firmly contracted. I f the
placenta remains adherent, no further action should be taken before a doctor is
notified. I t is possible that manual removal may be indicated. I f the placenta is
palpable in the vagina, it is probable that separation has occurred and when the uterus
is well contracted then maternal effort, with a fully upright posture, may be
encouraged (see expectant management, above). I f there is any doubt, the midwife
applies fresh sterile gloves before performing a vaginal examination to ascertain
whether this is so. A s a last resort, if the woman is unable to push effectively then
gentle fundal pressure may be used, following administration of a uterotonic drug.
Great care is exercised to ensure that placental separation has already occurred and
the uterus is well contracted. The woman should be relaxed as the midwife exerts
downward and backward pressure on the firmly contracted fundus. This method can
cause considerable pain and distress to the woman and result in the stretching and
bruising of supportive uterine ligaments. I f it is performed without good uterine
contraction, acute inversion may ensue. This is an extremely dangerous procedure in
unskilled hands and is not advocated in everyday practice when alternative, safer
methods may be employed. It is very unlikely that this would be practised in the UK.
Manual removal of the placenta
This should be carried out by a doctor. A n intravenous infusion must first be sited and
an effective anaesthetic in progress. The choice of anaesthesia will depend upon the
woman's general condition. If an effective epidural anaesthetic is already in progress, a
top-up may be given in order to avoid the hazards of general anaesthesia. A spinal
anaesthetic offers an alternative but where time is an urgent factor a general
anaesthetic will be initiated.
Management
Manual removal is performed with full aseptic precautions and, unless in a dire
emergency situation, should not be undertaken prior to adequate analgesia being
ensured for the woman. With the left hand, the umbilical cord is held taut while the
right hand is coned and inserted into the vagina and uterus following the direction of
the cord. O nce the placenta is located the cord is released so that the left hand may be
used to support the fundus abdominally, to prevent rupture of the lower uterine
segment (Fig. 18.11). The operator will feel for a separated edge of the placenta. The
fingers of the right hand are extended and the border of the hand is gently eased
between the placenta and the uterine wall, with the palm facing the placenta. The
placenta is carefully detached with a sideways slicing movement. W hen it is
completely separated, the left hand rubs up a contraction and expels the right hand
with the placenta in its grasp. The placenta should be checked immediately for
completeness, so that any further exploration of the uterus may be carried out without
delay. A uterotonic drug is given upon completion.
FIG. 18.11 Manual removal of the placenta.
I n very exceptional circumstances, when no doctor is available to be called, a
midwife would be expected to carry out a manual removal of the placenta. O nce she
has diagnosed a retained placenta as the cause of PPH, the midwife must act swiftly to
reduce the risk of onset of shock and exsanguination. I t must be remembered that the
risk of inducing shock by performing a manual removal of the placenta is greater
when no anaesthetic is given. I n a developed country, the midwife is unlikely to find
herself dealing with this situation.
At home
I f the placenta is retained following a home birth, emergency obstetric help must be
summoned. Under no circumstances should a woman be transferred to hospital until
an intravenous infusion is in progress and her condition stabilized. I t is best if the
placenta can be delivered without moving the mother but if this is not possible, or if
further treatment is needed, she should be transferred to a consultant unit, with her
baby.
Morbid adherence of placenta
Very rarely, the placenta remains morbidly adherent; this is known as placenta accreta.
I f it is totally adherent, then bleeding is unlikely to occur and it may be left in situ to
absorb during the puerperium. I f, however, only part of the placenta remains
embedded then the risks of fatal haemorrhage are high and an emergency
hysterectomy may be unavoidable.
Trauma as a cause of PPH
I f bleeding occurs despite a well-contracted uterus, it is almost certainly the
consequence of trauma to the uterus, vagina, perineum or labia, or a combination of
these. A s stated previously, Poeschmann et al (1991) cautioned that episiotomy may
contribute up to 30% of total blood loss; in their study the severity of blood loss was
linked to the length of time that elapsed between incision of the perineum and the
commencement of repair. Predictably, the longer the wait the greater is the blood loss.
I n order to identify the source of bleeding, the mother is placed in the lithotomy
position under a good directional light. A n episiotomy wound or tears to the anterior
labia, clitoris and perineum often bleed freely. These external injuries are easily
identified and torn vessels may be clamped with artery forceps prior to ligation.
I nternal trauma to the vagina, cervix or uterus more commonly occurs following
instrumental or manipulative delivery. A speculum is inserted to enable the cervix and
vagina to be clearly visualized and examined. Tissue or artery forceps may be used to
apply pressure prior to suturing under general anaesthesia.
I f bleeding persists when the uterus is well contracted and no evidence of trauma
can be found, uterine rupture must be suspected. Following a laparotomy this is
repaired, but if bleeding remains uncontrolled a hysterectomy may become inevitable.
Blood coagulation disorders causing PPH
A s well as the causes already listed above, PPH may be the result of coagulation
failure (see Chapters 12 and 13). The failure of the blood to clot is such an obvious sign
that it can be overlooked in the midst of the frantic activity that accompanies torrential
bleeding. I t can occur following severe pre-eclampsia, antepartum haemorrhage,
massive PPH, amniotic fluid embolus, intrauterine death or sepsis. Evaluation should
include coagulation status and replacing appropriate blood components (Anderson
and Etches 2007). Fresh blood is usually the best treatment, as this will contain
platelets and the coagulation factors V and VI I I . The expert advice of a haematologist
will be needed in assessing specific replacement products such as fresh frozen plasma
and fibrinogen.
Maternal observation following PPH
O nce bleeding is controlled, the total volume lost must be measured and/or estimated
as accurately as possible. Large amounts appear less than they are in reality. A
MEO W S chart should be maintained postpartum and abnormal scores should be
reported and prompt action taken (CMA CE 2011 ). Maternal pulse and blood pressure
are recorded every 15 minutes and the temperature taken every 4 hours. The uterus
should be palpated frequently to ensure that it remains well contracted and lochia lost
must be observed. I ntravenous fluid replacement should be carefully calculated to
avoid circulatory overload. Monitoring the central venous pressure (see Chapter 22)
will provide an accurate assessment of the volume required, especially if blood loss
has been severe. Fluid intake and urinary output are recorded as indicators of renal
function. The output should be accurately measured on an hourly basis by the use of a
self-retaining urinary catheter.
The woman may need high dependency care if closer monitoring is required, until
her condition is stable. A ll records should be meticulously completed and signed
contemporaneously. Continued vigilance will be important for 24–48 hours. A s this
woman will need a period of recovery, she will not be suitable for early transfer home.
Secondary postpartum haemorrhage
S econdary postpartum haemorrhage is any abnormal or excessive bleeding from the
genital tract occurring between 24 hours and 12 weeks postnatally. I n developed
countries, 2% of postnatal women are admi ed to hospital with this condition, half of
them undergoing uterine surgical evacuation (Alexander et al 2007). I t is most likely to
occur between 10 and 14 days after birth. Bleeding is usually due to retention of a
fragment of the placenta or membranes, or the presence of a large uterine blood clot.
Typically occurring during the second week, the lochia is heavier than normal and will
have changed from a serous pink or brownish loss to a bright red blood loss. The
lochia may also be offensive if infection is a contributory factor. S ubinvolution, pyrexia
and tachycardia are usually present. A s this is an event that is most likely to occur at
home, women should be alerted to the possible signs of secondary PPH prior to
discharge from midwifery care.
Management
The following steps should be taken:
• call a doctor
• reassure the woman and her support person(s)
• rub up a contraction by massaging the uterus if it is still palpable
• express any clots
• encourage the mother to empty her bladder
• give a uterotonic drug either by the intravenous or intramuscular route
• keep all pads and linen to assess the volume of blood lost
• if bleeding persists, discuss a range of treatment options with the woman and, if
appropriate, prepare her for theatre.
I f the bleeding occurs at home and the woman has telephoned the hospital, midwife
or her GP, she should be told to lie down flat until professional assistance arrives (the
front door should be left unlocked if the woman is alone). O n arrival, the doctor,
midwife or paramedic will assess the amount of blood loss and the woman's condition
and a empt to arrest the haemorrhage. I f the loss is severe or uncontrolled, the
nearest emergency obstetric unit will be called and the mother and baby prepared for
transfer to hospital. The doctor, midwife or paramedic who a ends will start an
intravenous infusion and ensure that the mother's condition is stable first.
Careful assessment is usually undertaken prior to the uterus being explored under
general anaesthetic. The use of ultrasound as a diagnostic tool is invaluable in
minimizing the number of mothers who have operative intervention. I f retained
products of conception cannot be seen on a scan, the mother may be treated
conservatively with antibiotic therapy and oral ergometrine. The haemoglobin should
be estimated prior to discharge. I f it is below 9 g/dl, options for iron replacement
should be discussed with the woman. The severity of the anaemia will assist in
determining the most appropriate care, which may be dependent on whether or not
the woman is symptomatic (e.g. feeling faint, dizzy, short of breath). Management may
vary from increased intake of iron-rich foods, iron supplements or, in extreme cases,
blood transfusion. I t is also important to discuss the common symptoms that may be
experienced as a result of anaemia following PPH, including extreme tiredness and
general malaise. Encourage the woman to seek assistance and stress the importance of
making an appointment to see her GP to have her general health and haemoglobin
levels checked.
Haematoma formation
PPH may also be concealed as the result of progressive haematoma formation. This
may be obvious at such sites as the perineum or lower vagina, but it is more difficult
to diagnose if it occurs into the broad ligament or vault of the vagina. A large volume
of blood may collect insidiously (up to 1 litre). I nvolution and lochia are usually
normal, the main symptom being increasingly severe maternal pain. This is often so
acute that the haematoma has to be drained in theatre under a general anaesthetic.
Secondary infection is a strong possibility.
Care after a postpartum haemorrhage
W hatever the cause of the haemorrhage, the woman will need the continued support
of her midwife until she regains her confidence. Her partner may also be fearful of a
recurrence and need much reassurance. I f the mother is breastfeeding, lactation may
be impaired but this will only be temporary and she should be reassured that
persevering will result in a return to normal lactation.
Conclusion
Key issues in the management of the third stage of labour are summarized in Box 18.3.
Box 18.3
K e y issue s in t he m a na ge m e nt of t he t hird st a ge of
la bour
• Difficulty of implementing well-documented research evidence into
practice (e.g. delayed cord clamping, avoidance of CCT, using EMTSL for
low-risk women) needs to be addressed.
• Care during the third stage of labour should not be viewed in isolation
from what has occurred during the first and second stages of labour.
• The development of the mother–baby–father relationship should be given
priority.
• The global PPH rate has not reduced significantly in the past decade
regardless of interventions applied (see CMACE 2011 for UK).
• Possible research: How does delayed childbearing (increased age of
women having a first baby), assisted reproductive technology, high rates
of oxytocin use in the first stage, or obesity affect the risk of PPH?
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Scandinavica. 1995;74:270–274.
Whitfield MF, Salfield S A W. Accidental administration of Syntometrine in
adult dosage to the newborn. Archives of Disease in Childhood. 1980;55:68–70.
WHO (World Health Organization). Managing complications in pregnancy and
childbirth: a guide for midwives and doctors. World Health Organization: Geneva;
2003.
WHO (World Health Organization). Maternal mortality. Fact sheet Number 348.
[Available from] www.who.int/mediacentre/factsheets/fs348/en/index.html;
2012 [(accessed 22 October 2012)] .
Wiberg N, Kallen K, Olofsson P. Delayed umbilical cord clamping at birth has
effects on arterial and venous blood gases and lactate concentrations. BJOG:
An International Journal of Obstetrics and Gynaecology. 2008;115:697–703.
Further reading
Aflaifel N, Weeks AD. The active management of the third stage of labour. BMJ.
2012;345:e4546.
A thought-provoking editorial..
Rogers C, Harman J, Selo-Ojeme D. The management of the third stage of
labour: a national survey of current practice. British Journal of Midwifery.
2012;20(12):850–857.
This article debates the non-uniformity of third stage management in England in a
variety of practice settings..
Useful website
POPPHI. www.pphprevention.org [(Prevention of Postpartum Hemorrhage
Initiative)] .
C H AP T E R 1 9
Prolonged pregnancy and disorders of
uterine action
Annie Rimmer
CHAPTER CONTENTS
Prolonged pregnancy 418
Incidence 418
Possible implication for mother, fetus and baby 418
Predisposing factors 419
Plan of care for prolonged pregnancy 419
The midwife's role 420
Induction of labour (IOL) 420
Indications for induction of labour 421
Methods of induction 422
Midwife's role when caring for the mother where labour is being induced 425
Alternative approaches to initiating labour 426
Failure to progress and prolonged labour 426
Delay in the latent phase of labour 426
Delay in the active phase of labour 427
The influence of the 3 ‘Ps’ 427
The midwife's role in caring for a woman in prolonged labour 428
Delay in the second stage of labour 429
Obstructed labour 429
Precipitate labour 430
Making birth a positive experience 430
References 431
Further reading 433
Useful websites 433
This chapter examines the evidence relating to prolonged pregnancy,
induction of labour, prolonged labour and precipitate labour. Any decision
with regards to the management of a pregnancy that continues beyond term
is based on discussion between the woman and obstetrician, but the
midwife is in a unique position to help the woman make sense of such
discussions, thereby enabling her to make an informed decision based on
informed choice.
When labour is induced, when there is failure to progress in labour or when
labour is prolonged, with or without further complications, the midwife
remains in a key position to ensure the woman is kept informed so that she
is enabled to continue to exercise her ability to be autonomous in the plan
of care of her own labour and birth and the execution of that plan.
The role of the midwife in the care of the woman will be discussed
throughout.
The chapter aims to:
• explore the issues relating to prolonged pregnancy with reference to research and
other evidence
• outline the indications for the induction of labour and examine the methods used to
induce labour in contemporary practice
• describe the process where there is perceived failure to progress in labour or labour is
prolonged and review the current evidence used to support the management and care
in such cases
• describe the serious complication that is obstructed labour and discuss the importance
of competent midwifery management and care of women during the antenatal and
intrapartum period if such complications are to be avoided
• highlight the significant events in a precipitate labour.
Prolonged pregnancy
Much of the confusion when exploring the research and other evidence on pregnancies
that go beyond the expected date of birth (ED B) and more specifically beyond 42
weeks (294 days) lies in the terms used to describe such pregnancies such as post-term
pregnancy, prolonged pregnancy and postdates. A ccording to Hermus et al (2009)
post-term pregnancy is defined as a pregnancy where the gestation exceeds 42
completed weeks (294 days). This definition is also used by others when referring to
prolonged pregnancy (N I CE [N ational I nstitute for Health and Clinical Excellence
2008a; Simpson and Stanley 2011). Gülmezoglu et al (2012) refer to pregnancies that go
beyond 294 days as both post-term and postdate.
W hat is clear is that all these terms refer to a specific gestation of the pregnancy and
not the fetus or neonate. For the purposes of this chapter the term prolonged
pregnancy will be used to describe a pregnancy equal to or beyond 42 weeks.
Postmaturity refers to a description of the neonate with peeling of the epidermis, long
nails, loose skin suggestive of recent weight loss and an alert face (Koklanaris and
Tropper 2006). The relationship, if any, between prolonged pregnancy and
postmaturity will be explored later in the chapter.
I f prolonged pregnancy is defined by weeks of gestation, whether this is based on a
calculation of the ED B using N aegele's rule or by ultrasound scan no later than 16
weeks, is to consider women as a homogenous group and neglects, among other
things, the racial variations with shorter gestational age in S outh A sian and Black
women (Balchin et al 2007). I f the anxiety pertaining to prolonged pregnancy is
possible adverse neonatal outcome then perhaps we need to consider how prolonged
pregnancy is defined for these groups of women. Laursen et al (2004) suggest the
notion of prolonged pregnancy as ‘a normal variation of human gestation’. A ccording
to Hovi et al (2006) only a small proportion of prolonged pregnancies have babies that
are postmature as described above.
Incidence
A ccording to N I CE (2008a), the frequency or incidence of prolonged pregnancy is
between 5% and 10%. The wide variation is a reflection of the disparate definitions as
highlighted above, the number of women where ED B is uncertain and different
induction policies (S impson and S tanley 2011). Based on a definition of equal to or
more than 42 weeks a true incidence of prolonged pregnancy is difficult to assess
because in many cases women's labour is induced before reaching that time for
specific complications in the pregnancy, for maternal request or because the
pregnancy has gone beyond the ED B. A ccording to the D epartment of Health DH (
2006), prolonged pregnancy was the most common indication given for induction of
labour (I O L) in England, accounting for approximately 46% of inductions overall.
Unfortunately the latest figures from the Health and S ocial Care I nformation Centre
(HS CI C 2012) do not provide the same breakdown of statistics, only giving an overall
induction rate for England for 2011–2012 of 22.1%. I t is acknowledged that in this
period in England 4.2% of women gave birth at 42 weeks and over (HSCIC 2012).
The use of an early ultrasound scan to date the pregnancy (Chapter 11), whether or
not there is uncertainty with the last menstrual period (LMP), is thought by many to
reduce the number of pregnancies categorized as prolonged (Ragunath and McKewan
2007; N I CE 2008a; S impson and S tanley 2011; Tun and Tuohy 2011; O ros et al 2012).
Both accurately defining prolonged pregnancy and the accurate dating of a pregnancy
is important if the woman is to be advised appropriately regarding the possible risks
when discussing the options of expectant management or I O L where pregnancy is
prolonged in order to avoid unnecessary intervention in an otherwise ‘low-risk’
pregnancy.
Possible implications for mother, fetus and baby
I n exploring the research and other evidence, a number of studies suggest there is an
increase in perinatal mortality and morbidity as the pregnancy goes beyond 41 weeks
(Hermus et al 2009; S impson and S tanley 2011; Cheyne et al 2012; Gülmezoglu et al
2012; O ros et al 2012). W hilst many authors acknowledge that the ‘absolute risk is
small’ ( N I CE 2008a; McCarthy and Kenny 2010; S impson and S tanley 2011; Cheyne
et al 2012; Gülmezoglu et al 2012), this information almost appears as an afterthought
and not worthy of further discussion. I f prolonged pregnancy is to be perceived as a
‘complication’ the possible ‘risks’ need to be viewed from the perspectives of the
mother, fetus and neonate with regards to morbidity and mortality.
S impson and S tanley (2011) suggest that if a pregnancy continues beyond 41
completed weeks the risks for the mother are associated with a large for gestational
age or macrosomic infant such as shoulder dystocia, genital tract trauma, operative
birth and postpartum haemorrhage (PPH). I n an otherwise low-risk pregnancy such
risks must be balanced with the risks of I O L, such as increased need for epidural
anaesthesia, uterine hyperstimulation, operative birth, PPH and failed induction
(Ragunath and McKewan 2007; Hermus et al 2009; McCarthy and Kenny 2010; Bailit
et al 2010; Gülmezoglu et al 2012; Jowitt 2012; Oros et al 2012).
A ccording to S impson and S tanley (2011), the possible risks for the fetus and
neonate in a prolonged pregnancy appear to be two-fold: placental dysfunction linked
to oligohydramnios, restricted fetal growth, meconium aspiration, asphyxia and still
birth; conversely the cases where growth continues resulting in a macrosomic infant at
risk of bony injury, soft tissue trauma, hypoxia and cerebral haemorrhage. The work of
Fox (1997) suggests that the changes in the placenta over the course of pregnancy are
part of a process of maturation and an increase in functional efficiency as opposed to a
decrease in functional efficiency. Given that few post-term neonates exhibit signs of
postmaturity, possible changes in placental function might be more appropriately
linked to pregnancies where the neonate displays such characteristics rather than in
prolonged pregnancies per se (Koklanaris and Tropper 2006).
Predisposing factors
Factors that might predispose a woman to a prolonged pregnancy include: obesity,
nulliparity, family history of prolonged pregnancy, male fetus, fetal anomaly such as
anencephaly (O lesen et al 2006; Biggar et al 2010; A rrowsmith et al 2011; Morken et al
2011; S impson and S tanley 2011) . Cardozo et al (1986) suggest there might be three
sub-groups related to a prolonged pregnancy, which include those where the dates are
incorrect, those with a normal prolonged gestation where physiological maturity is
achieved after 42 weeks and those with correct dates and are functionally mature but
who do not go into labour at term. Biggar et al (2010) looking at whether the
spontaneous onset of labour is immunologically mediated found the risk of prolonged
pregnancy is higher in first pregnancies and subsequently reduces with each following
pregnancy, where the father is the same. I f there is a different father the risk of
prolonged pregnancy is as if it were a first pregnancy. Morken et al (2011) found there
was a familial factor in relation to the recurrence of prolonged pregnancy across
generations, which involves both the mother and the father. Laursen et al (2004)
demonstrate a lower perinatal mortality rate in prolonged pregnancies where the
mother has had a previous prolonged pregnancy, which would seem to support a
possible genetic influence with a prolonged gestation as a normal variation on human
gestation.
Plan of care for prolonged pregnancy
I n previous editions of this book the subheading ‘Management of prolonged
pregnancy’ has been used, which may give the impression that the woman has li le to
contribute to the pregnancy and how it should proceed once she has reached 42 weeks.
This implies compliance with the ‘choices’ given by the healthcare professional rather
than active participation in the discussion on the options and choices available which
every woman is entitled to (Kirkham et al 2002; Cheyne et al 2012; S tevens and Miller
2012). The concept of ‘plan of care’ for prolonged pregnancy is perhaps less autocratic,
the term implying an approach the purpose of which is for the healthcare professional
to work with the woman to determine the most appropriate way forward with the
pregnancy in order to ensure the optimum outcome for both mother and baby. I n a
prolonged pregnancy where there are any obstetric or medical complications the
priority in the plan of care should, with maternal consent, follow the practice for the
specific complication. I f the pregnancy is otherwise low risk, the plan of care can
follow an expectant or active approach, and the decision on which approach to take
should be based on the woman (and partner) receiving the information on the
possible benefits and risks of each to enable her to make an informed decision based
on informed choice (NICE 2008a; Jowitt 2012).
I f a woman chooses the expectant approach the recommendations from NICE
(2008a) are increased antenatal surveillance which includes cardiotocography (CTG) at
least two times a week, and an ultrasound scan to estimate the maximum amniotic
fluid pool depth rather than a more complex approach to antenatal fetal surveillance
which includes ‘computerised CTG, amniotic fluid index, and assessment of fetal
breathing, tone and gross body movements’ (NICE 2008a: 279).
The use of a cervical membrane sweep (CMS ) at 41 weeks' gestation has been shown
to increase the spontaneous onset of labour before 42 weeks in some nulliparous and
parous women (Mitchell et al 1977; de Miranda et al 2006). The purpose of CMS is to
a empt to initiate the onset of labour physiologically thus avoiding the intervention of
I O L using prostaglandin, artificial rupture of membranes (A RM) and oxytocin. CMS i
designed to separate the membranes from their cervical a achment by introducing
the examining fingers into the cervical os and passing them circumferentially around
the cervix. The process of detaching the membranes from the decidua results in an
increase in the concentration of circulating prostaglandins that may contribute to the
initiation of the onset of labour in some individuals (Mitchell et al 1977). Massage of
the cervix can be used when the cervical os remains closed and this process may also
cause release of local prostaglandin. I f after an appropriate time labour has not started
spontaneously the process can be repeated. The practice of CMS is not associated with
any increase in maternal or neonatal infection although women report more vaginal
blood loss and painful contractions in the 24-hour period following the procedure.
S impson and S tanley (2011) state that to avoid I O L in one woman CMS would need to
performed for seven women and suggest the benefit is therefore small. However,
when one compares this to S tock et al (2012), who state that 1040 women would need
to be induced to avoid one perinatal death, whilst leading to seven additional
admissions to the special care baby unit, the ‘odds’ for CMS as a possible means to
initiate labour seem extremely favourable.
Menticoglou and Hall (2002) argue that ‘ritual induction’ at 41 weeks is based on
flawed evidence and interferes with a ‘normal physiologic situation’. Heimstad et al
(2007) compared I O L at 41 weeks' gestation with expectant management and found no
difference between the two groups with regards to neonatal morbidity or mode of
birth. A number of authors cite evidence that where there is an active approach and
I O L is undertaken beyond 41 weeks there is a reduction in perinatal mortality (NICE
2008a; S impson and S tanley 2011; Tun and Tuohy 2011). But as stated above, many
authors acknowledge that the ‘absolute risk of perinatal death is small’ (N I CE 2008a;
McCarthy and Kenny 2010; S impson and S tanley 2011; Cheyne et al 2012; Gülmezoglu
et al 2012). Oros et al (2012) found that I O L at 41 weeks led to an increase in the length
of hospital stay for the mother and an increase in the caesarean section rate.
The debate on the management of prolonged pregnancy centres on the disparate
evidence with regards to fetal risk and neonatal outcome in terms of perinatal
mortality and morbidity, and implementing a policy of ‘management’ rather than a
‘plan of care’ is designed to reduce these risks. W hen looking at the evidence
surrounding post dates (40+0 weeks to 41+6 weeks) and prolonged pregnancy (42
weeks), what is clear is that nothing is clear. There is a plethora of evidence but much
of it is contradictory and much of it is couched in emotive terms. Reference is
consistently made to the ‘risks of ’ prolonged pregnancy or the ‘risk of ’ recurrence of
prolonged pregnancy, which seems to imply that a poor outcome is inevitable. NICE
(2008a) refers to the ‘risks of ’ prolonged pregnancy against the harms and benefits of
I O L to avoid prolonged pregnancy. The mechanisms leading to the onset of labour
remain largely unknown and the possibility of a prolonged pregnancy being a
variation on human gestation within normal parameters should be considered.
Like many authors, NICE (2008a) seem to imply, either implicitly or explicitly, there
are no benefits to a prolonged pregnancy. Can nature really have got it so wrong? The
emphasis appears to be that in human parturition an ED B is calculated, and it is
downhill all the way from there; and whilst the ED B remains the focus, the debate and
controversy will continue. A number of women will gladly accept, and may even
request I O L once they go beyond their ED B and that decision must be respected, but
the decision not to have labour induced must also be respected, rather than, as NICE
(2008a: 29), suggest ‘should’ be respected.
The midwife's role
The woman and her partner must be given clear and unbiased information pertaining
to the benefits and possible risks of any proposed plan of care to enable the woman to
make an informed decision based on informed choice. I t is clear from the literature
that this is not always the case, and the woman is being directed towards I O L by
overemphasizing the risks of prolonged pregnancy whilst downplaying the risks
associated with I O L (G atward et al 2010; Cheyne et al 2012; S tevens and Miller 2012).
W hilst the obstetrician will take the lead in such cases, the midwife has a key role in
facilitating the woman's right to autonomy by ensuring she has been given clear and
unbiased information, that she fully understands the options available to her, and in
appropriate cases, acting as the woman's advocate (N MC [N ursing and Midwifery
Council] 2012, 2008). W omen are put in an unenviable situation at an extremely
vulnerable time in their lives and they expect, quite rightly, that the experts will help
them to make sense of the choices available to them. The midwife has a duty of care to
assist women at this time. I t is, however, important to understand that whatever plan
of care is put in place in any pregnancy, it is not always possible to avoid a perinatal
death.
See Box 19.1 for a summary of the key points relating to prolonged pregnancy.
Box 19.1
K e y point s in t he m a na ge m e nt of prolonge d
pre gna ncy
• Accurate EDB determined by LMP and early ultrasound reduces the
incidence of pregnancies diagnosed as prolonged.
• The length of gestation in some racial groups must also be considered
with regards to a definition of prolonged pregnancy in these groups of
women to improve perinatal outcomes.
• A membrane sweep can be offered from 40 weeks as a means to initiate
the onset of spontaneous labour.
• Where there is any complication in a pregnancy approaching or beyond
term the priority in management should follow the practice for the
specific complication.
• Where the woman makes the choice for expectant management she must
be informed that any deviations highlighted in antenatal surveillance will
necessitate a review of the plan of care and the options available to her.
Induction of labour (IOL)
Labour is the process whereby the uterine muscle contracts and retracts leading to
effacement and dilatation of the cervix, the birth of the baby, expulsion of the placenta
and membranes, and the control of bleeding (see Chapters 16–18). I t is only one part
of the passage in the childbirth experience but for the majority of women and their
partners it is the singular most important part and the care and management they
receive will always be remembered.
I O L is an intervention to initiate the process of labour described above by artificial
means and involves the use of prostaglandins, A RM (amniotomy), intravenous
oxytocin, or any combination of these (W HO [W orld Health O rganization] 2011 ). I t is
the term used when initiating this process in pregnancies from 24 weeks' gestation,
the legal definition of fetal viability in the United Kingdom (UK) (House of Commons
S elect Commi ee 2007). W here labour is being induced a full assessment must be
made to ensure that any intervention planned will confer more benefit than risk for
both mother and baby.
There has been a steady rise in I O L in recent years, the most recent statistics
showing an I O L rate of 22.1% (H S CI C 2012
). I n the UK it is an intervention that has
become routine practice in maternity units within the N ational Health S ervice (N HS )
W hen comparing I O L to a spontaneous onset of labour, evidence demonstrates that it
is more painful, that women are more likely to require epidural anaesthesia and an
assisted mode of birth (N I CE 2008a; W HO 2011). The decision therefore to induce
labour should only be made when it is clear that a vaginal birth is the most
appropriate outcome in this pregnancy, at this time, for that particular woman and her
baby.
Indications for IOL
I O L is considered when the maternal or fetal condition suggests that a be er outcome
will be achieved by intervening in the pregnancy than by allowing it to continue. This
most commonly applies to cases where there are deviations from the normal
physiological processes of childbirth as a result of hypertension, diabetes, fetal growth
restriction or macrosomia. A list of some of the indications for I O L can be seen inBox
19.2, although this should not be considered as a definitive list. The mother may also
request to have labour induced, although N I CE (2008a) state this should only be
agreed in exceptional circumstances. Ultimately, the grounds on which the decision is
made to induce labour must be sound enough to support the outcome whatever that
outcome might be. There is no guarantee I O L will result in a vaginal birth or positive
outcome for mother and/or her baby.
Box 19.2
I ndica t ions for induct ion of la bour
Maternal
• Prolonged pregnancy – defined as one that exceeds 42 completed weeks
or 294 days. This is the commonest reason for induction of labour in
England because of the increased risk of perinatal mortality and
morbidity when the pregnancy continues beyond term, although the
absolute risk is small (see above).
• Hypertension, including pre-eclampsia – the decision to induce labour
and expedite delivery is done in the best interests of the woman and her
baby and the timing of induction will be influenced by the severity of her
symptoms.
• Diabetes – the type and severity of diabetes influence the decision to
induce. The risk of fetal macrosomia is increased where diabetic control is
poor. In women with pre-existing type 1 and type 2 diabetes, the risk of
adverse perinatal outcome is significantly increased over the national
population (NICE 2008b). Where the fetus is normally grown, elective IOL
is offered after 38 weeks' gestation.
• Prelabour rupture of membranes – the longer the interval between
membrane rupture and birth of the baby increases the risk of infection to
mother and fetus. For the majority of women spontaneous labour will
commence within 24 hours of rupture of membranes but women should
be offered the choice of IOL after 24 hours or expectant management
(NICE 2008a).
• Maternal request – this may be for psychological or social reasons. For
some women there are compelling reasons for requesting IOL when there
is no clinical indication. In such cases it is important the woman is quite
clear about the implications of such a decision. IOL may be considered
from 40 weeks (NICE 2008a).
Fetal
• Fetal death – if there are no complications such as SRM, infection or
bleeding the choice of immediate IOL or expectant management should
be offered. Where there are complications IOL is recommended.
• Fetal anomaly not compatible with life.
The contraindications for I O L are situations that preclude a vaginal birth in the best
interests of the mother and/or baby. These are listed in Box 19.3.
Box 19.3
S om e cont ra indica t ions for induct ion of la bour
• Placenta praevia
• Transverse lie or compound presentation
• HIV-positive women not receiving any anti-retroviral therapy or women
on any anti-retroviral therapy with a viral load of 400 copies/ml or more
(RCOG 2010; NICE 2011)
• Active genital herpes
• Cord presentation or cord prolapse when vaginal birth is not imminent
• Known cephalo-pelvic disproportion (CPD)
• Severe acute fetal compromise
Methods of induction
The cervix must maintain its integrity during pregnancy and then undergo
remodelling prior to labour. For an induction to be successful the cervix needs to have
undergone the changes that will ensure the uterine contractions are effective in the
progressive dilatation and effacement of the cervix, descent of the presenting part and
the birth of the baby.
The cervix is said to be ripe when it has undergone these changes. The Bishop score,
devised in the 1960s (Bishop 1964), is the means by which the ripeness of the cervix is
assessed using a scoring that examines four features of the cervix and the relationship
of the presenting part to the ischial spines. Each of these five elements is scored
between 0 and 3 on vaginal examination (VE). The scoring system has been modified
and it is this version that is used in contemporary practice (see Table 19.1). W hilst a
score of ≤6 is considered to be unfavourable, a score of 8 or more suggests a greater
probability of a vaginal birth, similar to that when the onset of labour is spontaneous
(N I CE 2008a; Gülmezoglu et al 2012). A ripe or favourable cervix is one that for the
purpose of I O L is more compliant, offering less resistance as the contraction and
retraction of the myometrium forces the presenting part down (NICE 2008a).
Table 19.1
Modified Bishop's pre-induction pelvic scoring system
A VE to assess the cervix and the likelihood of successful induction in this way is by
nature a subjective examination and as such there will be inter-observer variations.
Transvaginal ultrasound assessment of cervical length was found to be superior to the
Bishop's score in predicting the success of I O L E
( lghorori et al 2006), but currently VE
remains the most common method of cervical assessment for I O L. W hilst it is
acknowledged that a VE is a subjective means of assessment, if the same individual
undertakes the assessment each time then inter-observer variation does not apply.
This would also provide the woman with continuity of caregiver at an extremely
vulnerable and anxious time for her, which is in the woman's best interest and a
standard of care midwives should aim to meet.
Cervical membrane sweep
A cervical membrane sweep (CMS ), as described previously, is considered byNICE
(2008a) to be an addition to, rather than a method of I O L per se. They recommend it is
offered to nulliparous women at the 40- and 41-week antenatal examination and to
parous women at the 41-week review. I t is commonly undertaken by a doctor or
midwife experienced in the practice and has been shown to reduce the need for further
methods to induce labour (Mitchell et al 1977; Boulvain et al 2005; McCarthy and
Kenny 2010). However, Rogers (2010) suggests the evidence on this is inconclusive and
both women and midwives need to be aware of this if the woman is to be able to make
an informed choice. S ome women may find the procedure uncomfortable or painful
and they may experience vaginal spo ing and abdominal cramps ( McCarthy and
Kenny 2010). W ong et al (2002) found that whilst the procedure was safe in that it did
not lead to prelabour rupture of membranes, bleeding or maternal or neonatal
infection, for some women it did cause significant discomfort and in their study was
not found to reduce the need for I O L.Boulvain et al (2005) suggest the possible
benefits in terms of a reduction in more formal induction methods need to be weighed
against the discomfort of the VE and other adverse effects of bleeding and irregular
contractions not leading to labour. The recommendation from N I CE (2008a)to offer
CMS at 40/41 weeks is to avoid prolongedpregnancy and is not meant for high-risk
cases. W hilst the evidence on whether it leads to spontaneous labour is inconclusive, if
the alternative is I O L for women whose only risk factor seems to be their ED B it is
perhaps an ‘intervention’ that is worthy of consideration.
Prostaglandin E2 (PGE2) (Dinoprostone)
Prostaglandins are naturally occurring female hormones present in tissues throughout
the body. Prostaglandin E2 and F2 are known to be produced by tissues of the cervix,
uterus, decidua and the fetal membranes and to act locally on these structures.
D inoprostone is the active ingredient in PGE2 vaginal tablets, gel and pessaries (BNF
[British N ational Formulary] 2013). I t replicates prostaglandin E2 produced by the
uterus in early labour to ripen the cervix and is seen as a more natural method than
the use of oxytocin. PGE2 placed high in the posterior fornix of the vagina, taking great
care to avoid inserting it into the cervical canal (see Fig. 19.1) is absorbed by the
epithelium of the vagina and cervix leading to relaxation and dilatation of the muscle
of the cervix and subsequent contraction of uterine muscle. A ccording to Blackburn
(2013), the use of a prostaglandin greatly increases the probability of delivery
occurring within 24 hours, and prior to the use of oxytocin potentiates the effects of
the oxytocic agent (BNF 2013).
FIG. 19.1 Insertion of prostaglandins. The posterior fornix of the vagina is used to insert
prostaglandins for ripening or induction of labour. The key point is that when undertaking a vaginal
examination to assess the cervix midwives should follow the direction of the vagina, which will be
directed posteriorly if the woman is semi-recumbent. The uterus is anteverted and anteflexed,
creating the posterior fornix. The cervix may appear ‘difficult to reach’, particularly when
unfavourable.
There are a number of preparations of PGE2, which have been found to be clinically
equivalent; but not bioequivalent. The current recommendation from N I CE (2008a)is
the use of gel, tablet or controlled release pessary. I n a small study by Tomlinson et al
(2001), the women receiving the slow release pessary gave a higher satisfaction score
with regards to their perception of labour. W hilst the slow release preparation would
appear to confer more benefit from the woman's perspective with regard to fewer
vaginal examinations, the difference in cost between the gel, tablet and controlled
release pessary, with currently the la er being marginally more expensive, may
prohibit its use in some NHS Trusts for routine use in IOL.
Prior to the insertion of PGE2, the midwife will carry out an abdominal examination
to confirm fetal lie, presentation, descent of presenting part and fetal wellbeing by use
of electronic fetal monitoring (EFM). A ll findings are clearly recorded in the woman's
maternity records and if there is any doubt or concern in the findings the process must
be stopped and the doctor informed (N MC 2012). Following insertion of PGE2 the
woman is advised to lie down for 30 minutes. W hen contractions begin continuous
EFM is used to assess fetal wellbeing. If the CTG is confirmed to be normal, i.e. all four
features are considered to be reassuring, the CTG can be discontinued and
intermi ent auscultation used unless there are any other clear indications for the use
of continuous EFM (N I CE 2007, 2008a). Currently the I O L process commonly takes
place as an inpatient, either on the antenatal ward or labour suite depending on the
reason for I O L. There is evidence to support starting the I O L process in the morning
rather than the evening, citing increased maternal satisfaction with the process (NICE
2008a). Prior to the administration of the PGE2 the midwife must confirm there is a
bed available on the labour suite in the event there is a need to transfer the woman as
a ma er of urgency. For the safety of the woman and her baby any decision to proceed
with I O L must take cognisance of the current situation on the labour suite because the
woman's response to insertion of PGE2 cannot be predicted. I f there are any maternal
or fetal risk factors in the pregnancy the IOL must take place on the labour suite.
W here the membranes are intact or ruptured the recommended initial dose for all
women, whether it is a first or subsequent pregnancy, is one dose of PGE2 tablet (3 mg)
or gel (1–2 mg), re-assess in 6 hours and if labour is not established, and the woman
has given consent, a second dose of tablet or gel is inserted into the posterior fornix of
the vagina. This equates to one cycle. Alternatively one cycle of PGE2 controlled-release
pessary (10 mg) can be given over 24 hours, which is one pessary. The maximum
recommended dose of PGE2 tablet, gel or controlled-release pessary being one cycle
(NICE 2008a). Side-effects of PGE2 include nausea, vomiting and diarrhoea (BN F 2013).
I f labour is not established after one cycle of treatment the I O L is classed as having
failed, and having established both mother and baby are in good health discussion
must take place between the woman and doctor with regards to further options – these
being another attempt to induce labour or elective caesarean section (NICE 2008a).
Vaginal PGE2 is currently the only recommended route for the use of prostaglandins
for IOL. Misoprostol (PGE1) is not licensed for use in the UK. W hilst it is thought to be
more effective and less expensive than PGE2 and oxytocin for the I O L there remain
questions about safety issues with regards to uterine hyperstimulation. Currently in
the UK PGE1 is recommended for I O L only where there is an intrauterine fetal death
(IUFD).
With a caesarean section (CS) rate in excess of 25% (HSCIC 2012), it is inevitable that
more and more women with a uterine scar will be faced with the decision regarding
I O L. W hilst previously PGE 2 was not recommended where there was a scar on the
uterus, women with a previous lower segment caesarean section (LS CS ) may now be
offered I O L using PGE2. I t is important for the midwife to understand the significance
of a scarred uterus and choices with regards to I O L to ensure the woman is informed
of the increased risk of requiring an emergency CS and increased risk of rupture of the
uterus.
Risk associated with use of PGE2
The use of PGE2 can be unpredictable and may lead to uterine hyperstimulation,
placental abruption, fetal hypoxia, pulmonary or amniotic fluid embolism (Kramer
et al 2006). The risk of uterine rupture is rare, occurring in between 0.3% and 7% of
labours.
Artificial rupture of membranes (ARM)
There are two layers of membrane surrounding the fetus: the amnion is closest to the
fetus, and the chorion is nearest to the decidua. A RM is a relatively simple process
that can be used in an a empt to induce labour if the cervix is favourable and the
presenting part is fixed in the pelvis, particularly where the woman does not want to
use drugs such as PGE2 or oxytocin, or where there is a risk of hyperstimulation if
using PGE2. Prior to the procedure an abdominal examination is carried out and if the
lie is longitudinal, the presenting part is engaged and the fetal heart rate is within
normal limits, a VE is done to assess the cervix, confirm the presentation and station
and to exclude possible cord presentation or vasa praevia. I f these findings are
satisfactory the bag of membranes lying in front of the presenting part (forewaters) is
ruptured with the use of an amnihook or similar device to release the amniotic fluid.
The fluid is assessed for colour and volume and following A RM it may be possible to
distinguish other features on the presenting part to identify the position of the fetus.
A fter the procedure the woman is made comfortable, the fetal heart is auscultated and
all findings are recorded in the maternity notes. The longer the interval between A RM
and birth increases the risk of the woman developing chorioamnionitis as a result of
an ascending infection from the genital tract leading to an increased risk of perinatal
mortality (Bricker and Luckas 2012; Blackburn 2013). For this reason if a decision has
been made to induce labour for perceived risks it is common practice to start an
oxytocin infusion within a few hours if labour has not been established following the
A RM. I n their review of two trialsBricker and Luckas (2012) found insufficient
evidence to recommend amniotomy alone for the IOL.
Changes to ripen the cervix are thought to be in response to prostglandin produced
by the amnion and cervix. I n pregnancy the chorion provides a barrier to the amnion
and fetus from the vagina and cervix. Prostaglandin dehydrogenase (PGD H) is an
enzyme produced by the chorion that breaks down prostaglandin. A s a result of the
actions of this enzyme the changes in the cervix do not take place and pre-term labour
is avoided (S myth et al 2013) . Mitchell et al (1977) found that VE in late pregnancy
rapidly increases the concentration of circulating prostaglandins. This change occurs
both in sweeping the membranes and with A RM. I t is thought it is the disruption of
the a achment of the membranes to the uterine wall that facilitates this change. I n
contrast, Van Meir et al (1997) found that in labouring women the part of the chorion
that was in close contact with the cervical os released less PGD H allowing the
prostaglandin from the amnion to come into contact with the cervix and facilitate
ripening of the cervix. The theory is that if an A RM is performed too early the action of
the amniotic prostaglandins on the cervix is lost.
Oxytocin
O xytocin is synthesized in the hypothalamus and then transported to the posterior
lobe of the pituitary gland from where it is episodically released to act on smooth
muscle. The number of oxytocin receptors in the myometrium significantly increases
by term increasing uterine oxytocin sensitivity (Blackburn 2013).
I n its synthetic form, oxytocin (S yntocinon) is a powerful uterotonic agent that may
be used as part of the process for I O L following A RM.N I CE (2008a) do not
recommend the use of oxytocin alone for I O L, or the use of A RM and oxytocin as a
‘primary method’ of IOL, unless the use of vaginal PGE2 is specifically contraindicated.
O xytocin should be administered by slow intravenous infusion using an infusion
pump or syringe driver with non-return valve. The infusion rate should follow N HS
Trust protocol and the maximum rate of 0.2 units/minute should not be exceeded (BNF
2013). The dose is titrated against uterine activity, usually increasing the dose every 30
minutes with the aim of 3–4 contractions every 10 minutes with each contraction
lasting approximately one minute, using the lowest possible dose. I f contractions
exceed this rate, or the contractions fail to establish, the infusion must be stopped and
the case reviewed to determine the next step. There should be an interval of at least six
hours between administration of prostaglandins and commencement of an oxytocin
infusion.
W hen using an oxytocin infusion the fetal heart rate and uterine activity should be
monitored using continuous EFM to ensure the fetus does not become compromised
by the induced uterine contractions. There is a risk of hyperstimulation and
hypertonic uterus leading to fetal compromise (Ragunath and McEwan 2007; McCarthy
and Kenny 2010). I n such cases the infusion is decreased or discontinued and medical
aid summoned. Even with the use of the CTG the midwife still has an important role
to play in assessing the woman's progress. The graphic representation on the CTG
provides an indication of the frequency of the contractions but does not necessarily
provide an accurate representation of the length and strength of the contractions, and
for this reason it is important that the midwife continues to palpate the uterus to
assess contractions for their length and strength. W hatever ‘science’ is being
employed to assess maternal and fetal wellbeing the midwife has a valuable
opportunity to be with the woman and to use her ‘art’ to make a more holistic
assessment of the woman and how she is responding to the process and what she
wants and needs at this time.
Risks associated with use of intravenous oxytocin include:
• Uterine hyperstimulation or hypertonus
• Fetal hypoxia and asphyxia
• Uterine rupture
• Fluid retention as a result of the antidiuretic effect of oxytocin
• Postpartum haemorrhage
• Amniotic fluid embolism (AFE)
Midwife's role when caring for the mother where labour is
being induced
The midwife's responsibilities regarding I O L include care during the antenatal and
intrapartum period. W here a decision has been made to induce labour it is important
the midwife ensures the woman and her partner have been fully informed and
understand the process and how it might be undertaken. A s can be seen from above
there are a number of ways that labour can be induced and the manner the induction
will take will depend on the individual circumstances of each woman. A ll information
should be given in an objective manner to ensure the woman and her partner
understand the reason for the induction, any possible consequences or risks of
having/not having the procedure as well as any alternatives to I O L (N I CE 2008a). I t is
important for the woman and her partner to understand that induction may be
delayed if the labour suite is busy, that it might take some time for contractions to be
initiated, and the possibility the induction process will be unsuccessful. W hilst the
assumption may be that this will already have been discussed, it is incumbent upon
the midwife to ensure the woman is fully informed (NMC 2008, 2012). Time should be
allowed for discussion with the midwife or obstetrician and it must be remembered
that consent to a treatment can be withdrawn at any time and this decision by the
woman must be respected (Griffith et al 2010). The midwife or doctor should record
any discussion that takes place and any requests made in the maternity notes.
D uring the induction process all maternal and fetal observations will be recorded in
the maternity notes. Until labour is established and the partogram is commenced the
observation are normally recorded in the antenatal section of the notes. Because the
layout is not as comprehensive and logical as the partogram it is important the
midwife is clear and methodical in her documentation at this time (N MC 2012). The
frequency and type of monitoring of the mother and fetus will depend on the reason
for and method of induction. The midwife is advised to follow the local N HS Trust
guidelines regarding I O L in each case, if this is what the woman wishes and has
consented to. I t is important when monitoring the wellbeing of the mother and fetus
during the induction process that the midwife understands the possible risks
associated with each method of induction and is confident and competent in
recognizing and responding to any deviations from normal.
W hen the onset of labour is spontaneous it is a more insidious process and as such
the woman has time to adjust to the changes in her body and is usually be er able to
cope with contractions. W hen labour is induced the sudden onset of strong painful
contractions occurring every three to four minutes can be quite overwhelming and
result in an early request for pain relief. A s well as this the woman has to make a
temporal shift from how she planned to birth her baby to what is now taking place.
This can be extremely hard for the woman and her partner to come to terms with and
can have a negative impact on this singularly important time in both their lives.
Continuity of caregiver in labour is important in developing a rapport with the woman
and her partner and in being able to make an assessment of her progress based on
physical observations of abdominal examination and VE as well as less tangible
observations of body language and behaviour (Lowe 2007; Laursen et al 2009; Hodnett
et al 2012). I n this way the midwife may be be er able to advise the woman of her
progress to help her in her decision as to how she would like her labour to proceed.
I O L does not have to be a negative experience and the midwife is in a key position to
use her ‘art’ to enable the woman to have a positive birthing experience, whatever the
outcome.
I t must be remembered that each woman's labour, whether it is spontaneous onset
or induced, is their own individual experience, and what they wish for their labour
may not always conform to N HS Trust guidelines. A s inall care the midwife provides,
valid consent must be obtained before any examination or intervention, and this
requires taking time to give the woman the information so that she is fully informed
and knows and understands what she is consenting to. W hen a woman is experiencing
painful contractions in labour the information about any examinations or procedures
that the midwife or doctor may wish to perform should be given between contractions.
Alternative approaches to initiating labour
For some women avoidance of any surgical or pharmacological intervention in an
otherwise low-risk pregnancy is extremely important and they might seek advice from
the midwife on this ma er. A lternative approaches include the ingestion of castor oil,
nipple stimulation, sexual intercourse, acupuncture and the use of homeopathic
methods. W hilst some reviews, for example Kavanagh et al (2008) and S mith and
Crowther (2012), have found insufficient evidence to recommend some of these as a
method to initiate labour it is important for the midwife to understand how each of
these are thought to work, and to be familiar with the wider literature on these
subjects to develop a broad understanding to ensure that any advice given on
alternative therapies is in line with her sphere of practice (N MC 2012). For the
complete list of reviews on alternative approaches to initiating labour visit the
Cochrane database online.
O ne alternative approach with more positive findings is that of stimulation of the
breast. The findings of Kavanagh et al (2005) suggest stimulation of the breast either
by massage or nipple stimulation ‘appears beneficial in relation to the number of
women not in labour after 72 hours, and reduced postpartum haemorrhage rates’. I t
appears to be less effective where the cervix is not ripe. S timulation of the breast or
more specifically the nipple appears to cause the release of endogenous oxytocin, the
effect being to initiate a uterine response, but further studies are needed before it can
be considered for use in high-risk groups.
Failure to progress and prolonged labour
The physiology of labour encompasses effective uterine contractions and cervical
changes leading to progressive effacement and dilatation of the cervix, rotation of the
fetus and descent of the presenting part, the birth of the baby, and expulsion of the
placenta and membranes and the control of bleeding. The psychology of labour
encompasses the need for a safe and stress-free environment, one in which the woman
feels in control of events and has trust in those caring for her (Laursen et al 2009) and
is an equally important part of the process of labour (see Chapter 1).
For many, the process of labour starts spontaneously and continues that way
without the need to intercede. For others the process may falter and the caregiver
must assess whether this is a temporary slowing down in progress as the woman's
mind and body adjusts to what is happening, and to what has yet to happen, or
whether it is the first signs of a delay in progress that may benefit from a change in the
status quo. Historically, terms such as ‘failure to progress’, ‘prolonged labour’ and
‘dystocia’ have been used when labour is perceived not to be following a pre-
determined line of progress, whether that is the rate of cervical dilatation/hour or if
the labour is considered to have exceeded a set number of hours. N I CE (2007)do not
specify these terms but refer to a change in progress in the first or second stage of
labour as ‘suspected delay’ or ‘delay’ depending on the findings.
Prolonged labour is not easily defined, primarily because there is no consensus as to
what constitutes a normal time limit for labour either in the latent or active part of the
first stage or the passive or active part of the second stage. W hen labour is slow to
progress or prolonged there is an increased risk of chorioamnionitis if there has been
prolonged rupture of membranes, and an increased risk of postpartum haemorrhage
as a result of an atonic uterus. N onetheless it must also be remembered the
interventions used to correct a dystocia, such as amniotomy, oxytocin infusion and
instrumental or operative birth, are not risk-free and therefore any decision to
intervene must take account of the full clinical picture and as importantly the wishes
of the woman.
Delay in the latent phase of labour
I n the first stage of labour, the latent phase is the period when structural changes
occur in the cervix and it becomes softer and shorter (from 3 cm to less than 0.5 cm),
its position is more central in relation to the presenting part and there are painful
contractions (Chapter 16). A ccording to NICE (2007), the dilatation of the cervix at this
time is up to 4 cm. D uring this period the woman needs support and encouragement
from those caring for her. The perceived result of painful contractions may be
disappointing when hearing the cervix is 3 cm dilated after several hours. I f progress
in this phase of labour is considered to be slow the emphasis is on conservative
management rather than intervention (Hayman 2004). The midwife must ensure the
woman knows to keep eating and drinking if she feels able to as this will not only help
maintain her energy levels but can also bring a sense of normality and comfort. I t is
important for the woman to rest at this time and not to feel that if she tries to sleep the
contractions will cease. A dvice on how to relieve pain might include simple back
massage, changes of position, a warm bath or some simple analgesia; all are an
important part of care at this time. A ny intervention such as an A RM at this stage can
interfere with the action of amniotic prostaglandin on the cervix and be
counterproductive (Smyth et al 2013).
Delay in the active first stage of labour
NICE (2007) refers to the established first stage of labour rather than the active phase,
and define this as the period when the uterine contractions are regular and painful
and the cervix dilates progressively from 4 cm. N eal et al (2010) suggest that the active
phase begins between 3 and 5 cm when there are regular uterine contractions.
For nulliparous women delay is suspected if their progress, in terms of cervical
dilatation, is less than 2 cm in 4 hours. For parous women it is the same, or there is
considered to be a ‘slowing in progress’ ( N I CE 2007: 40). This suggests the rate of
cervical dilatation and duration of labour is measurable and such measurements can
be applied to all nulliparous or multiparous women. I t is, however, rather more
complex and needs to take account of a wide range of variables in terms of maternal
age, maternal size, fetal position etc. S uch factors may mean labour does not conform
to a pre-determined rate of progression whilst still being normal for that particular
woman. N onetheless, when caring for women in labour midwives do need some
parameters to work within in order to be er understand what is considered acceptable
in terms of progress (N eal et al 2010) . N I CE (2007)acknowledges the active phase of
labour does not follow the trajectory that Friedman (1954) put forward to suggest a
rate of 0.5 cm/h. A lthough they suggest that consideration should also be given to the
rotation, descent and station of the presenting part, these observations do not appear
to merit the same importance as cervical dilatation. For some women good progress
will be made in terms of rotation, descent and station of the presenting part, although
such progress is not always reflected in a corresponding change in cervical dilatation.
N eal et al (2010: 317) suggest that for low-risk, nulliparous women, with spontaneous
onset of labour ‘contemporary expectations of active labour are overly stringent’.
W hen there is ‘suspected delay’ the midwife needs to discuss with the woman how
the situation might be best managed from this point onwards, with appropriate
consideration of all the facts in the context of that particular woman. A lleviating
anxiety by ensuring there is continuous support in labour, changing maternal position,
alleviating pain using non-pharmacological means are some of the ways in which the
midwife can help the woman at this time. Medical interventions to correct this include
A RM or oxytocin or a combination of both, and the means to augment labour in this
way has become common practice in the UK, with as many as 50% of nulliparous
women receiving an oxytocin infusion in labour (Hayman 2004). I f these means fail, an
instrumental or operative birth may be the only course of action depending on the
stage of labour reached. The caesarean section rate in England is currently 25% with
14.8% being emergency caesarean sections (HSCIC 2012), and many of these will be for
a diagnosis of failure to progress or prolonged labour.
The partogram or partograph is a graphical representation of the maternal and fetal
condition in established labour and the dilatation of the cervix against time.
I nformation on a number of findings that are important in making an appropriate
assessment of the ongoing progress of labour are usually recorded on a single sheet.
N I CE (2007)recommends the use of a partogram once the woman is in established
labour despite the only evidence to support its use being studies from low-income
countries. In a recent review by Lavender et al (2012), the routine use of a partogram as
part of the management of labour could not be recommended, suggesting that its use
should be determined at a local level. Possibly one of the most debated issues in the
use of a partogram is the plo ing of cervical dilatation on a graph which has an ‘alert
line’ and an ‘action line’. The assumption is that the cervix dilates at a given rate in
established labour, with the graph highlighting any perceived deviations from this
pre-determined trajectory. W hilst a record of observations in labour on one sheet of
paper might for example make for easier reading for anyone taking over care of a
woman in labour, the plo ing of cervical dilatation in this way suggest progress in
labour can be assessed based on cervical dilatation alone.
The influence of the 3 ‘Ps’
D ystocia can be as a result of ineffective uterine contractions, malposition of the fetus
leading to a relative or absolute CPD , malpresentation, or any combination of these.
These may result in poor progress during the active phase or a cessation of cervical
dilatation following a period of normal dilatation (Hayman 2004). An understanding of
the role played by the 3 ‘Ps’ – passages, passenger and powers – will help in
determining why there is a delay in progress in first or second stage of labour and
what action might be taken.
I n the developed world the majority of women have grown up well nourished, fit
and healthy, and the passages the fetus must negotiate are unlikely to be seriously
flawed, excluding possible trauma to the pelvis. N onetheless the impact of a full
rectum, full bladder and fibroids cannot be ignored in causing a delay in the progress
of labour. A malpresentation such as shoulder, brow or face (mento-posterior) is one
of the causes of poor progress or prolonged labour and this may occur as a result of a
problem with the passage (Chapter 20). A brow might revert to a face (mento-anterior)
or vertex presentation and the face in mento-posterior position may rotate to mento-
anterior at the pelvic floor and if so a vaginal birth may be possible ( S ingh and
Paterson-Brown 2006). The shoulder, brow or face (mento-posterior) cannot be born
vaginally but a carefully executed abdominal and vaginal examination will exclude or
confirm this so that the necessary action can be taken to prepare the woman for
caesarean section.
W hen the fetus is adopting an a itude where the head is deflexed or slightly
extended and the occiput is posterior the presenting diameters are larger and there
will be a degree of ascynclitism. This inevitably slows progress but does not
necessarily mean progress is abnormal. This might be considered a relative CPD
because with effective uterine contractions the fetus may adopt a more flexed a itude.
O n some occasions more time is needed to do this safely. El Halta (1998) suggests that
rupturing the membranes when the fetus is an occipitoposterior position may result in
a sudden descent of the fetal skull resulting in a deep transverse arrest whereby the
occipitofrontal diameter (11.5 cm) is caught on the bi-spinous diameter of the outlet
(10–11 cm). Epidural anaesthesia has been found to delay the progress of labour in the
first and second stage (Lowe 2007; Cheng et al 2009), particularly so where there is an
occipitoposterior position (Chapter 20). The musculature of the pelvic floor plays an
important part in assisting the rotation of the presenting part and epidural
anaesthesia causes the pelvic floor to relax inhibiting rotation. I t also has an impact on
the stretching of the birth canal that normally triggers the neuro-hormonal reflex
(Ferguson's reflex). I n some cases the head is simply (normally) large and any decision
to intervene at this point with oxytocin may increase strength and frequency of uterine
contractions in such a way as to unduly force this process with inevitable fetal heart
rate changes prompting further intervention.
A lthough the uterus has prepared itself for the metabolic activity of labour, as
labour continues the smooth muscle uses up its metabolic reserves and becomes tired.
A ny change to the strength, length or frequency of contractions will affect progress
and is indicative of inefficient uterine action. W hilst some ketosis is considered
normal in labour there remains a need for additional supplies of energy if the uterus is
to continue contracting effectively and enable labour to progress without the need for
medical intervention (Lowe 2007; Blackburn 2013). W omen need to have adequate oral
intake in order to cope with the very real demands that labour puts on their body.
The midwife's role in caring for a woman in prolonged
labour
A prolonged labour leads to increased levels of stress, anxiety, fear and fatigue, and
increases the risk of infection, PPH and emergency caesarean section (S värdby et al
2006; Laursen et al 2009). The importance of effective antenatal education in
developing a plan of care for labour should not be underestimated. A dvice on suitable
food and drink to eat in the early stages of labour to maintain energy levels, positions
and activities to encourage a forward rotation where there is an occipitoposterior
position are just some of the ways that might help to assist the woman in the normal
progress of labour.
W hen the woman and her partner come into hospital, continuity of caregiver helps
to create a sense of trust between the woman, partner and midwife but also allows for
more accurate assessment over time to enable the midwife to suggest non-
interventionist ways in which progress can be maintained if appropriate. A n
alternative position might help to facilitate more effective contractions or improve
pelvic diameters when the position of the baby is posterior. At this stage it is also
important to maintain hydration, to encourage voiding and to suggest non-
pharmacological ways to relieve pain. Facilitating autonomy by keeping the woman
and her partner informed of her progress and the choices she has is important in
helping her to feel in control and to alleviate anxiety. Raised adrenalin levels as a
result of fear, anxiety or pain can impact negatively on uterine activity and can slow
progress in labour.
A ccurate observations in labour are critical in assessing progress. Recognition and
detection of abnormal progress in labour with appropriate clinical response will
improve the outcome of labour for both mother and baby (N eilson et al 2003). A n
abdominal examination deftly undertaken can provide vital information about the
labour with regard to the lie, presentation, position and descent of presenting part as
well as the length, strength and frequency of contractions whereby any change in the
pa ern of the contractions can be picked up. I f the woman consents to VE the findings
can be compared to provide a more comprehensive picture of the progress of labour.
O n VE the midwife is assessing the presence and degree of moulding of the fetal skull,
the presence and position of caput in relation to sutures and fontanelles, and the
dilatation of the cervix noting any thickening and its application to the presenting
part. A ny changes to the colour of the liquor if the membranes have previously
ruptured, or to the fetal heart rate will give some indication as to how the fetus is
coping with the progress of labour. Continuity of caregiver at this time reduces the
likelihood of interobserver variations whilst increasing the chance of spontaneous
vaginal birth (Hodnett et al 2012).
W hen the decision to augment labour has been agreed by all parties, the woman
and her partner will need additional support from the midwife, as the interventions
necessary for this process may be very different from the birth they had previously
imagined. Psychological as well as physical support is important at this time, as the
control of the birth of their baby now appears to be in the hands of a third party and
this can lead to negative feelings of the childbirth experience (Nystedt et al 2005, 2006).
The management of prolonged labour is a collaborative effort involving the woman
and her partner, the midwife, obstetrician and anaesthetist. The normal pa ern of
observations and care in labour apply and any deviations from normal are reported to
the obstetrician. When an ARM has been performed to augment labour an appropriate
period of grace should be given for effective uterine contractions to resume before
commencing an oxytocin infusion. The uterus responds with increased sensitivity to
the oxytocin infused as the cervix dilates and it may be necessary to reduce the rate of
the infusion as full dilatation is approached to avoid hyperstimulation of the uterus
and the concomitant effects on mother and fetus. With the woman's consent, an
assessment will be made 2–4 hours after A RM or after commencing oxytocin to
ascertain the likelihood of a successful vaginal birth. I f there is persistent poor
progress in the active phase despite optimal contractions, 4 to 5 per 10 minutes lasting
more than 40 seconds, and the woman is pain-free, well hydrated and with an empty
bladder, it is unlikely that continuing with an oxytocin infusion will lead to a vaginal
birth.
The decision to augment labour in parous women or in women with prior caesarean
section must be made by an experienced obstetrician because of the very real risk of
hyperstimulation and uterine rupture.
Delay in the second stage of labour
The second stage of labour can be divided into a passive (pelvic) phase and active
(perineal) phase (Chapter 17). D elay in this stage of labour may be due to malposition
causing failure of the vertex to descend and rotate; ineffective contractions due to a
prolonged first stage; large fetus and large vertex; or absence of the desire to push
with epidural analgesia. A ssuming the woman is receiving active support and
encouragement during the second stage, and has trust in those caring for her, some of
these situations may be rectified with a change of position and further
encouragement, or the judicious use of an oxytocin infusion to avoid the need for an
instrumental or operative birth.
Time limits in second stage range from 30 minutes to 2 hours for parous women and
1 to 3 hours for nulliparous women (NICE 2007), but an understanding of the different
phases as the head negotiates the birth canal can avoid the encouragement of
premature bearing down efforts, which only serve to tire and demoralize the mother.
The variation in time limits takes into consideration the impact of epidural analgesia
on the desire to push in the second stage. The active phase when the mother is bearing
down is the most critical time. W hen a diagnosis of delay in the second stage has been
made the case is referred to the obstetrician for review and assessment. The impact on
both mother and fetus if the second stage is allowed to exceed a pre-determined time
limit must be weighed against the risks of any interventions at this critical time in the
childbirth experiences. W here there is any indication that the mother or the fetus is
compromised the birth must be expedited as soon as possible but imposing an
arbitrary time limit is felt by some to be unnecessary if both mother and fetus are
doing well (Neilson et al 2003; Hayman 2004; Gilchrist et al 2010).
Obstructed labour
W hilst obstructed labour is not uncommon in developing countries (N eilson et al
2003), in the UK it is only likely to be seen where a woman has laboured una ended at
home for several hours and then seeks help at a hospital.
O bstructed labour occurs when despite good uterine contractions there is no
advance of the presenting part. Possible causes of obstructed labour include absolute
CPD , deep transverse arrest, malpresentation, lower segment fibroids, fetal
hydrocephaly and multiple pregnancy with conjoined or locked twins. Because of the
high presenting part if the woman goes into labour there may be spontaneous rupture
of the membranes and cord prolapse with related risk to the fetus. I f the condition is
not recognized the mother's uterus will continue to contract to overcome the
obstruction. S he will become progressively more dehydrated, ketotic, pyrexial and
tachycardic. The fetus will develop a bradycardia because of the relentless
contractions. A s the uterus continues to contract and retract the upper segment
becomes progressively thicker, closely enveloping the fetus, and the lower segment
becomes increasingly thinner. I n nulliparous women the contractions may cease for a
period before resuming again with increasing strength and frequency with li le
interval between contractions until the uterus assumes a state of tonic contraction. The
difference between upper and lower segment may be seen as a ridge obliquely
crossing the abdomen (Bandl's ring). The mother is in severe and unrelenting pain. I f
VE is possible the presenting part will be high with excessive moulding (Fig. 19.2). The
uterus is in imminent danger of rupture and emergency measures must be taken if the
situation has been allowed to get this far. Uterine rupture leads to maternal mortality
and the tonic contractions and uterine rupture cause the hypoxia, asphyxia and
subsequent perinatal mortality (Neilson et al 2003).
FIG. 19.2 Obstructed labour. The uterus is moulded around the fetus; the thickened upper
segment is obvious on abdominal palpation.
I f the woman has been discovered in this condition at home a paramedic ambulance
should be called for immediate transfer to hospital. The labour suite should be
informed, which, in turn, should contact the senior obstetrician, anaesthetist,
paediatrician, theatre staff and special care unit. W hilst waiting for the ambulance the
midwife should cannulate, take blood for urgent cross-match and site an intravenous
infusion. The woman's General Practitioner (GP) can be called if close by to provide
additional help and support until the ambulance arrives. O bservations of mother and
fetus, and any actions taken and by whom, are recorded in the maternity notes as soon
as possible. I f obstructed labour is diagnosed on admission to hospital an emergency
caesarean section is performed.
I n the UK obstructed labour is not something that is managed, in that when a
woman is receiving skilled antenatal and intrapartum care it is not something that
should occur. D uring antenatal care the midwife will highlight any predisposing
maternal or fetal factors that might impact on normal progress in labour with
appropriate referral to the obstetrician so that a full and frank discussion can take
place and a decision made with the woman on the safest mode of birth. D uring labour,
skilled observation and assessment of progress, particularly skilled abdominal
examination, will alert the midwife to any malpresentation or failure of the presenting
part to advance despite optimal uterine contractions. VE will confirm suspected
malpresentation, and where the presentation is vertex, reveal increasing caput or
moulding. With a high presenting part in labour cervical dilatation will be extremely
slow and there will be li le if any application to the presenting part. The obstetrician
is informed as soon as possible so that the birth can be expedited. A s for all women,
despite the very real threat to maternal and perinatal wellbeing these procedures
should only be undertaken with maternal consent.
Precipitate labour
Precipitate labour is defined as ‘expulsion of the fetus within 3 hours of
commencement of contractions’ ( N I CE 2008a: 40). I n some women the uterus is over-
efficient and much or all of the first stage is not recognized because contractions are
not painful and the realization of the birth of the head may be the first indication that
labour has actually started. I n women with spontaneous onset of labour the incidence
of precipitate labour is approximately 2%, and women having a precipitate labour are
at risk of placental abruption (NICE 2008a).
O ther problems that may be associated with a precipitate labour include soft tissue
trauma of the maternal genital tract due to sudden stretching and distension as the
baby is born, fetal hypoxia as a result of the frequency and strength of the
contractions, intracranial haemorrhage from the sudden compression and
decompression of the fetal skull as it passes through the birth canal with speed, and
possible injury as the head and body emerge rapidly and fall to the floor. The
unexpected nature of the event means that the place of birth may be inappropriate and
the baby may be further compromised if the importance of maintaining the baby's
temperature is not recognized. The overefficient uterus may relax after the birth of the
baby, resulting in retained placenta and/or PPH. The psychological impact of such a
rapid birth must not be underestimated, and not surprisingly some women will be in a
state of shock after the event.
W hilst precipitate labour will often recur in subsequent pregnancies there is no
evidence to recommend I O L as a preventative measure. However, a woman who has
experienced an una ended precipitate labour and birth may request I O L in order to
ensure an attended birth in a safe environment (NICE 2008a)
Making birth a positive experience
For the woman who has a spontaneous onset of labour at term, has a single fetus in a
cephalic presentation and who has no underlying medical disorders, labour should be
about the normal physiological event. The only intervention it requires on the part of
the midwife is to be there to meet the needs of the woman and to offer continuous
support and encouragement to enable her to feel secure and confident in those caring
for her at this momentous time.
The views of midwives and doctors on childbirth are often considered to be
diametrically opposite, with midwives looking on childbirth as normal until proved
otherwise (RCM 2008) and obstetricians viewing it as normal retrospectively (El-
Hamamay and A rulkumaran 2005) . W hatever the perspective taken, the primary
outcome is the safety of the mother and baby. W hilst a high-risk pregnancy and labour
cannot be made low-risk it can still be a positive birthing experience for the woman
and her partner. Childbearing is a time of major life transition and each woman and
partner deserve to have a positive birth experience whether labour is spontaneous or
induced and the birth is vaginal or by caesarean section. W orking together as a team
cannot but help to contribute to that positive birth experience.
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Jukic A M, Baird D D, Weinberg C R, et al. Length of human pregnancy and
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online 6 August 2013)] .
Although the study appears underpowered in its small sample size, it provides useful
nuggets of information, highlighting that healthy human pregnancy varies
considerably by as much as 37 days for a number of reasons..
Mandruzzato G, Alfirevic Z, Chervenak F, et al. Guidelines for the management
of post-term pregnancy. Journal of Perinatal Medicine. 2010;38(2):111–119.
From an international perspective this is a useful resource that addresses a number of
salient issues relating to prolonged pregnancy. It highlights that there is no
unequivocal evidence that prolonged pregnancy is a major risk per se..
Useful websites
Cochrane Library of Systematic Reviews. http://onlinelibrary.wiley.com.
Health and Social Care Information Centre. www.hscic.gov.uk/.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
Royal College of Midwives. www.rcm.org.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
World Health Organization. www.who.net.
C H AP T E R 2 0
Malpositions of the occiput and
malpresentations
Terri Coates
CHAPTER CONTENTS
Introduction 436
Occipitoposterior positions 436
Causes 436
Antenatal diagnosis 436
Antenatal preparation 437
Intrapartum diagnosis 438
Midwifery care 439
Manual rotation 439
Mechanism of right occipitoposterior position (long rotation) 440
Possible course and outcomes of labour 441
The birth 442
Complications 442
Face presentation 444
Causes 444
Antenatal diagnosis 445
Intrapartum diagnosis 445
Mechanism of a left mentoanterior position 445
Possible course and outcomes of labour 446
Management of labour 447
Complications 448
Brow presentation 448
Causes 449
Diagnosis 449
Management 449
Complications 449
Shoulder presentation 449
Causes 449
Antenatal diagnosis 450
Intrapartum diagnosis 450
Possible outcome 451
Complications 451
Management 451
Unstable lie 451
Causes 451
Management 452
Compound presentation 452
References 452
Further reading 453
Malposition refers to any position other than occipitoanterior (OA) in a fetus
with a vertex presentation. In a normal physiological labour, the fetal head
presents with the occiput in lateral position in early stages of labour with
anterior rotation as labour progresses.
Malpresentations are all presentations of the fetus other than the vertex.
Malpresentations that occur due to extension of the fetal head, causing
brow or face to present, are usually diagnosed during active labour. Prompt
and appropriate referral must be made.
Both malpositions and malpresentations are associated with a difficult
labour and an increased risk of operative intervention. The midwife must
undertake regular clinical examinations to monitor the progress of labour to
ensure fetal and maternal wellbeing. Effective communication and record
keeping is crucial to provide safe care. The woman and her partner must be
kept fully informed and supported throughout. Vaginal birth is possible in
many cases, but intervention or operative birth become necessary when the
malposition or malpresentation persist and labour fails to progress.
This chapter aims to:
• understand the features of the malpresentations and malpositions
• recognize the predisposing factors
• outline possible causes of these positions and presentations
• describe the physical landmarks to aid recognition and diagnosis
• demonstrate sound knowledge of the mechanisms
• consider the outcomes for each position
• explore the midwife's management and the current uncertainties.
Introduction
Malpositions and malpresentations present the midwife with challenges of recognition
and diagnosis both in the antenatal period and during labour. The midwife must
ensure all examinations and discussions with the woman are documented and
appropriate obstetric referral is made where a malpresentation or malposition has
been found. The midwife should take time to discuss this with the women to ensure
they understand what may happen and the activities that may help (Munro and
Jokinen 2012).
The presenting diameters do not fit well onto the cervix and therefore do not
produce optimal stimulation for uterine contractions and labour. Labour with a fetus
in a malposition or a malpresentation can be long, tedious and painful, requiring
empathy, sustained encouragement and support for the woman and her partner. A ll
the usual care in labour is provided, paying particular a ention to comfort and
hydration (see Chapter 16). The woman should be encouraged to take an active part in
decision-making and must be kept informed throughout.
I n labour women should be encouraged to adopt postures and positions they find
comfortable and encouraged to remain mobile. They should be supported to use
coping methods to deal with their particular pa ern of labour (S imkin 2010). The
progress of labour may be slow so midwives should take care to avoid the use of
language that may demoralize the woman and her partner. A ny sign of fetal or
maternal distress or delay in labour must be referred promptly to an obstetrician.
Practices that are considered unhelpful include immobility and labouring on a bed,
the se ing of arbitrary time limits on the various stages of labour and the early use of
epidural analgesia (Munro and Jokinen 2012).
Occipitoposterior positions
O ccipitoposterior (O P) positions are the most common type of malposition of the
occiput and occur in approximately 10–30% of labours, but only around 5% of births
(Pearl et al 1993; Ponkey et al 2003; Munro and Jokinen 2012). W omen can be reassured
that internal rotation to anterior positions can be expected in the majority of cases. A
persistent OP position results from a failure of internal rotation or malrotation prior to
birth (Gardberg et al 1998; Peregrine et al 2007). The vertex is presenting, but the
occiput lies in the posterior rather than the anterior part of the pelvis. A s a
consequence, the fetal head is deflexed and larger diameters of the fetal skull present
(Fig. 20.1).
FIG. 20.1 (A) Right occipitoposterior position. (B) Left occipitoposterior position.
Causes
The direct cause of the occipitoposterior position is often unknown, but it may be
associated with an abnormally shaped pelvis. I n an android pelvis, the forepelvis is
narrow and the occiput tends to occupy the roomier hindpelvis. The oval shape of the
anthropoid pelvis, with its narrow transverse diameter, favours a direct OP position.
Antenatal diagnosis
Abdominal examination
Listen to the woman, as she may complain of backache and report feeling that her
baby's bo om is very high up against her ribs, as well as feeling movements across
both sides of her abdomen.
On inspection
There is a saucer-shaped depression at or just below the umbilicus. This depression is
created by the ‘dip’ between the head and the lower limbs of the fetus. The outline
created by the high, unengaged head can look like a full bladder (Fig. 20.2).
FIG. 20.2 Comparison of abdominal contour in (A) posterior and (B) anterior positions of the
occiput.
On palpation
W hile the breech is easily palpated at the fundus, the back is difficult to palpate as it is
well out to the maternal side, sometimes almost adjacent to the maternal spine. Limbs
can be felt on both sides of the midline. The head is unusually high in an O P position
which is the most common cause of non-engagement in a primigravida at term. This is
because the large presenting diameter, the occipitofrontal (11.5 cm), is unlikely to
enter the pelvic brim until labour begins and flexion occurs. The occiput and sinciput
are on the same level (Figs 20.3 and 20.4). Flexion allows the engagement of the
suboccipitofrontal diameter (10 cm).
FIG. 20.3 Engaging diameter of a deflexed head: occipitofrontal (OF) 11.5 cm.
FIG. 20.4 Flexion with descent of the head.
The cause of the deflexion is a straightening of the fetal spine against the lumbar
curve of the maternal spine. This makes the fetus straighten its neck and adopt a more
erect attitude.
On auscultation
The fetal back is not well flexed so the chest is thrust forward, therefore the fetal heart
can be heard in the midline. However, the fetal heart may be heard more easily at the
flank on the same side as the back.
Antenatal preparation
There is no current evidence that suggests active changes of maternal posture will help
to achieve an optimal fetal position before labour (Hunter et al 2007; Munro and
J okinen 2012). Research has shown that the woman adopting a knee–chest position
several times a day may achieve temporary rotation of the fetus to an anterior position
but has only a short-term effect upon fetal presentation (Kariminia et al 2004; Hunter
et al 2007). There is insufficient evidence to suggest that women should adopt the
hands and knees posture, unless they find it comfortable (S imkin 2010; Munro and
J okinen 2012). Further research is needed to evaluate the effect of adopting a hands
and knees posture on the presenting part during labour (Hunter et al 2007).
For customary antenatal assessment of fetal position Leopold's manoeuvres can be
used during abdominal examination (see Chapter 10). These traditional methods of
examination are only an assessment of the placement of the fetal spine and cannot
estimate the direction of the fetal head. Peregrine et al (2007) used ultrasound scans to
confirm abdominal palpation and found that the fetal head is often aligned differently
within the pelvis than the fetal spine within the uterus. I n other words, the fetus may
have turned its head to the right or left and the head may be anterior within the pelvis
but the fetal back may palpate as lateral.
A review of current techniques used to diagnose fetal position such as Leopold's
manoeuvres, the location of fetal heart sounds, vaginal examinations and presence of
back pain are often unreliable (S imkin 2010). Failure to identify fetal position
accurately can impact on the ability of the midwife to offer appropriate care.
Consequently it is considered that ultrasound is the most reliable way to accurately
detect the fetal position (Munro and J okinen 2012). More research studies are needed
to examine the efficacy of midwifery skills in diagnosing fetal malpositions and non-
technological approaches to improving the birth outcome for the woman and fetus.
Intrapartum diagnosis
The large and irregularly shaped presenting circumference (Fig. 20.5) does not fit well
onto the cervix. This may hinder cervical ripening and predispose to a prolonged latent
phase (A kmal and Paterson-Brown 2009). The contractions may also be in-coordinate.
A high head predisposes to early spontaneous rupture of the membranes at an early
stage of labour, which, together with an ill-fi ing presenting part, may result in cord
prolapse (see Chapter 22).
FIG. 20.5 Presenting dimensions of a deflexed head.
The woman may complain of continuous and severe backache, worsening with
contractions. However, the absence of backache does not necessarily indicate an
anteriorly positioned fetus. D escent of the head can be slow even with good
contractions. The woman may have a strong desire to push early in labour because the
occiput is pressing on the rectum.
Vaginal examination
The findings (Fig. 20.6) will depend upon the degree of flexion of the head. Locating
the anterior fontanelle in the anterior part of the pelvis is diagnostic but this may be
difficult if caput succedaneum is present. The direction of the sagi al suture and
location of the posterior fontanelle will help to confirm the diagnosis. The position of
the fetal head may be checked using ultrasound where reason for the delay in labour
requires accurate diagnosis.
FIG. 20.6 Vaginal touch pictures in a right occipitoposterior position. (A) Anterior fontanelle felt to
left and anteriorly. Sagittal suture in the right oblique diameter of the pelvis. (B) Anterior fontanelle
felt to left and laterally. Sagittal suture in the transverse diameter of the pelvis. (C) Following
increased flexion, the posterior fontanelle is felt to the right and anteriorly. Sagittal suture in the left
oblique diameter of the pelvis. The position is now right occipitoanterior.
Midwifery care
First stage of labour
The woman may experience severe and unremi ing backache, which is tiring and can
be very demoralizing, especially if the progress of labour is slow. Continuous support
from the midwife will help the woman and her partner to cope with the labour (Simkin
2010; Hodne et al 2012) (see Chapter 16). The midwife can help to provide physical
support such as massage and other comfort measures. Mobility should be encouraged
with changes of posture and position and where possible, the use of a bath or birthing
pool and other non-pharmacological measures such as transcutaneous electrical nerve
stimulation (TEN S ) or aromatherapy. There is no evidence that theall-fours position
either during pregnancy or in labour will rotate a malpositioned baby (Kariminia et al
2004; Munro and J okinen 2012) but may help reduce persistent back pain. A n
exaggerated Sims position in labour may offer some relief, and anecdotal evidence
suggests that it may also aid rotation of the fetal head.
The woman may experience a strong urge to push long before the cervix has become
fully dilated. This is because of the pressure of the occiput on the rectum. However, if
the woman pushes at this time, the cervix may become oedematous and this would
further delay the onset of the second stage of labour. The urge to push may be eased
by a change in position and the use of breathing techniques, inhalational analgesia or
other methods to enhance relaxation. The woman's partner and the midwife can assist
throughout labour with massage and physical support. The woman may choose a
range of pain control methods (see Chapter 16) throughout her labour depending on
the level and intensity of pain she is experiencing at that time. The midwife must
ensure that any delay in labour and fetal or maternal distress are promptly recognized
and appropriate referrals made (Nursing and Midwifery Council [NMC] 2012).
Second stage of labour
Full dilatation of the cervix may need to be confirmed by a vaginal examination
because moulding and formation of a caput succedaneum may be in view while an
anterior lip of cervix remains. The second stage of labour is usually characterized by
significant anal dilatation some time before the head is visible. The midwife can
encourage the woman to adopt upright positions that may help to shorten the length
of the second stage and reduce the need for operative assistance (see Chapter 17).
S qua ing may increase the transverse diameter of the pelvic outlet which may
increase the chance of a vaginal birth.
The length of the second stage of labour is usually increased when the occiput is
posterior, and there is an increased likelihood of an operative birth (Pearl et al 1993;
Gimovsky and Hennigan 1995). I n some cases where contractions are weak and
ineffective an oxytocin infusion may be administered to stimulate adequate
contractions and achieve advancement/descent of the presenting part.
Manual rotation
Manual rotation of the head from occipitoposterior (O P) or occipitotransverse (O T)
positions to an anterior position has been shown to reduce the need for assisted birth
and caesarean section by correcting the fetal malposition. This will facilitate the
descent of the fetal head, to encourage a spontaneous vaginal birth (Shaffer et al 2011).
There are two techniques for undertaking manual rotation either by an obstetrician
or an experienced and trained midwife. Both techniques require informed consent
from the woman and adequate analgesia. The woman's bladder must be empty and the
cervix should be fully dilated. Either, constant pressure is exerted with the tips of the
fingers against the lambdoidal suture to rotate the fetal head into the occiput anterior
position, or the whole hand is introduced into the birth canal and fingers and thumb
positioned under the lateral posterior parietal bone and the anterior parietal bone
(Phipps et al 2011): the head is then rotated to the anterior position. Using either
method, the rotation may take two or three contractions to complete and then should
be held for two contractions whilst the woman bears down to reduce the risk of the
rotation reverting (Phipps et al 2011; S haffer et al 2011). I f a midwife is practising in a
se ing where operative birth is not readily available, such as in a birthing centre, this
intervention may reduce maternal and neonatal morbidity and mortality (S haffer et al
2011).
Malpositions and malpresentations are generally associated with a higher incidence
of interventions in labour, complications and instrumental birth (Cheng et al 2006).
I mmediate and subsequent postnatal care of the woman and her baby following an
instrumental birth are discussed in Chapter 21 and Chapter 31.
Mechanism of right occipitoposterior position (long
rotation) (Figs 20.7–20.10)
• The lie is longitudinal.
• The attitude of the head is deflexed.
• The presentation is vertex.
• The position is right occipitoposterior.
• The denominator is the occiput.
• The presenting part is the middle or anterior area of the left parietal bone.
• The occipitofrontal diameter, 11.5 cm, lies in the right oblique diameter of the pelvic
brim. The occiput points to the right sacroiliac joint and the sinciput to the left
iliopectineal eminence.
FIG. 20.7 Head descending with increased flexion. Sagittal suture in right oblique
diameter of the pelvis.
FIG. 20.8 Occiput and shoulders have rotated of a circle forwards. Sagittal
suture in transverse diameter of the pelvis.
FIG. 20.9 Occiput and shoulders have rotated of a circle forwards. Sagittal
suture in the left oblique diameter of the pelvis. The position is right occipitoanterior.
FIG. 20.10 Occiput has rotated of a circle forwards. Note the twist in the neck.
Sagittal suture in the anteroposterior diameter of the pelvis.
FIGS 20.7–20.10 Mechanism of labour in right occipitoposterior position.
Flexion
Descent takes place with increasing flexion. The occiput becomes the leading part.
Internal rotation of the head
The occiput reaches the pelvic floor first and rotates forwards of a circle along the
right side of the pelvis to lie under the symphysis pubis. The shoulders follow, turning
of a circle from the left to the right oblique diameter.
Crowning
The occiput escapes under the symphysis pubis and the head is crowned.
Extension
The sinciput, face and chin sweep the perineum and the head is born by a movement
of extension.
Restitution
The occiput turns of a circle to the right and the head realigns itself with the
shoulders.
Internal rotation of the shoulders
The shoulders enter the pelvis in the right oblique diameter; the anterior shoulder
reaches the pelvic floor first and rotates forwards of a circle to lie under the
symphysis pubis.
External rotation of the head
At the same time the occiput turns a further of a circle to the right.
Lateral flexion
The anterior shoulder escapes under the symphysis pubis, the posterior shoulder
sweeps the perineum and the body is born by a movement of lateral flexion.
Possible course and outcomes of labour
Long internal rotation
This is the commonest outcome. With good uterine contractions producing flexion and
descent of the head, the occiput will rotate forward of a circle as described above.
Short internal rotation
The term persistent occipitoposterior position (Figs 20.11 and 20.12) indicates that the
occiput fails to rotate forwards. I nstead, the sinciput reaches the pelvic floor first and
rotates forwards. A s a result, the occiput goes into the hollow of the sacrum. The baby
is born facing the pubic bone (face to pubis).
FIG. 20.11 Persistent occipitoposterior position before rotation of the occiput: position is right
occipitoposterior.
FIG. 20.12 Persistent occipitoposterior position after short rotation: position direct
occipitoposterior.
Cause
Failure of flexion: the head descends without increased flexion and the sinciput
becomes the leading part. I t reaches the pelvic floor first and rotates forwards to lie
under the symphysis pubis.
Diagnosis
I n the first stage of labour: signs are those of any posterior position of the occiput,
namely a deflexed head and a fetal heart heard in the flank or in the midline. D escent
is slow.
I n the second stage of labour: delay is common. O n vaginal examination the anterior
fontanelle is felt behind the symphysis pubis, but a large caput succedaneum may
mask this. I f the pinna of the ear is felt pointing towards the woman's sacrum, this
indicates a posterior position.
The long occipitofrontal diameter causes considerable dilatation of the anus and
gaping of the vagina while the fetal head is barely visible, and the broad biparietal
diameter distends the perineum and may cause excessive bulging. A s the head
advances, the anterior fontanelle can be felt just behind the symphysis pubis.
Consequently the fetus is born facing the pubis. Characteristic upward moulding is
present with the caput succedaneum on the anterior part of the parietal bone (Fig.
20.13).
FIG. 20.13 Upward moulding (dotted line) following persistent occipitoposterior position. OF,
occipitofrontal.
The birth (Figs 20.14–20.17)
The sinciput will first emerge from under the symphysis pubis as far as the root of the
nose and the midwife maintains flexion by restraining it from escaping further than
the glabella, allowing the occiput to sweep the perineum and be born. S he then
extends the head by grasping it and bringing the face down from under the symphysis
pubis. Perineal trauma is common and the midwife should watch for signs of rupture
in the centre of the perineum (button-hole tear). A n episiotomy may be required, owing
to the larger presenting diameters.
FIG. 20.14 Allowing the sinciput to escape as far as the glabella.
FIG. 20.15 The occiput sweeps the perineum, sinciput held back to maintain
flexion.
FIG. 20.16 Grasping the head to bring the face down from under the symphysis
pubis.
FIG. 20.17 Extension of the head.
FIGS 20.14–20.17 Birth of head in a persistent occipitoposterior position.
Undiagnosed face to pubis
I f the signs are not recognized at an earlier stage, the midwife may first be aware that
the occiput is posterior when the hairless forehead is seen escaping beneath the pubic
arch. A ny accidental extension of the fetal head should be corrected by flexion towards
the symphysis pubis.
Deep transverse arrest
The head descends with some increase in flexion. The occiput reaches the pelvic floor
and begins to rotate forwards. Flexion is not maintained and the occipito-frontal
diameter becomes caught at the narrow bi-spinous diameter of the outlet. A rrest may
be due to weak contractions, a straight sacrum or a narrowed pelvic outlet.
The sagi al suture is found in the transverse diameter of the pelvis and both
fontanelles are palpable. N either sinciput nor occiput leads. The head is deep in the
pelvic cavity at the level of the ischial spines although the caput may be lower still.
There is no advance and obstetric assistance will be required. Manual rotation may be
attempted first, and then vaginal birth may follow with the woman's effort.
Management
The woman must be kept informed of progress and participate in decisions. Pushing
at this time may not resolve the problem but the midwife and the woman's partner can
help by encouraging ‘sigh out slowly’ (S O S ) breathing. A change of position may help
to overcome the urge to bear down (see Chapter 17).
W here assistance is needed for a safe birth the woman's informed consent is
required. The procedure would be undertaken under local, regional or more rarely
general anaesthesia (see Chapter 21) considering the choice of the woman, her
condition and that of her unborn baby. The baby's head will be brought into an
anterior position and the birth completed using forceps or vacuum extraction (see
Chapter 21).
Conversion to face or brow presentation
W hen the head is deflexed at the onset of labour, extension occasionally occurs instead
of flexion. I f extension is complete then a face presentation results, but if incomplete,
the head is arrested at the brim with the brow presenting. This is a rare complication
of posterior positions, and is more commonly found in multigravidae.
Complications
A part from prolonged labour with its a endant risks to the woman and fetus and the
increased likelihood of instrumental birth, there are a number of complications that
may occur which the midwife should consider.
Obstructed labour
This may occur when the head is deflexed or partially extended and becomes impacted
in the pelvis (see Chapter 19).
Maternal trauma
A forceps birth will result in perineal bruising and trauma. Birth of a baby in the
persistent occipitoposterior position, particularly if previously undiagnosed, may
cause a third or fourth degree tear (Melamed et al 2013).
Neonatal trauma
The unfavourable upward moulding of the fetal skull, found in an occipitoposterior
position, can cause intracranial haemorrhage, as a result of the falx cerebri being
pulled away from the tentorium cerebelli. The larger presenting diameters also
predispose to a greater degree of compression. Cerebral haemorrhage (see Chapter 31)
may also result from chronic hypoxia, which may accompany prolonged labour.
N eonatal trauma occurring following birth from an occipitoposterior position has
also been associated with forceps or ventouse births.
Face presentation
W hen the a itude of the head is one of complete extension, the occiput of the fetus
will be in contact with its spine and the face will present. The incidence is about ≤1 :
500 (Bhal et al 1998; A kmal and Paterson-Brown 2009) and the majority develop during
labour from vertex presentations with the occiput posterior; this is termed secondary
face presentation. Less commonly, the face presents before labour; this is termed
primary face presentation. There are six positions in a face presentation; the
denominator is the mentum and the presenting diameters are the submentobregmatic
(9.5 cm) and the bitemporal (8.2 cm) (Figs 20.18–20.23).
FIG. 20.18 Right mentoposterior.
FIG. 20.19 Left mentoposterior.
FIG. 20.20 Right mentolateral.
FIG. 20.21 Left mentolateral.
FIG. 20.22 Right mentoanterior.
FIG. 20.23 Left mentoanterior.
FIGS 20.18–20.23 Six positions of face presentation.
Causes
Anterior obliquity of the uterus
The uterus of a multigravida with slack abdominal muscles and a pendulous abdomen
will lean forward and alter the direction of the uterine axis. This causes the fetal
bu ocks to lean forwards and the force of the contractions to be directed in a line
towards the chin rather than the occiput, resulting in extension of the head.
Contracted pelvis
I n the flat pelvis, the head enters in the transverse diameter of the brim and the
parietal eminences may be held up in the obstetrical conjugate causing the head to
become extended such that a face presentation develops. A lternatively, if the head is
in the posterior position with the vertex presenting, and remains deflexed, the parietal
eminences may be caught in the sacrocotyloid dimension of the maternal pelvis so
that the occiput cannot descend, and the head becomes extended resulting in a face
presentation. This is more likely in the presence of an android pelvis, in which the
sacrocotyloid dimension is reduced.
Hydramnios (polyhydramnios)
I f the vertex is presenting and the membranes rupture spontaneously, the resulting
rush of an excess of amniotic fluid may cause the head to extend as it sinks into the
lower uterine segment.
Congenital malformation
A nencephaly can be a fetal cause of a face presentation. I n a cephalic presentation,
because the vertex is absent the face is thrust forward and presents. More rarely, a
tumour of the fetal neck may cause extension of the head.
Antenatal diagnosis
A ntenatal diagnosis is rare since face presentation develops during labour in the
majority of cases. A cephalic presentation in a known anencephalic fetus may be
presumed to be a face presentation.
Intrapartum diagnosis
Abdominal palpation
Face presentation may not be detected, especially if the mentum is anterior. The
occiput feels prominent, with a groove between the head and back, but it may be
mistaken for the sinciput. The limbs may be palpated on the side opposite to the
occiput and the fetal heart is best heard through the fetal chest on the same side as the
limbs. I n a mentoposterior position the fetal heart is difficult to hear because the fetal
chest is in contact with the maternal spine (Fig. 20.24).
FIG. 20.24 Abdominal palpation of the head in a face presentation. Position right mentoposterior.
Vaginal examination
The presenting part is high, soft and irregular. W hen the cervix is sufficiently dilated,
the orbital ridges, eyes, nose and mouth may be felt. However, confusion between the
mouth and anus could arise. The mouth may be open, and the hard gums are
diagnostic with the possibility of the fetus sucking the examining finger. A s labour
progresses the face becomes oedematous, making it more difficult to distinguish from
a breech presentation. To determine the position the mentum must be located. I f it is
posterior, the midwife should decide whether it is lower than the sinciput, and if it can
advance, it will rotate forwards. I n a left mentoanterior position, the orbital ridges will
be in the left oblique diameter of the pelvis (Fig. 20.25). Care must be taken not to
injure or infect the eyes with the examining finger.
FIG. 20.25 Vaginal touch pictures of left mentoanterior position. (A) The mentum is felt to left
and anteriorly. Orbital ridges in left oblique diameter of the pelvis. (B) Following increased
extension of the head, the mouth can be felt. (C) The face has rotated of a circle forwards.
Orbital ridges in transverse diameter of the pelvis. Position direct mentoanterior.
Mechanism of a left mentoanterior position
• The lie is longitudinal.
• The attitude is one of extension of the fetal head and neck.
• The presentation is the face (Fig. 20.26).
FIG. 20.26 Diameters involved in the birth of a face presentation. Engaging diameter,
submentobregmatic (SMB) 9.5 cm. The submentovertical (SMV) diameter, 11.5 cm, sweeps the
perineum.
• The position is left mentoanterior.
• The denominator is the mentum.
• The presenting part is the left malar bone.
Extension
Descent takes place with increasing extension. The mentum becomes the leading part.
Internal rotation of the head
This occurs when the chin reaches the pelvic floor and rotates forwards of a circle.
The chin escapes under the symphysis pubis (Fig. 20.27A).
FIG. 20.27 Birth of head in mentoanterior position. (A) The chin escapes under symphysis
pubis. Submentobregmatic diameter at outlet. (B) The head is born by a movement of flexion.
Flexion
This takes place and the sinciput, vertex and occiput sweep the perineum; the head is
born (Fig. 20.27B).
Restitution
This occurs when the chin turns of a circle to the woman's left side.
Internal rotation of the shoulders
The shoulders enter the pelvis in the left oblique diameter of the maternal pelvis and
the anterior shoulder reaches the pelvic floor first, rotating forwards of a circle along
the right side of the pelvis.
External rotation of the head
This occurs simultaneously. The chin moves a further of a circle to the left.
Lateral flexion
The anterior shoulder escapes under the symphysis pubis, the posterior shoulder
sweeps the perineum and the baby's body is born by a movement of lateral flexion.
Possible course and outcomes of labour
Prolonged labour
Labour is often prolonged because the face is an ill-fi ing presenting part and does
not therefore stimulate effective uterine contractions. The woman should be kept
informed of her progress and any proposed intervention throughout labour.
I n addition, the facial bones do not mould and, in order to enable the mentum to
reach the pelvic floor and rotate forwards, the shoulders must enter the pelvic cavity at
the same time as the head. The fetal axis pressure is directed to the chin and the head
is extended almost at right-angles to the spine, increasing the diameters to be
accommodated in the pelvis.
Mentoanterior positions
With good uterine contractions, descent and rotation of the head occur (Fig. 20.27) and
labour progresses to a spontaneous birth as described below.
Mentoposterior positions
I f the head is completely extended, so that the mentum reaches the pelvic floor first,
and the contractions are effective, the mentum will rotate forwards and the position
becomes anterior.
Persistent mentoposterior position
I n this case, the head is incompletely extended and the sinciput reaches the pelvic
floor first and rotates forwards of a circle, which brings the chin into the hollow of
the sacrum (Fig. 20.28). There is no further mechanism. The face becomes impacted
because, in order to descend further, both head and chest would have to be
accommodated in the pelvis. W hatever emerges anteriorly from the vagina must pivot
around the subpubic arch. W hen the chin is posterior this is impossible because the
head can extend no further.
FIG. 20.28 Persistent mentoposterior position.
Reversal of face presentation
A face presentation in a persistent mentoposterior position may, in some cases, be
manipulated to an occipitoanterior position using bimanual pressure (N euman et al
1994; Gimovsky and Hennigan 1995). This method was developed to reduce the
likelihood of an operative birth for those women who refused caesarean section. Using
a tocolytic drug, such as terbutaline, to relax the uterus, the fetal head is disengaged
using upward transvaginal pressure. The fetal head is then flexed with bimanual
pressure under ultrasound guidance to achieve an occipitoanterior position.
Management of labour
First stage of labour
Upon diagnosis of a face presentation, the midwife should inform the doctor of this
deviation from the normal. Routine observations of maternal and fetal conditions are
made as in a normal physiological labour (see Chapter 16). A fetal scalp electrode
must not be applied, and care should be taken not to infect or injure the eyes during
vaginal examinations.
I mmediately following rupture of the membranes, a vaginal examination should be
performed to exclude cord prolapse which is more likely because the face is an ill-
fi ing presenting part. D escent of the fetal head should be assessed abdominally, and
careful vaginal examination performed every 2–4 hours to determine cervical dilatation
and descent of the head.
I n mentoposterior positions the midwife should note whether the mentum is lower
than the sinciput, since rotation and descent depend on this. I f the head remains high
in spite of good contractions, caesarean section is likely. The woman may be
prescribed oral ranitidine, 150 mg every 6 hours throughout labour if it is considered
that an anaesthetic may be necessary.
Birth of the head (Fig. 20.29)
W hen the face appears at the vulva, extension must be maintained by holding back the
sinciput and permi ing the mentum to escape under the symphysis pubis before the
occiput is allowed to sweep the perineum. I n this way, the submentovertical diameter
(11.5 cm) instead of the mentovertical diameter (13.5 cm) distends the vaginal orifice.
Because the perineum is also distended by the biparietal diameter (9.5 cm), an elective
episiotomy may be performed to avoid extensive perineal lacerations.
FIG. 20.29 Birth of face presentation. (A) The sinciput is held back to increase extension until
the chin is born. (B) The chin is born. (C) Flexing the head to bring the occiput over the perineum.
(D) Flexion is completed; the head is born.
I f the head does not descend in the second stage of labour, the doctor should be
informed. I n a mentoanterior position it may be possible for the obstetrician to assist
the baby's birth with forceps when rotation is incomplete. I f the position remains
mentoposterior, the head has become impacted, or there is any suspicion of
disproportion, a caesarean section will be necessary.
Complications
Obstructed labour
Because the face, unlike the vertex, does not mould, a minor degree of pelvic
contraction may result in obstructed labour (see Chapter 19). I n a persistent
mentoposterior position the face becomes impacted and caesarean section is
necessary.
Cord prolapse
A prolapsed cord is more common when the membranes rupture because the face is
an ill-fi ing presenting part. The midwife should always perform a vaginal
examination when the membranes rupture to rule out cord prolapse (see Chapter 22).
Facial bruising
The baby's face is always bruised and swollen at birth, with oedematous eyelids and
lips. The head is elongated (Fig. 20.30) and the baby will initially lie with the head
extended. The midwife should warn the parents in advance of the baby's battered
appearance, reassuring them that this is only temporary as the oedema will disappear
within 1 or 2 days, with the bruising usually resolving within a week. Trauma during
labour may cause tracheal and laryngeal oedema immediately after the birth, which
can result in neonatal respiratory distress. I n addition, fetal anomalies or tumours,
such as fetal goiters that may have contributed to fetal malpresentation, may make
intubation difficult. A s a result, a clinician with expertise in neonatal resuscitation
should be present at the birth.
FIG. 20.30 Moulding in a face presentation (dotted line). SMB, submentobregmatic; SMV,
submentovertical.
Cerebral haemorrhage
The lack of moulding of the facial bones can lead to intracranial haemorrhage caused
by excessive compression of the fetal skull or by rearward compression, in the typical
moulding of the fetal skull found in this presentation (Fig. 20.30).
Maternal trauma
Extensive perineal lacerations may occur at birth owing to the large submentovertical
and biparietal diameters distending the vagina and perineum. There is an increased
incidence of operative birth by either forceps or by caesarean section, both of which
increase maternal morbidity.
Brow presentation
I n the brow presentation the fetal head is partially extended with the frontal bone,
which is bounded by the anterior fontanelle and the orbital ridges, lying at the pelvic
brim (Fig. 20.31). The presenting diameter of 13.5 cm is the mentovertical (Fig. 20.32),
which exceeds all diameters in an average-sized gynaecoid pelvis. This presentation is
rare, with an incidence of approximately 1 in 1000 births (Bhal et al 1998).
FIG. 20.31 Brow presentation.
FIG. 20.32 Brow presentation. The mentovertical (MV) diameter, 13.5 cm, lies at the pelvic brim.
Causes
These are the same as for a secondary face presentation (see above); during the
process of extension from a vertex presentation to a face presentation, the brow will
present temporarily and in a few cases this will persist.
Diagnosis
Brow presentation is not usually detected before the onset of labour.
Abdominal palpation
The head is high, appears unduly large and does not descend into the pelvis despite
good uterine contractions.
Vaginal examination
The presenting part is high and may be difficult to reach. The anterior fontanelle may
be felt on one side of the maternal pelvis and the orbital ridges, and possibly the root
of the nose, at the other (Fig. 20.33). A large caput succedaneum may mask these
landmarks if the woman has been in labour for some hours.
FIG. 20.33 Moulding in a brow presentation (dotted line). MV, mentovertical.
Management
The doctor must be informed immediately this presentation is suspected. This is because
vaginal birth is extremely rare and obstructed labour usually results. I t is possible that
a woman with a large pelvis and a small baby may give birth vaginally. W hen the brow
reaches the pelvic floor the maxilla rotates forwards and the head is born by a
mechanism somewhat similar to that of a persistent occipitoposterior position.
However, the midwife should never expect such a favourable outcome. The woman
should be warned about the possible course of labour and that a vaginal birth is
unlikely.
I f there is no evidence of fetal compromise, the doctor may allow labour to continue
for a short while in case further extension of the head converts the brow presentation
to a face presentation. O ccasionally spontaneous flexion may occur, resulting in a
vertex presentation. I f the head fails to descend and the brow presentation persists, a
caesarean section is performed, with the woman's consent.
Complications
These are the same as in a face presentation, except that obstructed labour requiring
caesarean section is the probable rather than a possible outcome.
Shoulder presentation
W hen the fetus lies with its long axis across the long axis of the uterus (transverse lie)
the shoulder is most likely to present. O ccasionally the lie is oblique but this does not
persist as the uterine contractions during labour make it longitudinal or transverse.
S houlder presentation occurs in approximately 1 : 300 pregnancies near term. O nly
17% of these cases remain as a transverse lie at the onset of labour of which the
majority are multigravidae (Gimovsky and Hennigan 1995; A kmal and Paterson-Brown
2009). The head lies on one side of the abdomen, with the breech at a slightly higher
level on the other. The fetal back may be anterior or posterior (Figs 20.34 and 20.35).
FIG. 20.34 Shoulder presentation, dorsoanterior.
FIG. 20.35 Shoulder presentation, dorsoposterior.
Causes
Maternal
Before term, transverse or oblique lie may be transitory, related to the woman's
position or displacement of the presenting part by an overextended bladder prior to
ultrasound examination. Other causes are described below.
Lax abdominal and uterine muscles
This is the most common cause and is found in multigravidae, particularly those of
high parity.
Uterine malformation
A bicornuate or subseptate uterus may result in a transverse lie, as, more rarely, may a
cervical or low uterine fibroid.
Contracted pelvis
Rarely, this may prevent the head from entering the pelvic brim.
Fetal
Pre-term pregnancy
The amount of amniotic fluid in relation to the fetus is greater, allowing the fetus
more mobility than at term.
Multiple pregnancy
There is a possibility of hydramnios but the presence of more than one fetus reduces
the room for manoeuvre when amounts of amniotic fluid are normal. I t is the second
twin that more commonly adopts a transverse lie after the birth of the first baby.
Hydramnios
The distended uterus is globular in shape and the fetus can move freely in the
excessive amniotic fluid volume.
Macerated fetus
Lack of muscle tone causes the fetus to slump down into the lower pole of the uterus.
Placenta praevia
This may prevent the fetal head from entering the pelvic brim.
Antenatal diagnosis
Abdominal palpation
The uterus appears broad and the fundal height is less than expected for the period of
gestation. O n pelvic and fundal palpation, neither head nor breech is felt. The mobile
head is found on one side of the abdomen and the breech at a slightly higher level on
the other.
Antenatal management
A cause for the shoulder presentation must be sought before deciding on a course of
management and requires a medical referral. Ultrasound examination can detect
placenta praevia or uterine malformations, while X-ray pelvimetry will demonstrate a
contracted pelvis (see Chapter 3). A ny of these causes requires elective caesarean
section. O nce such causes have been excluded, external cephalic version (ECV) may be
a empted. I f this fails, or if the lie is transverse again at the next antenatal visit, the
woman is admi ed to hospital while further investigations into the cause are made.
The woman frequently remains in hospital until labour commences because of the risk
of cord prolapse if the membranes rupture.
Intrapartum diagnosis
The findings are as above but when the membranes have ruptured the irregular
outline of the uterus is more marked. I f the uterus is contracting strongly and
becomes moulded around the fetus, palpation is very difficult. The pelvis is no longer
empty as the shoulder is wedged into the brim.
Vaginal examination
I n early labour the presenting part may not be felt. The membranes usually rupture
early because of the ill-fitting presenting part, with a high risk of cord prolapse.
I f the labour has been in progress for some time the shoulder may be felt as a soft
irregular mass. I t is sometimes possible to palpate the ribs, with their characteristic
grid-iron pa ern being diagnostic (Fig. 20.36). W hen the shoulder enters the pelvic
brim an arm may prolapse, which should be differentiated from a leg, i.e. the hand is
not at right-angles to the arm, the fingers are longer than the toes and of unequal
length, and the thumb can be opposed. N o os calcis can be felt and the palm is shorter
than the sole. If the arm is flexed, an elbow feels sharper than a knee.
FIG. 20.36 Vaginal touch picture of shoulder presentation.
Possible outcome
W henever the midwife detects a transverse lie she must obtain medical assistance.
There is no mechanism for the birth of a shoulder presentation.
If a transverse lie is detected in early labour while the membranes are still intact, the
doctor may a empt an ECV. I f this is successful, the doctor may then undertake a
controlled rupture of the membranes. (This may be considered before labour in some
cases [Hu on and Hofmeyr 2006]). I f the membranes have already ruptured
spontaneously, a vaginal examination must be performed immediately to detect
possible cord prolapse.
I f a shoulder presentation persists in labour, the birth of the baby must be by
caesarean section to avoid obstructed labour and subsequent uterine rupture (see
Chapter 22).
Immediate caesarean section must be performed:
• when ECV is unsuccessful
• when the membranes are already ruptured
• if the cord prolapses
• when labour has already been in progress for some hours.
Complications
Prolapsed cord
This may occur when the membranes rupture (see Chapter 22).
Prolapsed arm
This may occur when the membranes have ruptured and the shoulder has become
impacted. Birth should be by immediate caesarean section.
Neglected shoulder presentation
With adequate supervision both antenatally and during labour, this should never
occur.
The fetal shoulder becomes impacted, having been forced down and wedged into
the maternal pelvic brim. The membranes have ruptured spontaneously and if the arm
has prolapsed it becomes blue and oedematous. The uterus goes into a state of tonic
contraction, the overstretched lower segment is tender to touch and the fetal heartbeat
may be absent. A ll the maternal signs of obstructed labour are present (see Chapter
19) and the outcome, if not treated in time, is a ruptured uterus and a stillbirth.
Management
A n immediate caesarean section is performed regardless of whether the fetus is alive
or dead, as a empts at manipulative procedures or destructive operations can be
dangerous for the woman and may result in uterine rupture.
Unstable lie
The lie is defined as unstable when after 36 weeks' gestation, instead of remaining
longitudinal, it varies from one examination to another between longitudinal and
oblique or transverse.
Causes
A ny condition in late pregnancy that increases the mobility of the fetus or prevents
the fetal head from entering the pelvic brim may cause this.
Maternal
These include:
• lax uterine muscles in multigravidae
• contracted pelvis.
Fetal
These include:
• hydramnios
• placenta praevia.
Management
Antenatal
I t may be advisable for the woman to be admi ed to hospital to avoid unsupervised
onset of labour with a transverse lie. A lternatively, the woman may admit herself to
the hospital maternity unit as soon as labour commences. The risk associated with the
possibility of rupture of membranes and cord prolapse should be emphasized if the
woman chooses to remain at home.
Ultrasonography is used to exclude placenta praevia. A empts will be made to
correct the abnormal presentation by ECV. I f unsuccessful, caesarean section is
considered.
Intrapartum
O bstetricians may recommend induction of labour after 38 weeks' gestation, when the
lie is unstable. Having first ensured that the lie is longitudinal, a controlled rupture of
the membranes is performed so that the fetal head enters the pelvis and an
intravenous infusion of oxytocin is commenced to stimulate contractions.
The midwife should ensure that the woman has an empty rectum and bladder
before the procedure, as a loaded rectum or full bladder can prevent the presenting
part from entering the pelvis. The abdomen should be palpated at frequent intervals
to ensure that the lie remains longitudinal and to assess the descent of the fetal head.
Labour is regarded as a trial.
I f labour commences with the lie other than longitudinal, the complications are the
same as for a transverse lie.
Compound presentation
W hen a hand, or occasionally a foot, lies alongside the head, the presentation is said to
b e compound. This tends to occur with a small fetus or roomy maternal pelvis and
seldom is difficulty encountered except in cases where it is associated with a flat
pelvis. O n rare occasions the head, hand and foot are felt in the vagina – a serious
situation that may occur with a dead fetus.
I f a compound presentation is diagnosed during the first stage of labour, medical
aid must be sought. I f diagnosis occurs during the second stage of labour and the
midwife sees a hand presenting alongside the vertex, she should try to hold the hand
back.
References
Akmal S, Paterson-Brown S. Malpositions and malpresentations of the foetal
head. Obstetrics and Gynecology and Reproductive Medicine. 2009;199:240–246.
Bhal PS, Davies NJ, Chung T. A population study of face and brow presentation.
Journal of Obstetrics and Gynecology. 1998;18(3):231–235.
Cheng YW, Shaffer BL, Caughy AB. The association between persistent occiput
posterior and neonatal outcomes. Obstetrics and Gynecology. 2006;107(4):837–
844.
Gardberg M, Laakkonen E, Salevaara M. Intra-partum sonography and persistent
occiput posterior position: a study of 408 deliveries. Obstetrics and Gynecology.
1998;91(5):1746–1749.
Gimovsky M, Hennigan C. Abnormal fetal presentations. Current Opinion in
Obstetrics and Gynecology. 1995;7(6):482–485.
Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews. 2012.
Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or
labour for fetal malposition (lateral or posterior). Cochrane Database of
Systematic Reviews. 2007.
Hutton EK, Hofmeyr GJ. External cephalic version for breech presentation before
term. Cochrane Database of Systematic Reviews. 2006.
Kariminia A, Chamberlain ME, Keogh J. Randomised controlled trial of effect of
hands and knees posturing on incidence of occiput posterior position at birth.
British Medical Journal. 2004;328(7438):490–493.
Melamed N, Gavish O, Eisner M. Third- and fourth-degree perineal tears –
incidence and risk factors. Journal of Maternal–Fetal and Neonatal Medicine.
2013;26(7):660–664.
Munro J, Jokinen M. RCM evidence-based guidelines for midwifery-led care in labour.
Persistent lateral and posterior fetal positions at the onset of labour. Royal College
of Midwives Trust: London; 2012.
Neuman M, Beller U, Lavie O. Intrapartum bimanual tocolytic-assisted reversal
of face presentation: preliminary report. Obstetrics and Gynecology.
1994;84(10):146–148.
NMC (Nursing and Midwifery Council). Midwives Rules and Standards. NMC:
London; 2012.
Pearl ML, Roberts JM, Laros RK, et al. Vaginal delivery from the persistent
occiput posterior position. Influence on maternal and neonatal morbidity.
Journal of Reproductive Medicine. 1993;38(12):955–961.
Peregrine E, O’Brian P, Jauniaux E. Impact on delivery outcome of
ultrasonographic fetal head position prior to induction of labor. Obstetrics and
Gynecology. 2007;109(3):618–625.
Phipps H, de Vries B, Hyett J, et al. Prophylactic manual rotation for fetal
malposition to reduce operative delivery (Protocol). Cochrane Database of
Systematic Reviews. 2011.
Ponkey SE, Cohen AP, Heffner LJ, et al. Persistent fetal occiput posterior
position: obstetric outcomes. Obstetrics and Gynecology. 2003;101(9):15–20.
Shaffer BL, Cheng YW, Vargas JE, et al. Manual rotation to reduce caesarean
delivery in occiput posterior or transverse position. Journal of Maternal–Fetal
and Neonatal Medicine. 2011;24(1):65–72.
Simkin P. The fetal occiput position: state of the science and a new perspective.
Birth. 2010;37(1):61–71.
Further reading
Chapman K. Aetiology and management of the secondary brow. Journal of
Obstetrics and Gynaecology. 2000;20(1):39–44.
Six cases of vaginal birth from a brow presentation over a career of 39 years are recorded
in this article. Most midwives will never see a brow presentation birth vaginally; this
is a fascinating record from a long career..
Gardberg M, Tuppurainen M. Anterior placental location predisposes for occiput
posterior presentation near term. Acta Obstetrica et Gynecologica Scandinavica.
1994;73(2):151–152.
In a series of 325 ultrasound examinations the authors demonstrated an association
between an anteriorly situated placenta and OP position after 36 weeks of pregnancy..
Reichman O, Gdansky E, Latinsky B, et al. Digital rotation from occipito-
posterior to occipito-anterior decreases the need for caesarean section.
European Journal of Obstetrics and Gynecology and Reproductive Biology.
2008;136:25–28.
The results of a prospective study suggest that digital rotation should be considered
when managing the labour with a fetus in the OP position. The manoeuvre has been
shown to have a high success rate, in experienced hands, reducing the need for vacuum
extraction and caesarean section and so shortens the duration of hospital stay. The
intervention has the potential to reduce maternal and neonatal morbidity and
mortality..
Shaffer BI, Cheng YW, Vargas JE, et al. Manual rotation to reduce caesarean
delivery in persistent occiput posterior or transverse position. Journal of
Maternal Fetal and Neonatal Medicine. 2011;24(1):65–72.
Compared to expectant management manual rotation of the fetal head from OT or OP
positions was associated with a reduction of caesarean sections and adverse maternal
outcomes and no adverse neonatal outcomes. If a midwife is practising in a setting
where operative birth is not readily available, this intervention may reduce maternal
and neonatal morbidity and mortality..
C H AP T E R 2 1
Operative births
Richard Hayman
CHAPTER CONTENTS
Assisting a vaginal birth 456
Indications for ventouse or forceps 456
Fetal 456
Maternal 456
Contraindications to an instrumental vaginal birth 457
Absolute 457
Relative contraindications (for forceps or ventouse) 457
Prerequisites for any operative vaginal birth 457
Birth by ventouse 457
Types of ventouse 457
The use of the ventouse 458
Procedure 458
Precautions in use 459
The midwife ventouse practitioner 460
Birth by forceps 460
Characteristics of the obstetric forceps 460
Classification of obstetric forceps 460
Types of obstetric forceps 460
Procedure 460
Complications of instrumental vaginal birth 462
Caesarean section 463
Clarifying the indications for caesarean section 463
The operative procedure 464
Women's request for caesarean section 465
Psychological support and the role of the midwife 465
Vaginal birth after caesarean section (VBAC) 466
Postoperative care 466
Analgesia/anaesthesia 468
Research and the incidence of caesarean section: tackling high and rising
caesarean section rates 471
References 472
Further reading 473
Useful websites 473
This chapter describes the methods of operative birth that may be used
when the mother is unable to give birth without medical or surgical
assistance. The role of the midwife in these procedures will be explored, as
will the principles of ‘keeping the normal, normal’.
The chapter aims to:
• identify the areas of midwifery care that relate to the preparation for an assisted
vaginal birth (ventouse/forceps) or birth by caesarean section (CS)
• describe the role of the midwife in relation to the issues of informed consent and the
management of complications following assisted birth
• consider the various techniques used for assisted vaginal birth (ventouse/forceps) and
birth by CS, plus the skills required by the midwife to improve the experience for both
the mother and her partner
• discuss the changing role of the midwife in relation to medical intervention.
Assisting a vaginal birth
A ssisted vaginal birth is a frequently and widely practised intervention in the
provision of care to women during childbirth. I n England during 2011–12, of the 668
936 births recorded, 85 009 (13%) were assisted with forceps or ventouse (Health and
S ocial Care I nformation Centre, Hospital Episodes S tatistics 2012 ). However, the
incidence of instrumental intervention varies widely both between and within
countries, and may be performed as infrequently as 1.5% or as often as 26%. S uch
differences may be linked to the alternative management strategies employed during
labour in different units (Bragg et al 2010). Various techniques have been championed
to help lower the rates of operative births. These are summarized in Box 21.1.
Box 21.1
U se ful t e chnique s t o he lp lowe r t he ope ra t ive birt h
ra t e
• One-to-one care in labour (Hodnett et al 2011)
• Active management of the second stage with Syntocinon (O'Driscoll et al
1993; Brown et al 2008)
• Upright birth posture/mobilization (NICE 2007; Gupta et al 2012)
• Delaying the onset of the active second stage by 1–2 hours in women with
regional analgesia/anaesthesia (NICE 2007)
• Fetal blood sampling rather than expediting birth when fetal heart rate
abnormalities occur (NICE 2007)
I t should be noted, however, that other interventions, such as epidural analgesia,
have been observed to be associated with an increased risk of instrumental vaginal
birth and have been suggested to be linked to an increased risk of birth by caesarean
section (CS ) (A nim-S omuah et al 2011). However, such ‘disadvantages’ must be
balanced against the higher rates of maternal satisfaction that this form of analgesia
provides. I t is up to the woman to make an informed choice as to which of the benefits
and risks are most important, not up to the a ending medical staff to make didactic
decisions on her behalf. I ndeed, whilst it has been commented (J ohanson and Menon
1999) that, in general, maternal outcomes would be improved by lowering
instrumental birth rates, no evidence to support such a statement has ever been
forthcoming, as it is not easy to see what the alternatives are for a woman who, despite
her own best efforts, has not been able to secure a ‘normal birth’.
Indications for ventouse or forceps
The indications for assisted vaginal birth may be simply categorized into fetal and
maternal. However, the reasons cited for intervention are frequently imprecise as
multiple factors often interact.
Fetal
• Malposition of the fetal head (occipitolateral and occipitoposterior). Such positions
occur more frequently in the presence of regional anaesthesia, as alterations in the
tone of the pelvic floor may impede the spontaneous rotation to the optimal
occipitoanterior position during the decent of the presenting part (vertex of the fetal
head).
• Fetal ‘distress’ is a commonly cited indication for instrumental intervention;
however, ‘presumed fetal compromise’ is a more comprehensive term (unless a fetal
blood sample has been obtained showing hypoxia and acidosis, in which case ‘fetal
hypoxia’ should be used) (NICE [National Institute for Health and Clinical
Excellence] 2007).
• Elective instrumental intervention for infants of reduced weight. In infants weighing
<1.5 kg, delivery with forceps does not confer an advantage over spontaneous birth
and may increase the incidence of intracranial haemorrhage. Ventouse carries the
same risks, but in addition should be avoided in infants of <34+6 weeks of gestation.
• Assisted vaginal breech birth. Forceps can be applied to the after-coming head to
control the birth of the vertex, a situation where the ventouse is contraindicated.
Maternal
• The commonest maternal indications are those of maternal distress, exhaustion, or
prolongation of the second stage of labour. This has been suggested as greater than 2
hours in a primigravida (3 hours if an epidural is in situ), or more than 1 hour in a
multipara (2 hours if an epidural is in situ) (NICE 2007).
• Medically significant conditions such as: aortic valve disease with significant outflow
obstruction; myasthenia gravis; significant antepartum haemorrhage due to placental
abruption or vasa praevia; severe hypertensive disease; and previous CS (to minimize
the risk of scar rupture).
Contraindications to an instrumental vaginal birth
Absolute
• The vertex is ≥1/5th palpable abdominally.
• The position as determined by a vaginal examination (occipitoanterior/posterior or
lateral) of the fetal head is unknown.
• Before full dilatation of the cervix (although a possible exception occurs with the
ventouse birth of a second twin).
• When the operator is inexperienced in instrumental vaginal birth.
In addition the ventouse should not be used:
• In gestations of <34+6 weeks because of the increased risk of intracranial
haemorrhage in the fetus.
• With the fetus presenting by the face.
• If there is a significant degree of caput that may either preclude correct placement of
the cup or, more sinisterly, indicate a substantial degree of cephalopelvic
disproportion CPD).
Relative contraindications (for forceps or ventouse)
• Fetal bleeding disorders (e.g. alloimmune thrombocytopenia) or a predisposition to
fractures (e.g. osteogenesis imperfecta) are relative contraindications specifically to
an operative birth with the ventouse. However, the comparative risks of a birth by a
difficult second stage caesarean section must also be considered and a discussion
undertaken antenatally about the most appropriate plan for birth (it may be wiser to
recommend that such women have an elective CS).
• There is minimal risk of fetal haemorrhage if the vacuum extractor is employed
following fetal blood sampling or application of a scalp electrode.
Prerequisites for any operative vaginal birth
• Rupture of the membranes must be confirmed.
• The cervix must be fully dilated.
• Cephalic presentation with identification of the position (occipitoanterior/posterior
or lateral).
• Adequate pelvis as ascertained by clinical pelvimetry.
• The fetal head must be <1/5th palpable per abdomen, with the presenting part at or
below the ischial spines.
• Adequate analgesia/anaesthesia.
• Empty bladder/no obstruction below the fetal head (contracted pelvis/ovarian cyst).
• A knowledgeable and experienced operator with adequate preparation to proceed
with an alternative approach if necessary.
• An adequately informed woman (with signed consent form detailing appropriate
risks/benefits/complications as the situation demands).
Birth by ventouse
The ventouse is essentially a suction cup (made from plastic or metal) that is
connected (via tubing) to a vacuum source. Following the placement of the cup onto
the fetal head, traction can be applied to assist the birth.
There is no definitive guide as to which instrument to use on which occasion.
However the ventouse cup may not be successful at securing birth and therefore
obstetric forceps should be chosen if there is:
• suspected fetal macrosomia
• excessive caput or moulding
• poor maternal effort due to exhaustion (which may be compounded by epidural
analgesia and poor sensation)
• gestation <34 completed weeks.
Types of ventouse
Until recently, the most commonly used ventouse in use in the United Kingdom (UK)
was that of the ‘soft’ or silicone cup design (Fig. 21.1A). W hilst these cups have the
undoubted advantages of being extremely malleable (reducing maternal trauma by
being more easy to correctly place within the vagina) and having a reduced incidence
of fetal scalp trauma when compared to other cup designs, soft cups have a poorer
success rate than metal cups in achieving a vaginal birth (RCO G [Royal College of
Obstetricians and Gynaecologists] 2011).
FIG. 21.1 (A) The soft cup ventouse. (B) The Kiwi OmniCupTM. (C) Birth by ventouse.
Metal cup ventouse designs are of the Bird or Malstrom types, which have a centrally
placed traction chain with a laterally located vacuum conduit. They come in diameters
of 4, 5 and 6 cm.
Both the standard soft and metal cup designs require the generation of an operating
vacuum from an external source – and as such these pieces of equipment require two
operators for their successful use (one to control the placement of the ventouse and
assist the birth, the other (most commonly the a ending midwife) to control the
degree of vacuum that is generated.
More recent advances in design have removed the need for the external suction
generators by incorporating the vacuum mechanism into ‘hand-held’ pumps (e.g. Kiwi
OmniCupTM) as illustrated in Fig. 21.1(B). S uch devices are safe and may be useful for
rotational births because they are low profile and are easily manoeuvered into the
correct position. However, they have a significantly higher failure rate than the
conventional metal cup ventouse, with cup detachments occurring more frequently.
The use of the ventouse
The ventouse is more frequently employed by obstetricians than the obstetric forceps
due to its apparent ease of use and comparative safety. However, repeated meta-
analyses have demonstrated that the ventouse is less likely to achieve a successful
vaginal birth than forceps, although both types of instruments are associated with a
lowering of the overall CS rate (J ohanson and Menon 1999). A lthough the ventouse is
associated with an increased risk of neonatal complications such as
cephalohaematoma (Chapter 31), other facial (nerve palsies) and significant cranial
injuries (fractures) are more common with forceps.
Procedure
• The rationale for the birth is discussed with the woman and her partner. The
procedure is explained and consent obtained (written consent should be obtained if
time allows).
• The woman's legs should be placed into the lithotomy position.
• Whilst inhalational analgesia may be sufficient (entonox – N2O), more commonly a
pudendal nerve block with perineal infiltration may be administered, or an epidural,
if already in situ, may be topped up.
• Once adequate analgesia is assured, the maternal bladder is emptied.
• The fetal heart rate (FHR) must be continuously monitored (with a cardiotocograph –
CTG).
• For the successful use of the ventouse, it is essential to determine the flexion point,
which is located, in an average term infant, along the sagittal suture 3 cm anterior to
the posterior fontanelle (and thus 6 cm posterior to the anterior fontanelle). The
centre of the cup should be placed directly over this, as failure to adequately position
the cup can lead to a progressive deflexion of the fetal head during traction.
The operating vacuum pressure for nearly all ventouse is between 0.6 and 0.8 kg/cm2
(60–80 kPa/500–800 cmH2O ). N o evidence exists that a stepwise reduction in pressure
improves the rate of successful birth when compared with a linear reduction. Using
the la er technique with a silastic cup, a caput succedaneum (Chapter 31) is formed
instantly, and with the metal cup or O mniCupTM, an adequate chignon is produced in
<2 minutes. I t is important to note that a cup of 5 cm diameter is suitable for nearly all
births, even with larger babies.
W hen the vacuum is achieved, traction must be applied to coincide with a
contraction and thus maternal expulsive efforts. Without both of these contributing
factors, birth with a ventouse will fail. Traction is provided along a track defined by the
curve of Carus (Chapter 3): initially in a downwards and backwards direction, then in a
forward and upward manner. O nce the fetal head has crowned, the vacuum is
released, the cup removed and with further maternal efforts the baby will be born. I n
addition to the relative ease of use and low risk of complications, it is undoubtedly this
sense of contribution to the birth that makes the ventouse a more satisfactory birthing
experience for the mother and her partner than an operative birth with obstetric
forceps.
Precautions in use
With the ventouse, the operator should allow ≤2 episodes of breaking the suction in
any vacuum assisted birth, and the maximum time from application to birth should
ideally be ≤15 minutes. I f there is no evidence of descent with the first pull, the woman
should be reassessed to ascertain the reason for failure to progress. I n addition, care
should be taken to ensure that no vaginal skin is trapped in the edges of the cup as
this can result in complex degrees of perineal trauma that can be extremely difficult to
repair in a satisfactory fashion.
The midwife ventouse practitioner
S ome midwives feel that women will be be er served by a midwife ventouse
practitioner rather than an obstetrician and embrace such innovations (Tinsley 2010).
However, others see it as exceeding the limits of normal midwifery practice (Charles
1999). The fact is that midwifery care is changing and developing, specifically with the
advancement of care within stand-alone midwife-led units.
W hilst the idea of reducing the psychological trauma to a woman during a birth by
limiting the number of carers in a endance at this crucial and critical time is to be
commended, it would be foolhardy to assume that the midwife ventouse practitioner
would be the primary carer for every pregnant women on every occasion that required
an assisted vaginal birth. A s such it is likely that a midwife previously unknown to the
labouring woman would be asked to assist at the moment when help is required, an
event that would therefore be no less ‘traumatic’ for a woman or her partner than
asking an obstetrician to a end. A ll accoucheurs, including midwife ventouse
practitioners, must be well educated and trained before carrying out a ventouse birth –
although it is highly unlikely that the more complex surgical skills required of a birth
by forceps or CS would be mastered in addition. I t should be remembered that as a
ventouse will fail in up to 20% of cases, even in the most skilled hands, having no
ability to change instruments or resort to birth by CS will place those midwives who
work as ventouse practitioners in isolation in a most unenviable position.
Birth by forceps
Characteristics of the obstetric forceps
A ll obstetric forceps are composed of two separate blades (determined as right and
left by reference to their insertion around the fetal head within the maternal vagina),
two shanks (shafts) of varying length and two handles. Forceps are often described as
non-rotational or rotational. N on-rotational forceps are ‘held’ together by either an
English (non-sliding) lock on the shank or, in the case of rotational forceps, by a
sliding lock on the shank. The blades have a cephalic curve to accommodate the form
of the baby's head and are fenestrated (and not solid) to minimize the trauma to the
baby's head during both placement and birth. They also have a pelvic curve to reduce
the risks of trauma to the maternal tissues during the birth process.
W hen the blades are correctly positioned around the fetal skull, the handles will be
neatly aligned in the hands of the doctor who applies them and will be noted to ‘lock
with ease’. Forceps that do not lock are most commonly incorrectly placed.
Classification of obstetric forceps
Forceps operations fall into two categories: mid- and low-cavity. Mid-cavity forceps are
used when the leading part of the fetal head has reached below the level of the ischial
spines; low-cavity forceps are used when the head has descended to the level of the
pelvic floor. High-cavity forceps (with the leading part of the fetal head above the level
of the ischial spines) are now considered unsafe and a CS will be the preferred method
of birth in nearly all cases.
Types of obstetric forceps
Wrigley's forceps
These are designed for use in outlet lift-out when the head is on the perineum or to
assist the birth of the fetal head at caesarean section. They have a short shank,
fenestrated blades with both pelvic and cephalic curves, and an English lock (Fig. 21.2).
FIG. 21.2 Types of forceps. From above: Kielland's, Neville–Barnes and Simpson's. Note the
difference in cephalic curve. The rotational forceps (Kielland's) have a long shaft and little pelvic
curve. Wrigley's forceps have a shorter shank.
Neville–Barnes or Simpson's forceps
These are generally used for a low- or mid-cavity forceps birth when the sagi al suture
is in the anteroposterior diameter of the cavity of the pelvis. W hilst they have cephalic
and pelvic curves to the fenestrated blades, the handles are longer and heavier (Fig.
21.2) than those of the W rigley's. A nderson's and Haig–Ferguson's forceps are also
similar in shape and size.
Kielland's forceps
These were originally designed to deliver the fetal head at a station at, or above, the
pelvic brim. They are now more commonly used for the rotation and extraction of a
baby whose head is in the deep transverse or occipitoposterior malpositions. By
comparison to the non-rotational forceps, the Kielland's forceps blades have
fenestrated blades with a much-reduced pelvic curve (in order to allow for the safe
rotation of the fetus), longer shanks (to enable rotation within the mid-cavity of the
pelvis) and a sliding lock to allow for correction of any degree of asynclitism of the
fetal head. These forceps (Fig. 21.2) should be used only by an obstetrician skilled in
their application and use, and indeed in many units their use has been abandoned.
Procedure
I n addition to the key points outlined for ventouse on page 458, i.e. rationale, consent,
urinary bladder catheterization, FHR monitoring and position of the woman's legs,
specific issues to consider are:
• Consideration should be given as to the location of the birth – in the birthing room
(lift-out or low-cavity – non rotational deliveries) or in the obstetric theatre (all other
forceps births).
• Unlike the ventouse, inhalational analgesia or a pudendal nerve block with perineal
infiltration is unlikely to be sufficient for a forceps birth. In the majority of instances
an epidural, if already in situ, may be topped up, or a spinal anaesthetic should be
administered. These are mandatory before consideration is given to using Kielland's
forceps.
• The forceps should be held discretely in front of the woman (to visualize how they
will be inserted per vaginum) and placed around the fetal head. The left blade is
inserted before the right blade, with the accoucheur's hand protecting the vaginal
wall from direct trauma.
• The forceps blades come to lie parallel to the axis of the fetal head, and between the
fetal head and the pelvic wall. The operator then articulates and locks the blades,
checking their application before applying traction. The blades must be repositioned
or the procedure abandoned if the application is incorrect.
• Traction should be applied in concert with uterine contractions and maternal
expulsive efforts.
• As with the ventouse, the axis of traction changes during the birth and is guided
along the curve of Carus, the blades being directed to the vertical as the head crowns
(see Figs 21.3–21.6).
FIG. 21.3 Left blade being inserted. The fingers of the right hand guard the vaginal tissue.
FIG. 21.4 Right blade being inserted.
FIG. 21.5 Traction of the head is downwards until this point; when the head is low, the direction
of pull is outward, towards the operator.
FIG. 21.6 As the head crowns it is lifted upwards.
Complications of instrumental vaginal birth
A lthough forceps are less likely than the ventouse to fail to achieve a vaginal birth,
they are significantly more likely to be associated with third- or fourth-degree tears
(with or without the concurrent use of an episiotomy), vaginal trauma, use of general
anaesthesia, flatal, faecal and urinary continence (Chapter 15).
Maternal complications
Complications may include:
• Trauma or soft tissue damage – occurring to the cervix, vagina or perineum.
• Dysuria or urinary retention, which may result from bruising or oedema to the
tissues around the urethra.
• Perineal discomfort.
• Haemorrhage (both from tissue trauma and also uterine atony – the risk of which is
always increased following an assisted vaginal birth).
Neonatal complications
Complications may include:
• Marks on the baby's face and bruising (commonly caused by the pressure from the
forceps blades and around the caput succedaneum/chignon from the ventouse –
nearly all of which resolve within 48–72 hours after birth; see Chapter 31).
• Facial palsy, which may result from pressure from a blade compressing a facial nerve
(a transient problem in most instances).
▪ Prolonged traction during a birth with a ventouse will increase the likelihood of
scalp abrasions, cephalohaematoma or sub-aponeurotic bleeding (Chapter 31).
S ome authors suggest that failure rates of <1% should be achieved using the correct
technique and with well-maintained equipment. Many authors feel that this is an
unrealistic target. Failure of the ventouse realistically arises in up to 20% of cases and
indeed J ohanson and Menon (1999) achieved vaginal birth with the first instrument in
only 86% of assisted births.
The following as factors will often be found to have contributed to failure:
With the ventouse
• Failure to select the correct cup type – inappropriate use of the silastic cup –
especially in the presence of deflexion of the fetal head, excess caput, ‘dense’ epidural
block or fetal macrosomia (true CPD).
• Failure of the equipment to provide adequate traction as a consequence of a leakage
of the vacuum.
• Incorrect cup placement – too anterior or lateral, with or without inclusion of
maternal soft tissues within the cup.
With any instrument
• Inadequate initial case assessment – high head, misdiagnosis of the position and
attitude of the head.
• Traction along the wrong plane (often too anteriorly and not along the curve of
Carus).
• Poor maternal effort with inadequate use of syntocinon to maximize the contribution
from coordinated uterine activity.
W hatever the outcome, the midwife in a endance is vital to the success of any
manoeuvres undertaken, encouraging the mother to be an active participant in her
birth, supporting the mother and her partner through what may be perceived to be a
‘deviation from normal’ and importantly, to support the clinician undertaking the
assisted birth.
Caesarean section
Caesarean section is an operative procedure, which is carried out under anaesthesia
(regional or general), whereby the fetus, placenta and membranes are delivered
through an incision made in the abdominal wall and uterus.
T h e RCO G (2001) N ational S entinel Caesarean S ection Audit reported that the
overall CS rate was 21.5% (England and Wales), accounting for approximately 120 000
births per year. W hilst the CS rates for maternity units ranged from 10% to 65%, 10%
of women had CS before labour (range between maternity units 4% to 59%), and 12%
of women who went into labour had a CS (range between maternity units 2% to 22%).
I t is believed that some of the differences in CS rates observed may be explained by
differences in the demographic and clinical characteristics of the population, such as
maternal age, ethnicity, previous CS , breech presentation, prematurity and induction
of labour. However the exact reasons for these differences remains unclear.
A lthough there has been an increase in CS rates over the past 20 years, the four
major clinical determinants of the CS rate have not changed. Common primary
indications reported for women having a primary CS were: failure to progress in
labour (25%), presumed fetal compromise (28%) and breech presentation (14%). The
most common indications for women having a repeat CS were: previous CS (44%),
maternal request as reported by clinicians (12%), failure to progress (10%), presumed
fetal compromise (9%) and breech presentation (3%).
Currently in the UK, slightly more than one in seven women experience
complications during labour that provide an indication for CS . These problems can be
life-threatening for the mother and/or baby (e.g. eclampsia, abruptio placenta) and, in
approximately 40% of such cases, a CS provides the safest route for birth. I n all cases
the principal aims must be to ensure that those women and babies who need birth by
CS are so delivered, and that those who do not are saved from an unnecessary
intervention.
I n 1985, concern regarding the increasing frequency of caesarean section led the
W orld Health O rganization (W HO ) to hold a Consensus Conference Stephenson(
1992). This conference concluded that there were no health benefits above a CS rate of
10–15%. The S candinavian countries managed to hold CS rates at this level during the
1990s, with outcomes comparable to or be er than those of countries with higher CS
rates. However, this is no longer the case and CS rates in these countries have now
increased towards those in the other developed nations.
A lthough many factors have been associated with an increase in the CS rate, not all
have been to the detriment of the mother or baby. I nterestingly, whilst the CS rate has
risen over the two preceding decades, the instrumental vaginal birth rate has
remained relatively constant.
Clarifying the indications for caesarean section
N I CE (2011) recommends that the urgency of CS should be documented using the
following standardized scheme in order to aid clear communication between
healthcare professionals about the urgency of a CS:
1. Immediate threat to the life of the woman or fetus.
2. Maternal or fetal compromise which is not immediately life-threatening.
3. No maternal or fetal compromise but needs early delivery.
4. Delivery timed to suit woman or staff.
The need for birth by a category 1 (‘crash’) CS is fortunately a rare event as it can be
a psychologically traumatic event for the woman and her partner. I t is also extremely
stressful for the clinical staff in a endance. Resources may have to be obtained from
other areas of clinical care to facilitate such a birth and care standards risk being
compromised in the rush to secure a ‘safe’ outcome. Care should therefore be
exercised before making this decision, and in utero fetal resuscitation (fluids, tocolytics
and oxygen) may give enough time for a more considered and careful approach.
Indications for which elective caesarean section would be the
strongly recommended mode of birth:
• Past obstetric history
▪ previous classical caesarean section
▪ interval pelvic floor or anal sphincter repair
▪ previous severe shoulder dystocia with significant neonatal injury.
• Current pregnancy events
▪ significant fetal disease likely to lead to poor tolerance of labour
▪ monoamniotic twins or higher-order multiple pregnancy
▪ placenta praevia
▪ obstructing pelvic mass
▪ active primary herpes at onset of labour.
• Intrapartum events
▪ presumed fetal compromise in the first stage
▪ maternal disease for which delay in delivery may compromise the safety of the
mother
▪ absolute cephalopelvic disproportion (brow presentations etc).
These lists are not comprehensive and factors or other indicators may co-exist to
influence the decision-making process.
The operative procedure
• The rationale for the intervention is discussed with the woman and her partner. The
procedure is explained and consent obtained (written consent must be obtained in all
cases other than a category 1 or ‘crash section’). For elective procedures consent may
be taken in a dedicated preoperative assessment (the decision having been previously
discussed and agreed in the antenatal clinic by a senior clinician in consultation with
the woman and her partner).
• A preoperative assessment includes: weight and observations of blood pressure,
pulse and temperature. The woman is gowned, make-up, the presence of any nail
varnish and jewellery removed (rings/ear-rings taped).
• The woman is visited by the anaesthetist and the operating department practitioner
preoperatively, and assessed. An anaesthetic chart will be commenced.
• Results of any blood tests that have been requested are obtained (full blood count,
group and save and cross match, if required).
• The woman will have fasted and have taken the prescribed antacid therapy.
• Many women prefer to have urinary catheterization in the theatre once the regional
or general anaesthetic has been administered. However some women will prefer to
have this procedure undertaken in the privacy of their room before entering the
operating theatre.
• As the woman will need to lie flat, it is essential that a wedge or cushion is used, or
the table is tilted, to direct the gravid uterus away from the inferior vena cava. The
risks of supine hypotension syndrome will thus be reduced.
• The regional or general anaesthetics will be administered.
• A surgical ‘time out’ should be carried out on every woman entering the operating
theatre prior to the preparation of the skin. In competent hands this takes a matter of
seconds dramatically improving safety whilst not delaying the birth to any
perceptible degree.
• The skin is prepared in accordance with local and national guidelines. Currently, it
remains unclear what kind of skin preparation might be the most efficacious in the
prevention of post CS surgical wound infection (Hadiati et al 2012).
• Intravenous antibiotics should be administered as surgical prophylaxis before the
skin is incised. This reduces the risk of maternal infection more than prophylactic
antibiotics given after skin incision, and no effect on the baby has been
demonstrated.
The anatomical layers that need to be breached in order to reach the fetus are: skin,
subcutaneous fat, rectus sheath, muscle (rectus abdominis), abdominal peritoneum,
pelvic peritoneum and uterine muscle.
A transverse lower abdominal incision (bikini line incision) is usually performed
with the skin and subcutaneous tissues incised using a transverse curvilinear incision
at a level of two fingerbreadths above the symphysis pubis. The subcutaneous tissues
are subsequently separated by blunt dissection and the rectus sheath incised
transversely for 2 cm either side of the midline. This incision is then extended with
scissors or blunt dissection before the facial sheath is separated from the underlying
muscle. The recti are separated from each other, the peritoneum incised and the
abdominal cavity entered.
The fold of the peritoneum over the anterior aspect of the lower uterine segment
and above the bladder is incised and the bladder mobilized and reflected down. The
uterus is incised transversely taking care not to cause surgical trauma to the fetus (a
significant risk in the presence of low levels of amniotic fluid). The surgeon, with help
from the surgical assistant (who must apply fundal pressure), will then secure the safe
delivery of the baby.
The main reason for preferring the lower uterine segment technique is the reduced
incidence of dehiscence of the uterine scar in any subsequent pregnancy and/or birth
when compared to a classical or vertical incision (which may be the only surgical
approach that is suitable in situations such as anterior wall placenta praevia, in
extreme prematurity (where no lower uterine segment may be formed) or in the
presence of dense adhesions from previous surgery.
O xytocics (a bolus of 5 I U of S yntocinon) should be given by the anaesthetist after
birth of the baby and clamping of the umbilical cord. W hen the baby and placenta
have been delivered, the uterus is closed in two layers and the rectus sheath and skin
sutured. Most surgeons use a braided polyglactin suture (Vicryl) for all layers. The
wound is then dressed and the vagina swabbed to remove any clots. This also allows a
final intraoperative assessment of any ongoing bleeding from within the uterus.
W omen having a CS should be offered thromboprophylaxis because they are at
increased risk of venous thromboembolism (Lewis 2007; CMA CE [Centre for Materna
and Child Enquiries] 2011). The choice of method of prophylaxis (for example,
graduated stockings, hydration, early mobilization, low molecular weight heparin)
should take into account risk of thromboembolic disease, although in most cases it is
simplest, and safest, to administer low molecular weight heparin to all women until
they are fully mobile. Those with an increased risk (e.g. maternal obesity or concurrent
maternal morbidity) should have a more formal assessment of risk and an
individualized care plan put in place.
Early skin-to-skin contact between the woman and her baby should be encouraged
and facilitated as it improves maternal perceptions of the infant, mothering skills,
maternal behaviour, breastfeeding outcomes and reduces infant crying (Chapter 34).
I n addition, women who have had a CS should be offered additional support to help
them to start breastfeeding as soon as possible after the birth of their baby. This is
because women who have had a caesarean section are less likely to start breastfeeding
in the first few hours after the birth, but, when breastfeeding is established, they are
as likely to continue as women who have had a vaginal birth.
Women's request for caesarean section
The reasons behind the ‘demands’ for birth by CS are frequently complex. D espite the
focus of a ention in the media, evidence suggests that very few women actually
request CS in the absence of medical indications and the ‘too posh to push cohort’ are
in an extreme minority (Chaffer and Royle 2000; Weaver et al 2007). However, the
accounts of women who have had difficult experiences of childbirth describe ‘knowing
something was wrong but believe that they were not listened to’ are all too familiarly
encountered. S uch women frequently publicize their problems via Facebook or other
social media networks, fuelling the idea of ‘them against us’, and the joys of any future
pregnancy risk being overwhelmed by the focus for a birth by CS whatever the
rationale behind their beliefs.
Psychological support and the role of the midwife
Choice is an important element in understanding this sequence. W omen expect to be
actively involved in their care and all staff involved must ensure that recent, valid and
relevant information is provided in a comprehensible manner. This will help women
to decide what is best for them, in relation to their own specific circumstances. The
midwife, as an informed, confident and competent practitioner, will have a pivotal role
in this process and be able to provide women with clear and unbiased information
concerning the choices available (McA leese 2000). This will often relieve the stress of
the situation and help women make a competent decision, supporting them in the
midst of any misgivings.
O ne-to-one care from a support person during labour can influence the rate of birth
by CS as a continual, supportive presence in labour is undoubtedly of considerable
benefit, both to the woman and to her family (Walker and Golois 2001; Hodne et al
2011). It is important that midwives recognize the positive impact on outcomes of their
continuous presence during established labour (NICE 2007; Hodnett et al 2011).
Psychological support mechanisms may also help these women to overcome their
fears and, as such, it may be appropriate to develop links with trained counsellors to
enable women to explore their anxieties and reach a more informed and rational
decision prior to electing to undergo major abdominal surgery. However, N I CE (2011)
recommends for women requesting a CS that if, after discussion and offer of support
(including perinatal mental health support for women with anxiety about childbirth,
see Chapter 25), a vaginal birth is still not an acceptable option, a planned caesarean
section should be offered.
Vaginal birth after caesarean section (VBAC)
Ziadeh and S unna (1995) reported that the widespread adoption of a policy whereby
80% of women with a prior CS should have a VBA C would potentially eliminate up to
one-third of births by CS . This is still the target towards which those providing care to
women in pregnancy strive.
W hen advising about the mode of birth after a previous CS it is important to
consider the maternal preferences and priorities, the risks and benefits of repeat CS
and the risks and benefits of planned VBA C, including the risk of unplanned (i.e.
emergency) CS.
N I CE (2011) recommends that women who have had up to and including four
caesarean sections should be informed that the risks of fever, bladder injuries and
surgical injuries do not vary with the planned mode of birth and that the risk of
uterine rupture, although higher for planned vaginal birth, is rare. However it is a
‘brave’ clinician who would choose to recommend vaginal birth as a safe option in
those women who have had two previous CS.
I t is also important to remember that pregnant women with both a previous CS and
a previous vaginal birth should be informed that they have an increased likelihood of
achieving a vaginal birth than women who have had a previous CS but no previous
vaginal birth.
Pare et al (2006) argued that the concerns around the safety of VBA C ignored the
potential downstream consequences of a strategy whereby multiple elective repeat
caesarean sections are considered to be the safer option. These include an increased
length of stay in hospital and increased risks of placenta praevia and accreta in future
pregnancies. They confirmed that for women who desire two or more additional
children, the risks of multiple caesarean sections outweigh the risks of a VBA C
attempt.
Criteria for a successful VBAC:
• Adequate supervision including continuous electronic fetal monitoring with CTG.
• All the facilities for assisted birth are readily available.
• Progress of the labour is sufficient, observed both in the descent of the presenting
part and by the dilatation of the cervix.
• The woman and her partner are fully informed about the risks and benefits.
Postoperative care
A fter birth by CS women should be observed on a one-to-one basis by a properly
trained member of staff until they have regained airway control, have observed
cardiorespiratory stability and are able to communicate effectively. A fter recovery
from anaesthesia, observations (respiratory rate, heart rate, blood pressure, pain and
sedation) should be recorded every 15 minutes in the immediate recovery period (for
the first 30 minutes) and thereafter every half-hour for 2 hours, and hourly thereafter
provided that the observations are stable or satisfactory. I f these observations are not
stable, more frequent observations and medical review are recommended. I n addition
the wound and lochia must be inspected every 30 minutes to detect any ongoing blood
loss. I f the mother intends to breastfeed, the baby should be put to the breast as soon
as possible, a process that can usually be achieved with minimal disturbance to the
undertaking of these routine observations.
For women who have had intrathecal opioids, there should be a minimum hourly
observation of respiratory rate, sedation and pain scores for at least 12 hours if
diamorphine has been administered and for 24 hours in the case of morphine. For
women who have had epidural opioids or patient-controlled analgesia (PCA) with
opioids, there should be routine hourly monitoring of respiratory rate, sedation and
pain scores throughout treatment and for at least 2 hours after discontinuation of
treatment.
Postoperative analgesia
Postoperative analgesia should be given on a regular basis and may be given in a
variety of ways:
• Ongoing epidural anaesthesia/analgesia. Women should have diamorphine (3 mg) or
fentanyl (100 µg) administered into the epidural space for intra- and postoperative
analgesia as it reduces the need for supplemental analgesia after a caesarean section.
Intravenous or intramuscular administration of diamorphine (2.5–5 mg) is a suitable
alternative. However, intramuscular or intravenous analgesia should never be given
in conjunction with epidural opioids for at least the first 4 hours after administration
of the epidural dose because of the cumulative effects and risks of respiratory
depression.
• PCA using opioid analgesics may be offered after caesarean section as an alternative
pain relief regimen.
• Antiemetics (e.g. cyclizine; prochlorperazine) are usually prescribed when opioids
are required.
• Analgesia, such as diclofenac (oral or rectal) or paracetamol (oral, intravenous or
rectal) are the mainstays of postoperative analgesia.
• Oral drugs (e.g. dihydrocodeine, codydramol, ibuprofen or paracetamol).
Providing there are no contraindications (history of kidney disease, sensitivity to
nonsteroidal anti-inflammatory drugs [N S A I D s], peptic ulcer, severe bri le asthma),
N S A I D s should be offered post-caesarean section as an adjunct to other analgesics, as
they reduce the need for the administration of opioids.
Care following regional block
Following birth under epidural or spinal anaesthesia, the woman may sit up as soon as
she wishes, provided her blood pressure is not low. A ll observations must be recorded
as described above.
W omen who are recovering well after CS and who do not have complications can eat
and drink when they feel hungry or thirsty, at which point the intravenous fluid
infusion can be discontinued.
The baby should remain with the mother unless there is a medical reason for care
being provided elsewhere (e.g. on a special care or neonatal intensive care unit) and
indeed they should be transferred to the postnatal ward together once it is safe to do
so. S uch care is undoubtedly of benefit to a woman's psychological health and long-
term wellbeing.
Care in the postnatal ward
O nce care is transferred to the postnatal ward, the blood pressure, temperature,
respirations and pulse must be checked every 4 hours and recorded using a modified
obstetric early warning score chart (MO EW S ) Lewis
( 2007). I n addition, the wound and
lochia should be inspected at the same time. Removal of the urinary bladder catheter
should be carried out once a woman is mobile after a regional anaesthetic and not
sooner than 12 hours after the last epidural ‘top up’ dose. Healthcare professionals
caring for women who have had a CS and who have urinary symptoms should consider
the possible diagnosis of: urinary tract infection, stress incontinence (which occurs in
about 4% of women after CS ) or urinary tract injury (which occurs in about 1 per 1000
women after birth by CS).
The mother should be encouraged to move her legs and to perform leg and
breathing exercises, however routine respiratory physiotherapy does not need to be
offered to women after a caesarean section under general or regional anaesthesia, as it
does not improve respiratory outcomes such as coughing, phlegm, body temperature,
chest palpation and auscultatory changes.
The woman should be helped to get out of bed as soon as possible following a CS ,
and should also be encouraged to become fully mobile. Prophylactic low molecular
weight heparin and antiembolic or thromboembolic deterrent (‘TED ’) stockings
should be prescribed. However, the first dose of low molecular weight heparin should
be delayed until 4 hours after the intrathecal injection or removal of the epidural
catheter.
W omen who have had a general anaesthetic for CS may feel very tired and drowsy
for some hours. A woman may complain of a feeling of detachment and unreality and
may feel that she does not relate well to the baby. The woman who is concerned
should be reassured and be given the opportunity to talk freely.
The mother must be encouraged to rest as much as possible and tactful advice may
need to be given to her visitors. I f the mother becomes too tired, help is needed with
care for the baby. This should, preferably, take place at the mother's bedside and
should include support with breastfeeding. The clip-on cots, which may be a ached to
the mother's bed, are invaluable in promoting good care (Fig. 21.7).
FIG. 21.7 Baby in clip-on cot, adjacent to and within easy reach of mother when in bed.
Caesarean section wound care should include: removing the dressing 24 hours after
the delivery, assessing the wound for signs of infection (such as increasing pain,
redness or discharge) separation or dehiscence, encouraging the woman to wear loose
comfortable clothes and co on underwear, gently cleaning and drying the wound
daily if needed and planning the removal of sutures or clips if required.
S ome women may have a lingering feeling of failure or disappointment at having
had an emergency CS and may value the opportunity to talk this over with the midwife
or other clinicians involved in her care. I ndeed it is considered to be good practice for
the obstetrician who undertook the CS to review the woman postpartum, not only in
order to discuss the problems that necessitated the surgical intervention, but also to
counsel about the options for any future pregnancy.
Healthcare professionals caring for women who have heavy and/or irregular vaginal
bleeding following CS should be aware that this is more likely to be due to
endometritis than retained products of conception. A s a consequence, should this
complication be suspected, first line treatment with broad spectrum antibiotics should
be implemented rather than referral for ultrasound assessment. However, if there are
any concerns about the completeness of the placental tissue or membranes, referral
for senior review at an early stage should be the preferred course of action.
W hilst the length of hospital stay is likely to be longer after a caesarean section (an
average of 3–4 days) than after a vaginal birth (average 1–2 days), women who are
recovering well, are apyrexial and do not have complications following CS should be
offered early transfer home (after 24 hours) from hospital and follow-up at home, as
this is not associated with more infant or maternal readmissions compared with later
transfer.
Analgesia/anaesthesia
Pudendal block
This is the procedure where local anaesthetic is infiltrated into the tissue around the
pudendal nerve within the pelvis (Fig. 21.8). The pudendal nerve emerges from the
spine at the level of the S 2–S 4 vertebrae and ‘descends’ into the pelvis crossing behind
the ischial spine as it does so. The pudendal nerve supplies the levator ani muscles,
the deep and superficial perineal muscles and the sensory nerves (pain/stretch and
temperature) of the lower vagina and perineum. A pudendal needle (a specifically
designed needle incorporating a sheath guard) is employed with up to 20 ml of local
anaesthetic, usually 1% lidocaine (lignocaine), being injected into the region around
and below the ischial spine. A s both motor and sensory nerves are affected with this
technique it may be used to provide analgesia for the lower vagina and perineum, and
is therefore used during forceps and ventouse instrumental births.
FIG. 21.8 Locating the pudendal nerve.
Perineal infiltration
S ee Chapter 15 for infiltration and repair of episiotomy, as well as third- and fourth-
degree perineal trauma.
Regional anaesthesia
The two most commonly employed regional anaesthetic techniques are those of
epidural and intrathecal (spinal) anaesthetic.
The epidural space is the space located within the bony spinal canal just outside the
dura mater. I n contact with the inner surface of the dura is another membrane called
the arachnoid mater. The cerebrospinal fluid (CS F) is contained between the
arachnoid mater and the pia mater, another membrane that lies directly in contact
with the spinal cord. I n adults, the spinal cord terminates at the level of the lower
border of the L2 vertebra below which lies a bundle of nerves known as the cauda
equina (‘horse’s tail’).
I nsertion of an epidural needle involves threading a needle between the spinal
vertebrae, through the ligaments and into the epidural potential space taking great
care not to puncture the dura mater immediately below, which contains the CSF.
Techniques
Procedures involving injection of any substance into the epidural space require the
operator to be technically proficient in order to avoid complications.
The subject is most commonly placed in the seated or lateral positions. I ntravenous
access is mandatory.
Following a standard aseptic technique protocol, the level of the spine at which the
catheter/spinal needle is to be placed is identified.
Epidural
The iliac crest is a commonly used anatomical landmark for lumbar epidural
injections, as this level roughly corresponds with the fourth lumbar vertebra, which is
usually below the termination of the spinal cord. Following the infiltration of local
anaesthetic, a Tuohy needle is usually inserted in the midline, between the spinous
processes, passing below the vertebral lamina until reaching the ligamentum flavum
and the epidural space. A slight clicking sensation may be felt by the operator as the
tip of the needle breaches the ligamentum flavum and enters the epidural space.
A syringe containing saline is a ached to the Tuohy needle – most practitioners
using the loss of resistance to pressure to identify that the needle is correctly placed.
A catheter is then threaded through the needle (typically 3–5 cm into the epidural
space), the needle withdrawn and the catheter secured to the skin with adhesive tape
or dressings to prevent it becoming dislodged.
The catheter is a fine plastic tube, through which anaesthetic drugs may be injected
into the epidural space. Many epidural catheters have three or more orifices along the
shaft at the distal tip (far end) of the catheter to allow rapid and even dispersal of the
injected agents more widely around the catheter and reduce the incidence of catheter
blockage.
A person receiving an epidural for pain relief may receive local anaesthetic (most
commonly levo-bupivacaine), with or without an opioid (most commonly fentanyl).
These are injected in relatively small doses, compared to when they are injected
intravenously or intramuscularly.
For a short procedure, the anaesthetist may introduce a single dose of medication
(the ‘bolus’ technique), although the effects of this will eventually wear off. Thereafter,
the anaesthetist or midwife may repeat the bolus provided the catheter remains
undisturbed. For a prolonged effect, a continuous infusion of drugs may be employed.
However there is evidence that patient controlled epidural analgesia (PCEA), whereby
the administration of the boluses is controlled by the patient (up to a predetermined
maximum dose) provides be er analgesia than a continuous infusion technique,
although the total doses received by the individual are often identical.
Typically, the effects of the epidural block are noted below a specific level on the
body – a block at or below the T10 sensory level is ideal for women in labour or during
birth. N onetheless, giving very large volumes into the epidural space may spread the
block higher.
The epidural catheter is usually removed prior to transfer to the postnatal ward.
Spinal anaesthesia
I ntrathecal (spinal) anaesthesia is a technique whereby a local anaesthetic drug is
injected into the cerebrospinal fluid through a fine (24–26 gauge) spinal needle. The
technique has some similarity to epidural anaesthesia. However, important differences
include:
• Intrathecal anaesthesia requires a lower dose of drug and has a faster onset than
epidural anaesthesia.
• The block achieved with spinal anaesthesia is typically described as being more
dense.
• A spinal anaesthetic block typically lasts for 2 hours, however it cannot be topped
up, as no catheter is inserted.
• Intrathecal injections are performed below the second lumbar vertebral body to
avoid damaging the spinal cord.
Complications
A ccording to the A ssociation of A naesthetists of Great Britain and I reland (A A GBI
(2002), these include:
• Failure to achieve analgesia or anaesthesia occurs in about 5% of cases, while another
15% experience only partial analgesia or anaesthesia. If analgesia is inadequate,
another epidural may be attempted.
• The following factors are associated with failure to achieve epidural
analgesia/anaesthesia: obesity, history of a previous failure of epidural anaesthesia,
history of substance abuse (with opiates), advanced labour (cervical dilatation of
more than 7 cm at insertion) and previous history of spinal surgery.
• Accidental dural puncture with headache (common, about 1 in 100 insertions). The
epidural space in the adult lumbar spine is only 3–5 mm deep. It is therefore
comparatively easy to accidentally puncture the dura (and arachnoid) with the
needle, causing cerebrospinal fluid (CSF) to leak out into the epidural space. This
may, in turn, cause a post-dural puncture headache (PDPH). This can be severe and
last several days, and in some rare cases weeks or months. It is caused by a reduction
in CSF pressure and is characterized by postural exacerbation when the subject raises
his/her head above the lying position. If severe it may be successfully treated with an
epidural blood patch, however most cases resolve spontaneously with time.
• Bloody tap (about 1 in 30–50). It is easy to injure an epidural vein with the needle. In
people who have normal blood clotting, it is extremely rare for significant
complications to develop. However, people who have a coagulopathy may be at
increased risk.
• Catheter misplaced into the subarachnoid space (rare, less than 1 in 1000). If the
catheter is accidentally misplaced into the subarachnoid space (e.g. after an
unrecognized accidental dural puncture), normally cerebrospinal fluid can be freely
aspirated from the catheter (which would usually prompt the anaesthetist to
withdraw the catheter and re-site it elsewhere). If, however, this is not recognized,
large doses of anaesthetic may be delivered directly into the cerebrospinal fluid. This
may result in a high block, or, more rarely, a total spinal, where anaesthetic is
delivered directly to the brain stem, causing unconsciousness and sometimes
seizures.
• Neurological injury lasting less than 1 year (rare, about 1 in 6700).
• Death (very rare, less than 1 in 100 000).
• Epidural haematoma formation (very rare, about 1 in 168 000)
• Neurological injury lasting longer than 1 year (extremely rare, about 1 in 240 000).
• Paraplegia (extremely rare, 1 in 250 000).
General anaesthesia
D espite the increasing use of regional anaesthesia, general anaesthesia is required in
up to 5% of women requiring anaesthesia during birth. General anaesthesia can
usually be more rapidly administered than a regional block, and is therefore of value
when speed is important (such as when the fetus is in serious jeopardy). W omen are
pre-oxygenated (they are given oxygen to breathe for several minutes) prior to the
‘rapid sequence’ induction of anaesthesia with the intravenous administration of
anaesthetic (e.g. thiopentone or propofol) followed by a muscle relaxant (e.g.
suxamethonium) and cricoid pressure is applied (essential to reduce the risks of
aspiration of stomach contents). Maternal unconsciousness ensues within seconds and
orotracheal intubation is secured with a cuffed tube. There are minimal side-effects
and relatively li le negative fetal consequence at the time of birth provided
meticulous practices are in place.
A naesthesia is sustained by inhalational anaesthetic means (commonly enflurane or
sevoflurane) with an opioid administered intravenously after clamping the cord.
Difficult or failed intubation
This condition is more likely to occur in pregnant women, particularly with those who
have pregnancy-induced hypertension or who are obese. A ccess to the larynx may be
obstructed or difficult to view in these women and therefore anticipation of the
disorder is the key to its management. S hould difficulties be anticipated, anaesthetists
should carry out the intubation using a well-lubricated stylet or bougie to aid the
endotracheal intubation.
The management of a failed intubation is primarily to maintain adequate
oxygenation via assisted ventilation of the woman until the effects of suxamethonium
and thiopentone have worn off and the woman has regained consciousness. This is
done through the continued application of cricoid pressure and ventilation via a face
mask.
I t is therefore imperative that surgery is not commenced until the anaesthetist has
secured the airway and confirmed that the woman is adequately ventilated.
Complications
A lthough surgical and anaesthetic techniques have improved, women are still more
liable to suffer from complications and to have increased morbidity following
caesarean section under general anaesthetic when compared to regional blockade.
Mendelson's syndrome
This condition was described by Mendelson in 1946. I t is a chemical pneumonitis
caused by the reflux of gastric contents into the maternal lungs during a general
anaesthetic. The acidic gastric contents damage the alveoli, impairing gaseous
exchange. I t may become impossible to oxygenate the woman and death may result.
The predisposing factors are: the pressure from the gravid uterus when the woman is
lying down, and the effect of the progesterone relaxing smooth muscle and the cardiac
sphincter of the stomach. A nalgesics administered during labour (e.g. pethidine) can
cause significant delay in gastric emptying and will thereby exacerbate these risks.
Prevention of Mendelson's syndrome
Antacid therapy.
Prophylactic treatment should be administered to all women in whom a caesarean is
planned or anticipated. A usual regimen is for women having an elective operation to
be given two doses of oral ranitidine 150 mg approximately 8 hours apart. I f a general
anaesthetic is anticipated, 30 ml of sodium citrate should be orally administered
immediately before induction.
Cricoid pressure.
This is a technique whereby pressure is exerted on the cartilaginous ring below the
larynx, the cricoid, to occlude the oesophagus and prevent reflux (Fig. 21.9). This is the
most important measure in preventing pulmonary aspiration. Cricoid pressure is
administered during the induction of a general anaesthetic (most commonly by an
operating department practitioner) and is maintained until the tracheal tube is
confirmed as being correctly positioned and the seal of the cuff inflated.
FIG. 21.9 Cricoid pressure showing occlusion of the oesophagus by pressure applied to the
cricoid cartilage.
I n the UK the most recent review into anaesthetic complications during pregnancy
and childbirth, for the 2006–2008 triennium, reviewed 127 cases in which anaesthetic
services were involved in the care of women who died from either a direct or indirect
cause of maternal death. This comprised 49% (127 of 261) of all the maternal deaths
during that period. From these deaths the assessors identified seven (3%) women who
died from problems directly associated with anaesthesia a rate of 0.31 deaths per 100
000 women who gave birth. However, in a further 18 deaths, anaesthetic management
contributed to the outcome or there were lessons to be learned. There were also 12
women with severe pregnancy-induced hypertension or sepsis for whom obstetricians
or gynaecologists failed to consult with anaesthetic or critical-care services sufficiently
early, which the assessors considered may have contributed to the deaths.
It was concluded that:
• The effective management of failed tracheal intubation is a core anaesthetic skill that
should be rehearsed and assessed regularly.
• The recognition and management of severe, acute illness in a pregnant woman
requires multidisciplinary teamwork. An anaesthetist and/or critical-care specialist
should be involved early.
• Obstetric and gynaecology services, particularly those without an on-site critical-care
unit, must have a defined local guideline to obtain rapid access to, and help from,
critical-care specialists (CMACE 2011).
Research and the incidence of caesarean section:
tackling high and rising caesarean section rates
Low CS rates are associated with low levels of intervention and high levels of
psychological support. I t is difficult to decipher whether caesarean section rates have
been affected by interventions, such as proactive management of labour – that is,
artificial rupture of membranes and use of oxytocin – or whether other factors have
influenced these.
N I CE (2011)guidelines recommend that the clinical interventions proven to reduce
the rates of birth by CS include all the key points highlighted in Box 21.2.
Box 21.2
C inica l int e rve nt ions prove n t o re duce t he ra t e s of
birt h by C S
• External cephalic version (ECV) at 36 weeks
• Continuous support in labour
• Induction of labour for pregnancies beyond 41 weeks
• Use of a partogram with a 4 hour action line in labour
• Fetal blood sampling before caesarean section for abnormal
cardiotocograph in labour
• Support for women who choose vaginal birth after caesarean section
Source: NICE 2011
W hile there is no accepted optimal rate for CS in the UK, some units manage to
keep their CS rate below 20%. I f reductions in the rate are to be achieved, efforts
should focus on where there is the most potential for reduction: reducing primary CS ,
particularly in first-time mothers, and increasing rates of VBAC.
To provide more meaningful information to women when they are choosing their
mode of birth, N I CE has recommended that there is a pressing need to document the
medium- to long-term outcomes in women and their babies after a planned CS or a
planned vaginal birth. They note that it should be possible to gather data using
standardized questions (traditional paper-based questionnaires, face-to-face
interviews and I nternet-based questionnaires) about maternal septic morbidities and
emotional wellbeing up to 1 year after a planned CS in a population of women who
have consented for follow-up.
NICE (2011) also comment that it would be important to collect high-quality data on
infant morbidities after a planned CS compared with a planned vaginal birth. A long-
term morbidity evaluation (between 5 and 10 years after the CS ) could use similar
methodology to assess additional symptoms related to urinary and gastrointestinal
function.
Acknowledgement
The author would like to acknowledge the contribution of A dela Hamilton to this
chapter.
References
Anim-Somuah M, Smyth R M D, Jones L. Epidural versus non-epidural or no
analgesia in labour. Cochrane Database of Systematic Reviews. 2011;(Issue 12).
Association of Anaesthetists of Great Britain and Ireland (AAGBI). Immediate:
Post anaesthetic recovery. AAGBI: London; 2002.
Bragg F, Cromwell DA, Edozien LC, et al. Variation in rates of caesarean section
among English NHS trusts after accounting for maternal and clinical risk:
cross sectional study. British Medical Journal. 2010;341:c5065.
Brown HC, Paranjothy S, Dowswell T, et al. Package of care for active
management in labour for reducing caesarean section rates in low-risk women.
Cochrane Database of Systematic Reviews. 2008;(Issue 4).
Chaffer D, Royle L. The use of audit to explain the rise in caesarean section.
British Journal of Midwifery. 2000;8(11):677–684.
Charles C. How it feels to be a midwife practitioner. British Journal of Midwifery.
1999;7(6):380–382.
CMACE (Centre for Maternal and Child Enquiries). Saving mothers’ lives:
reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth
Report on Confidential Enquiries into Maternal Deaths in the United
Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology.
2011;118(Suppl 1):1–203.
Gupta JK, Hofmeyr GJ, Shehnmar M. Position in the second stage of labour for
women without epidural anaesthesia. The Cochrane Database of Systematic
Reviews. 2012;(Issue 5).
Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for preventing infection
following caesarean section. Cochrane Database of Systematic Reviews. 2012;
(Issue 9).
Health and Social Care Information Centre, Hospital Episodes Statistics. NHS
maternity statistics 2011–2012 summary report. [Accessed online at]
www.data.gov.uk; 2012 [14 May 2013] .
Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews. 2011;(Issue 2).
Johanson RB, Menon V. Vacuum extraction versus forceps for assisted vaginal
delivery. Cochrane Database of Systematic Reviews. 1999;(Issue 2).
Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH)
Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003–
2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the
United Kingdom. CEMACH: London; 2007.
McAleese S. Caesarean section for maternal choice? Midwifery Matters. 2000;84:1–
7.
NICE (National Institute for Health and Clinical Excellence). Intrapartum care.
Care of healthy women and their babies during childbirth. CG 55. NICE: London;
2007.
NICE (National Institute for Health and Clinical Excellence). Caesarean section.
CG 132. NICE: London; 2011.
O'Driscoll K, Meagher D, Boylan P. Active management of labour. 3rd edn. Mosby:
London; 1993.
Pare E, Quiñones J, Macones G. Vaginal birth after caesarean section versus
elective repeat caesarean section: assessment of maternal downstream health
outcomes. BJOG: An International Journal of Obstetrics and Gynaecology.
2006;113:75–85.
RCOG (Royal College of Obstetricians and Gynaecologists). Clinical Effectiveness
Support Unit. The National Sentinel Caesarean Section audit report. RCOG:
London; 2001.
RCOG (Royal College of Obstetricians and Gynaecologists). Operative vaginal
delivery. Green-top Guideline No. 26. RCOG: London; 2011.
Stephenson PA. International differences in the use of obstetrical interventions. World
Health Organization, Copenhagen, WHO EUR/ICP of MCH 112; 1992.
Tinsley V. Midwives undertaking ventouse births. Marshall J E, Raynor MD.
Advancing skills in midwifery practice. Churchill Livingstone: Edinburgh;
2010:67–75.
Walker R, Golois E. Why choose caesarean section? Lancet. 2001;357:636–637.
Weaver J, Stratham H, Richards M. Are there ‘unnecessary’ cesarean sections?
Perceptions of women and obstetricians about cesarean sections for
nonclinical indications. Birth. 2007;34(1):32–41.
Ziadeh SM, Sunna EI. Decreased cesarean birth rates and improved perinatal
outcome: a seven year study. Birth. 1995;22(3):144–147.
Further reading
CMACE. (Centre for Maternal and Child Enquiries) Perinatal mortality 2009: United
Kingdom. CMACE: London; 2011.
A useful audit report on perinatal deaths in the UK..
James DK, Steer PJ, Weiner CP, et al. High risk pregnancy: management options.
Elsevier Health Sciences: London; 2010.
This book examines the full range of challenges in general obstetrics, medical
complications of pregnancy, prenatal diagnosis, fetal disease and management of
labour and delivery. This comprehensive work features the fully searchable text
online at www.expertconsult.com, as well as more than 100 videos of imaging and
monitoring giving easy access to the resources needed to manage high-risk
pregnancies. It is a reference book, but a thoroughly readable one..
Luesley DM, Baker PN. Obstetrics and gynaecology: an evidence-based text for
MRCOG. 2nd edn. Hodder/Arnold: London; 2010.
This book, written by obstetricians approaching their Part 2 MRCOG examination, is a
useful handbook for students of midwifery and midwives alike. The perspective is
evidence-based and very woman-centred. Sections D and E focus on the first and
second stages of labour, their complications and management. It contains useful
references at the end of each chapter..
Simms R, Hayman R. Instrumental vaginal delivery. Obstetrics, Gynaecology and
Reproductive Medicine. 2011;21(1):7–14.
A general reference that informs the text of this chapter..
Useful websites
Mothers and Babies. Reducing Risk Through Audits and Confidential Enquiries
Across the UK. www.mbrrace.ox.ac.uk.
National Confidential Enquiry into Patient Outcome and Death.
www.ncepod.org.uk.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
National Patient Safety Agency. www.npsa.nhs.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
Scottish Intercollegiate Guideline Network. www.sign.ac.uk.
World Health Organization. www.who.net.
C H AP T E R 2 2
Midwifery and obstetric emergencies
Terri Coates
CHAPTER CONTENTS
Introduction 476
Communication 476
Use of the SBAR Tool 476
Vasa praevia 476
Diagnosis 477
Management 477
Presentation and prolapse of the umbilical cord 477
Predisposing factors 477
Cord presentation 478
Cord prolapse 478
Shoulder dystocia 479
Incidence 479
Risk factors 479
Warning signs and diagnosis 480
Management and manoeuvres 480
Outcomes following shoulder dystocia 483
Rupture of the uterus 484
Causes 484
Signs of intrapartum rupture of the uterus 484
Management 484
Amniotic fluid embolism 485
Predisposing factors 485
Clinical signs and symptoms 485
Emergency action 485
Complications of amniotic fluid embolism 486
Effect of amniotic fluid embolism on the fetus 486
Acute inversion of the uterus 486
Classification of inversion 486
Causes 487
Warning signs and diagnosis 487
Management 487
Basic life support measures 487
Shock 489
Hypovolaemic shock 489
Central venous pressure 491
Septic shock 492
Drug toxicity/overdose 492
References 492
Further reading 494
Useful websites 495
The emergency situations covered in this chapter are rare, but the
communication and actions of the midwife are fundamental to the wellbeing
of the woman, her baby and also her partner and family. Early detection of
severe illness in childbearing women remains a challenge to all health
professionals involved in their care. Awareness of local emergency
procedures and knowledge of correct use of any supportive equipment are
essential, and midwives in all practice settings must maintain skills that
enable them to act appropriately in an emergency. The use of
multiprofessional workshops to rehearse simulated situations can ensure
that all members of the care team know exactly what is required when
needed. Midwives need also to engage in reviews of practice to ensure that
policies and protocols are regularly reviewed to incorporate best practice
and current evidence.
The chapter aims to:
• recognize the importance of effective communication between members of the
multiprofessional team in critical clinical situations
• heighten awareness of sudden changes in maternal condition
• identify symptoms suggestive of serious illness
• discuss emergency situations with discussion of possible causes and the action to be
taken
• consider the rare obstetric conditions of uterine rupture, acute inversion of the uterus
and vasa praevia
• discuss amniotic fluid embolism and the prompt action required to preserve the
woman's life
• review the treatment of hypovolaemic shock and septic shock in midwifery practice
• outline the drills for basic resuscitation.
Introduction
The immediate management of the emergencies discussed in this chapter is
dependent on the prompt action of the midwife. Recognition of the problem and the
instigation of emergency measures may determine the outcome for the mother or the
fetus. The midwife should remain calm and a empt to keep the woman and her
partner fully informed to obtain her consent and cooperation for procedures that may
be needed.
I t is recognized that pregnancy and labour are normal physiological events, however
regular routine observations of vital signs must be an integral part of midwifery care.
There is potential for pregnant women and those who have recently given birth to be
at risk of physiological deterioration that is not always predicted or recognized (Centre
for Maternal and Child Enquiries [CMA CE] 2011 ). To improve recognition of women
who are unwell before they become critically ill the modified early obstetric warning
score (MEOWS) chart should now be used (CMACE 2011).
A ll midwifery and medical staff must be updated on the signs and symptoms of
critical illness from both obstetric and non-obstetric causes. Regular drills should be
held to maintain and improve these skills. A ll staff should be trained in basic life
support to a nationally recognized level and emergency drills for maternal
resuscitation should be regularly practised in all maternity units (CMA CE 2011 ;
N ational Health S ervice Litigation Authority [N HS LA ] 2011 ). Furthermore, effective
communication between members of the multiprofessional team is essential to ensure
the optimum outcome for the childbearing woman who becomes unwell and her baby
(National Health Service [NHS] Institute for Innovation and Improvement 2008).
Communication
Health services are often criticized for poor communication among their staff,
especially when the outcome does not go according to expectations. However, there
are very few instruments that specifically focus on how to improve verbal
communication. The S BA R: S ituation, Background, A ssessment and
Recommendations tool developed by the N HS I nstitute for I nnovations and
I mprovements (2008) is a framework that midwives can use to develop critical clinical
conversations that require immediate attention and action.
Use of the SBAR tool
The tool consists of standardized prompt questions about the condition of an
individual in four stages:
• Situation
• Background
• Assessment
• Recommendation.
These prompts can assist the midwife to assertively and effectively share concise
and focused information about a woman's condition, reducing repetition. The S BA R
tool can be used in all clinical conversations: face-to face, by telephone or through
collaborative multiprofessional team meetings.
I n each of the following midwifery and obstetric emergencies, the use of the S BA R
tool should be paramount in facilitating appropriate action that is always in the best
interest of the woman and her baby.
Vasa praevia
The term vasa praevia is used when a fetal blood vessel lies over the cervical os, in front
of the presenting part. This occurs when fetal vessels from a velamentous insertion of
the cord or to a succenturiate lobe (Chapter 6) cross the area of the internal os to the
placenta. The fetal life is at risk owing to the possibility of rupture of the vessels
leading to exsanguination unless birth occurs within minutes. Good outcome depends
on antenatal diagnosis and birth by caesarean section before the membranes rupture
(Oyelese and Smulian 2006).
Diagnosis
Vasa praevia may be diagnosed antenatally using ultrasound scan. S ometimes vasa
praevia will be palpated on vaginal examination when the membranes are still intact.
I f it is suspected, a speculum examination should be made. Fresh vaginal bleeding,
particularly if it commences at the same time as rupture of the membranes, may be
due to ruptured vasa praevia. Fetal distress disproportionate to blood loss may be
suggestive of vasa praevia.
Management
The midwife should call for urgent medical assistance. The fetal heart rate should be
monitored via cardiotocograph (CTG). I f the woman is in the first stage of labour and
the fetus is still alive, an emergency caesarean section is carried out. I f she is in the
second stage of labour, the birth should be expedited such that the baby may be born
vaginally. Caesarean section may be carried out but the mode of birth will be
dependent on parity and fetal condition.
There is a high fetal mortality associated with this emergency and a paediatrician
should therefore be present for the birth. I f the baby is born in poor condition,
resuscitation, urgent haemoglobin estimation and a blood transfusion with O -negative
blood may be necessary.
Presentation and prolapse of the umbilical cord
Predisposing factors
These are the same for both presentation and prolapse of the cord (for definitions see
Box 22.1). A ny situation where the presenting part is neither well applied to the cervix
nor well down in the pelvis may make it possible for a loop of cord to slip down in
front of the presenting part. Such situations include:
• high or ill-fitting presenting part
• high parity
• prematurity
• malpresentation
• multiple pregnancy
• hydramnios.
(Lin 2006; Holbrook and Phelan 2013)
Box 22.1
D e finit ions
Cord presentation
This occurs when the umbilical cord lies in front of the presenting part,
with the fetal membranes still intact.
Cord prolapse
The cord lies in front of the presenting part and the fetal membranes are
ruptured (see Fig. 22.1).
Occult cord prolapse
This is said to occur when the cord lies alongside, but not in front of, the
presenting part.
High head
I f the membranes rupture spontaneously when the fetal head is high, a loop of cord is
able to pass between the uterine wall and the fetus resulting in its lying in front of the
presenting part. A s the presenting part descends, the cord becomes trapped and
occluded.
Multiparity
The presenting part may not be engaged when the membranes rupture and
malpresentation is more common.
Prematurity
The smaller size of the fetus in relation to the pelvis and the uterus allows the cord to
prolapse. Babies of very low birth weight (<1500 g) are particularly vulnerable (Lin
2006; Holbrook and Phelan 2013).
Malpresentation
Cord prolapse is associated with breech presentation, especially complete or footling
breech. This relates to the ill-fi ing nature of the presenting parts and also the
proximity of the umbilicus to the bu ocks. I n this situation, the degree of
compression may be less than with a cephalic presentation, but there is still a danger
of asphyxia.
S houlder and compound presentation and transverse lie (Chapter 20) carry a high
risk of prolapse of the cord, occurring with spontaneous rupture of the membranes.
Multiple pregnancy
Malpresentation, particularly of the second twin, is more common in multiple
pregnancy with the consequences of possible cord prolapse.
Hydramnios
The cord is liable to be swept down in a gush of liquor if the membranes rupture
spontaneously. Controlled release of liquor during artificial rupture of the membranes
is sometimes performed to try to prevent this.
Cord presentation
This is diagnosed on vaginal examination when the cord is felt behind intact
membranes. I t may be associated with aberrations found during fetal heart
monitoring such as decelerations, which occur if the cord becomes compressed.
Management
Under no circumstances should the membranes be ruptured. The midwife should
discontinue the vaginal examination, in order to reduce the risk of rupturing the
membranes. Medical aid should be summoned. To assess fetal wellbeing, continuous
electronic fetal monitoring should be commenced or the fetal heart should be
auscultated as frequently as possible. The woman should be assisted into a position
that will reduce the likelihood of cord compression. Unless birth is imminent,
caesarean section is the most likely outcome.
Cord prolapse
Diagnosis
W henever there are factors present that predispose to cord prolapse (Fig. 22.1), a
vaginal examination should be performed immediately on spontaneous rupture of the
membranes.
FIG. 22.1 Cord prolapse.
Bradycardia and variable or prolonged decelerations of the fetal heart are associated
with cord compression, which may be caused by cord prolapse. The diagnosis of cord
prolapse is made when the cord is felt below or beside the presenting part on vaginal
examination. The cord may be felt in the vagina or in the cervical os or a loop of cord
may be visible at the vulva (Lin 2006).
Immediate action
W here the diagnosis of cord prolapse is made, the time should be noted and the
midwife must call for urgent assistance. The midwife should explain to the woman and
her birth partner her findings and any emergency measures that may be needed. I f an
oxytocin infusion is in progress this should be discontinued. I f the cord lies outside
the vagina, then it should be gently replaced to prevent spasm, to maintain
temperature and prevent drying. A dministering oxygen to the woman by face mask at
4 l/min may improve fetal oxygenation.
Relieving pressure on the cord
The risks to the fetus are hypoxia and death as a result of cord compression. The risks
are greatest with prematurity and low birth weight (Holbrook and Phelan 2013). The
midwife may need to keep her fingers in the vagina and hold the presenting part off
the umbilical cord, especially during a contraction. The woman can be supported to
change position and further reduce pressure on the cord. I f the woman raises her
pelvis and bu ocks or adopts the knee–chest position, the fetus will be encouraged to
gravitate towards the diaphragm (Fig. 22.2). The foot of the bed may also be raised
(Trendelenburg position) to relieve compression on the cord. A lternatively, the
woman can be helped to lie on her left side, with a wedge or pillow elevating her hips
(exaggerated Sims' position) (Fig. 22.3). There is some evidence to suggest that bladder
filling may also be an effective technique for managing cord prolapse (Houghton 2006;
Bord et al 2011). A self-retaining 16G Foley catheter is used to instill approximately
500–700 ml of sterile saline into the bladder. The full bladder can relieve compression
of the cord by elevating the presenting part about 2 cm above the ischial spines until
birth by caesarean section. The bladder would be drained in theatre immediately
before the caesarean section commences.
FIG. 22.2 Knee–chest position. Pressure on the umbilical cord is relieved as the fetus gravitates
towards the fundus.
FIG. 22.3 Exaggerated Sims' position. Pillows or wedges are used to elevate the woman's
buttocks to relieve pressure on the umbilical cord.
Birth must be expedited with the greatest possible speed to reduce the mortality and
morbidity associated with this emergency. Caesarean section is the treatment of choice
in those instances where the fetus is still alive and vaginal birth is not imminent.
I f a cord prolapse is diagnosed in the second stage of labour, with a multigravida,
the midwife may perform an episiotomy to expedite the birth. W here the presentation
is cephalic, assisted birth may be achieved through ventouse or forceps (Chapter 21).
I f a cord prolapse occurs in the community se ing , emergency transfer to a
consultant-led maternity unit is essential. The midwife should carry out the same
procedures to relieve the compression on the cord. S enior obstetric and anaesthetic
staff should be informed and be prepared to perform an emergency caesarean section.
A n experienced paediatrician should be available to resuscitate the baby, should it be
born alive.
Shoulder dystocia
The term shoulder dystocia describes failure of the shoulders to traverse the pelvis
spontaneously requiring additional manoeuvres after the birth of the head (Royal
College of O bstetricians and Gynaecologists [RCO G] 2012 ). However, a universally
accepted definition of shoulder dystocia has yet to be produced (RCOG 2012).
The anterior shoulder becomes trapped behind or on the symphysis pubis, while the
posterior shoulder may be in the hollow of the sacrum or high above the sacral
promontory (Fig. 22.4). This is, therefore, a bony dystocia, and traction at this point
will further impact the anterior shoulder, impeding attempts to assist the baby's birth.
FIG. 22.4 Shoulder dystocia.
Incidence
S houlder dystocia is not a common emergency: the incidence is reported as varying
between 0.58% and 0.7% in collected data (RCOG 2012).
Risk factors
A lthough it would be useful to identify those women at risk from a birth complicated
by shoulder dystocia, most risk factors can give only a high index of suspicion (Al-
N ajashi et al 1989). A ntenatal risk factors include diabetes, post-term pregnancy, high
parity, maternal age over 35 and maternal obesity (weight over 90 kg).
Fetal macrosomia (birth weight over 4000 g) has been associated with an increased
risk of shoulder dystocia, the incidence increasing as birth weight increases (Delpapa
and Mueller-Heubach 1991; Hall 1996). Ultrasound scanning for prediction of
macrosomia to prevent shoulder dystocia still has a poor record of success though it is
anticipated that ultrasound detection of macrosomia can be improved (Hall 1996;
S iggelkow et al 2011). I f a large baby is suspected then this fact must be
communicated clearly to the team caring for the woman in labour (Confidential
Enquiries into Stillbirths and Deaths in Infancy [CESDI] 1999).
Maternal diabetes and gestational diabetes have been identified as important risk
factors (Athukorala et al 2007). I n diabetic women, a previous birth complicated by
shoulder dystocia increases the risk of recurrence to 9.8%; this compares with a risk of
recurrence of 0.58% in the general population (S mith et al 1994; O uzounian et al 2012).
The N ational I nstitute for Health and Clinical Excellence (N I CE) diabetes guidelin
currently recommends elective birth is offered at 38 weeks' gestation (NICE 2008).
I n labour, risk factors that have been consistently linked with shoulder dystocia
include oxytocin augmentation, prolonged labour, prolonged second stage of labour
and operative births (Benede i and Gabbe 1978; A l-N ajashi et al 1989; Keller et al
1991; Bahar 1996; Gupta et al 2010). For a clinically suspected large baby, the
multiprofessional team must be alert for the possibility of shoulder dystocia (CESDI
1999).
Warning signs and diagnosis
The birth may have been uncomplicated initially, but the head may have advanced
slowly, with the chin having difficulty in sweeping over the perineum. O nce the head
is born, it may look as if it is trying to return into the vagina (the turtle sign). S houlder
dystocia is diagnosed when manoeuvres such as gentle downward axial traction* on
the head, that may normally be used by the midwife, fail to complete the birth (RCOG
2012). The woman should be discouraged from pushing and any further traction must
be avoided.
Management and manoeuvres
HELPERR is a mnemonic devised by the A merican A cademy for Family Physicians
(2004) for A dvanced Life S upport in O bstetrics (A LS O ®) to assist clinicians in
remembering a sequence of manoeuvres to relieve shoulder dystocia. The midwife
should exercise judgment when recalling manoeuvres and decide the appropriate
order required for an individual situation (see Box 22.2).
Box 22.2
H E L P E R R m ne m onic
Help
Episiotomy need assessed
Legs in McRoberts position
Pressure suprapubically
Enter vagina (internal rotation)
Remove posterior arm
Roll the woman over and try again
Adapted from the American Academy of Family Physicians (2004) Advanced Life Support in
Obstetrics (ALSO®)
Upon diagnosing shoulder dystocia, the midwife must summon help immediately:
the midwife coordinator, an experienced obstetrician, an anaesthetist and a person
proficient in neonatal resuscitation. S tating the problem early to the team has been
associated with improvements in outcomes in shoulder dystocia (RCOG 2012).
S houlder dystocia is a frightening experience for the woman, for her partner and for
the midwife. The midwife should keep calm and explain as much as possible to the
woman to ensure her full cooperation for the manoeuvres that may be needed to
complete the birth.
The purpose of all these manoeuvres is to disimpact the shoulders. The principle of
using the simplest manoeuvres first should be applied. The midwife will need to make
an accurate and detailed record of the time help was summoned and those who
a ended, the type of manoeuvre(s) used and the time taken, the amount of force used
and the outcome of each manoeuvre a empted (N ursing and Midwifery Council
[NMC] 2012). It is also important to record which of the fetal shoulders was anterior.
Non-invasive procedures
Change in maternal position
A ny change in the maternal position may be useful to help release the fetal shoulders
as shoulder dystocia is a bony, mechanical obstruction. However, certain manoeuvres
have proved useful and are described below. I t is anticipated that following the use of
one or more of these manoeuvres, the birth is likely to proceed.
The McRoberts manoeuvre
This manoeuvre involves assisting the woman to lie completely flat (pillows removed)
with her bu ocks at the edge of the bed and hyperflexing her hips to bring her knees
up to her chest as far as possible (Fig. 22.5).
FIG. 22.5 The McRoberts manoeuvre position.
This manoeuvre will rotate the angle of the symphysis pubis superiorly and use the
weight of the woman's legs to create gentle pressure on her abdomen, releasing the
impaction of the anterior shoulder (Gonik et al 1983, 1989). The McRoberts manoeuvre
is associated with the lowest level of morbidity and requires the least force to assist
the birth (Bahar 1996; RCOG 2012).
Suprapubic pressure
Pressure should be exerted on the side of the fetal back and towards the fetal chest.
This manoeuvre may help to adduct the shoulders and push the anterior shoulder
away from the symphysis pubis into the larger oblique or transverse diameter (Fig.
22.6). S uprapubic pressure can be employed together with the McRoberts manoeuvre
to improve success rates (RCOG 2012).
FIG. 22.6 Correct application of suprapubic pressure for shoulder dystocia. After Pauerstein C (ed),
Clinical obstetrics. Churchill Livingstone, New York, 1987, with permission.
All-fours position
The all-fours position (or Gaskin manoeuvre) is achieved by assisting the woman onto
her hands and knees. The act of the woman turning may be the most useful aspect of
this manoeuvre (Bruner et al 1998). I n shoulder dystocia, the impaction is at the pelvic
inlet and the force of gravity will keep the fetus against the anterior aspect of the
mother's uterus and pelvis. However, this manoeuvre may be especially helpful if the
posterior shoulder is impacted behind the sacral promontory as this position
optimizes space available in the sacral curve and may allow the posterior arm/shoulder
to be born first. Manipulative manoeuvres can be performed while the woman is on all
fours but clear verbal communication is needed as eye contact is difficult.
W here non-invasive procedures have not been successful, direct manipulation of the
fetus must be a empted, requiring the midwife to insert a whole hand into the vagina.
The McRoberts position as detailed above can be used, or the woman could be placed
in the lithotomy position with her buttocks well over the end of the bed so that there is
no restriction on the sacrum.
Episiotomy
The problem facing the midwife is an obstruction at the pelvic inlet which is a bony
dystocia, not an obstruction caused by soft tissue. A lthough episiotomy (Chapters 15
and 17) will not help to release the shoulders per se, the midwife should consider the
need to perform one to gain access to the fetus without tearing the perineum and
vaginal walls.
Rotational manoeuvres
The Rubin manoeuvre
Rubin (1964) advocated using suprapubic rocking to dislodge the anterior shoulder. I f
rocking alone proved unsuccessful, vaginal examination (inserting the whole hand)
was suggested to identify the most accessible shoulder (usually the posterior
shoulder), and push that shoulder in the direction of the fetal chest. This process
adducts the shoulders and allows rotation away from the symphysis pubis. The
manoeuvre reduces the 12 cm bisacromial diameter (Fig. 22.7).
FIG. 22.7 The Rubin manoeuvre.
The Woods manoeuvre
Woods' (1943) manoeuvre requires the midwife to insert a whole hand into the vagina
and identify the fetal chest. Then, by exerting pressure on to the posterior fetal
shoulder, rotation is achieved. A lthough this manoeuvre does abduct the shoulders, it
will rotate the shoulders into a more favourable diameter and enable the midwife to
complete the birth (Fig. 22.8).
FIG. 22.8 The Woods manoeuvre. After Sweet B R, Tiran D, Mayes' midwifery. Baillière Tindall, London,
1996: p 664, with permission.
Birth of the posterior arm
The midwife has to insert a hand into the vagina, making use of the space created by
the hollow of the sacrum, as shown in Figs 22.9A,B. Then two fingers grasp the wrist of
the posterior arm (see Fig. 22.9C), to flex the elbow and sweep the forearm over the
chest for the hand to be born, as shown in Fig. 22.9D (O 'Leary 2009). I f the rest of the
birth is not then accomplished, the birth of the second arm is assisted following
rotation of the shoulder using either the W oods or Rubin manoeuvre or by reversing
the Løvset manoeuvre (Chapter 17).
FIG. 22.9 Birth of the posterior arm. (A) Location of the posterior arm. (B) Directing the arm into
the hollow of the sacrum. (C) Grasping and splinting the wrist and forearm. (D) Sweeping the arm
over the chest and delivering the hand.
Zavanelli manoeuvre
I f the manoeuvres described above have been unsuccessful, the obstetrician may
consider the Zavanelli manoeuvre (S andberg 1985, 1999) as a last hope for birth of a
live baby. The Zavanelli manoeuvre requires the reversal of the mechanisms of birth
so far achieved and reinsertion of the fetal head into the vagina. The birth is then
completed by caesarean section.
Method: The head is returned to its pre-restitution position (Fig. 22.10A). Pressure is
then exerted onto the occiput and the head is returned to the vagina (Fig. 22.10B).
Prompt birth of the baby by caesarean section is then required.
FIG. 22.10 The Zavanelli manoeuvre. (A) Head being returned to direct anteroposterior (pre-
restitution) position. (B) Head being returned to the vagina. After Sandberg 1985, with permission.
Symphysiotomy
S ymphysiotomy is the surgical separation of the symphysis pubis and is used to
enlarge the pelvis to enable the birth. I t is usually performed in cases of cephalopelvic
disproportion (CPD ) and is used more routinely in the developing world. There are a
few recorded cases where symphysiotomy has been used successfully to relieve
shoulder dystocia (W ykes et al 2003), but the procedure has usually been associated
with a high level of maternal morbidity. The rarity of reported cases makes it difficult
to assess the technique for the relief of shoulder dystocia.
Outcomes following shoulder dystocia
Maternal
A pproximately two-thirds of women will have a blood loss of >1000 ml from injury
associated with the birth (O 'Leary 2009). Maternal death from uterine rupture has
been reported following the use of fundal pressure and from haemorrhage during and
following the birth (O'Leary 2009).
Fetal
N eonatal asphyxia may occur following shoulder dystocia in 5.7–9.7% of cases and the
a ending paediatrician must be experienced in neonatal resuscitation (CES D I 1999 ;
RCO G 2012). Brachial plexus injury is commonly associated with shoulder dystocia
(Gurewitsch et al 2006; S andmire and D eMo 2009). D amage to cervical nerve roots 5
and 6 may result in an Erb's palsy (Chapter 31).
N eonatal morbidity may be as high as 42% following shoulder dystocia and remains
a cause of intrapartum fetal death (CES D I 1999 ). Fetal damage may occur even with
excellent management using appropriate obstetric manoeuvres. Following shoulder
dystocia, examination of the newborn should be carried out by a senior neonatal
clinician (RCOG 2012).
The midwife must ensure that simulation training and practice drills are a ended
annually to maintain skills (Crofts et al 2006; RCO G 2012). Record keeping following
shoulder dystocia should include identification of the anterior shoulder and the
direction of the fetal head as shown in Box 22.3 (NMC 2012; RCOG 2012).
Box 22.3
K e y point s for re cord ke e ping following shoulde r
dyst ocia
• Time of birth of the head and time of birth of the body
• Anterior shoulder at the time of the dystocia
• Manoeuvres performed, their timing and sequence
• Maternal perineal and vaginal examination
• Estimated blood loss
• Staff in attendance and the time they arrived
• General condition of the baby (Apgar score)
• Umbilical cord blood acid–base measurements
• Neonatal assessment of the baby
• Time of completion of records
Adapted from RCOG (2012)
Rupture of the uterus
Rupture of the uterus is one of the most serious complications in midwifery and
obstetrics. I t is often fatal for the fetus and may also be responsible for the death of
the mother. I n the 2006–2008 triennial report, there were 111 cases of uterine rupture
reported as causing morbidity in women, however, of the nine maternal deaths from
haemorrhage, only one was associated with uterine rupture (N orman 2011).
N evertheless, uterine rupture remains a significant problem worldwide. With effective
antenatal and intrapartum care, some cases of uterine rupture may be avoided.
Rupture of the uterus is defined as being complete or incomplete:
• complete rupture involves a tear in the wall of the uterus with or without expulsion of
the fetus
• incomplete rupture involves tearing of the uterine wall but not the perimetrium.
Dehiscence of an existing uterine scar may also occur. This involves rupture of the
uterine wall but the fetal membranes remain intact. The fetus is retained within the
uterus and not expelled into the peritoneal cavity (Cunningham et al 2010; Landon
2010). The risk of uterine rupture is increased for those women who have a uterine
scar. S tudies cite figures of between 0.4 and 4% of labours following a previous
caesarean section (Landon 2010).
Causes
Cases of spontaneous rupture of an unscarred uterus in primigravidae are reported in
the literature (Roberts and Trew 1991; Uccella et al 2011), but are very rare in the
developed world (Hofmeyr et al 2005).
Rupture of the uterus can be precipitated in the following circumstances:
• antenatal rupture of the uterus, where there has been a history of previous uterine
surgery
• neglected labour, where there is previous history of caesarean section
• high parity
• use of oxytocin, particularly where the woman is of high parity
• use of prostaglandins to induce labour, in the presence of an existing scar (Lydon-
Rochelle et al 2001; Landon 2010)
• obstructed labour: the uterus ruptures owing to excessive thinning of the lower
segment (Bandl's ring)
• extension of severe cervical laceration upwards into the lower uterine segment – the
result of trauma during an assisted birth
• trauma, as a result of a blast injury or an accident (Michiels et al 2007)
• perforation of the non-pregnant uterus can result in rupture of the uterus in a
subsequent pregnancy (Usta et al 2007; Landon 2010).
Signs of intrapartum rupture of the uterus
Complete rupture of a previously non-scarred uterus may be accompanied by sudden
collapse of the woman, who complains of severe abdominal pain. The maternal pulse
rate increases and, simultaneously, alterations of the fetal heart may occur, including
the presence of variable decelerations (Landon 2010). I n the UK during the triennium
2003–2005 there were three intrapartum fetal deaths associated with ruptured uterus
(A colet 2007). There may be evidence of fresh vaginal bleeding. The uterine
contractions may stop and the contour of the abdomen alters. The fetus becomes
palpable in the abdomen as the presenting part regresses. The degree and speed of the
woman's collapse and shock depend on the extent of the rupture and the blood loss
(see Box 22.4).
Box 22.4
K e y signs of rupt ure of ut e rus
• Abdominal pain or pain over previous caesarean section scar
• Abnormalities of the fetal heart rate and pattern
• Vaginal bleeding
• Maternal tachycardia
• Poor progress in labour
I ncomplete rupture may have an insidious onset found only after birth or during a
caesarean section. This type is more commonly associated with previous caesarean
section. Blood loss associated with dehiscence, or incomplete rupture, can be scanty,
as the rupture occurs along the fibrous scar tissue, which is avascular (Landon 2010).
W henever shock during the third stage of labour is more severe than the type of
birth or blood loss would indicate, or the woman fails to respond to the treatment
given, the possibility of incomplete rupture should be considered. I ncomplete rupture
may also be manifest as a cause of abdominal pain and/or postpartum haemorrhage
following vaginal birth.
Management
A ll maternity units should have a protocol for dealing with uterine rupture. A n
immediate caesarean section is performed in the hope of procuring a live baby.
Following the birth of the baby and placenta, the extent of the rupture can be assessed.
Choice between the options to perform a hysterectomy or to repair the rupture
depends on the extent of the trauma and the woman's condition. Further clinical
assessment will include evaluation of the need for blood replacement and
management of any shock.
The woman will be unprepared for the events that have occurred and therefore may
be totally opposed to hysterectomy. Few reports of successful pregnancy following
repair of uterine rupture are available (Landon 2010).
Amniotic fluid embolism
A mniotic fluid embolism (A FE) is rare, unpredictable and unpreventable. I n the
triennium 2006–2008, there were a total of 13 maternal deaths (0.57/100 000
maternities) resulting from A FE with the diagnosis having been confirmed clinically
and by post-mortem examination (D awson 2011). A lthough A FE has now fallen to
fourth place among the leading causes of direct maternal deaths (D awson 2011) and
continues to be a significant factor in maternal mortality, it is no longer considered
universally fatal through improvements in resuscitation.
A mniotic fluid embolism occurs when amniotic fluid enters the maternal circulation
via the uterus or placental site such that maternal collapse can progress rapidly. The
body responds to A FE in two phases. The initial phase is one of pulmonary vasospasm
causing hypoxia, hypotension, pulmonary oedema and cardiovascular collapse. The
second phase sees the development of left ventricular failure, with haemorrhage and
coagulation disorder and further uncontrollable haemorrhage. Mortality and
morbidity are high (D awson 2011) though early diagnosis may lead to a be er
outcome (Knight et al 2010) and early transfer to an intensive care unit is associated
with decreased morbidity (Dawson 2011).
W hen A FE occurs in a well-equipped unit, it should be considered a treatable and
survivable event in the majority of cases (Knight et al 2010). Emergency drills for
maternal resuscitation and peri-mortem caesarean section should be regularly
practised in clinical areas in all maternity units (Dawson 2011).
Predisposing factors
A mniotic fluid embolism can occur at any gestation. Chance entry of amniotic fluid
into the circulation under pressure may occur through the uterine sinuses of the
placental bed. I t is mostly associated with labour and its immediate aftermath, but
cases in early pregnancy and postpartum have been documented (Knight et al 2010).
The barrier between the maternal circulation and the amniotic sac may be breached
during periods of raised intra-amniotic pressure, such as termination of pregnancy or
during placental abruption. Procedures such as artificial rupture of the membranes
(A RM) and insertion of an intrauterine catheter, have been associated with A FE.
A mniotic fluid embolism can also occur during an intrauterine manipulation, such as
internal podalic version or during a caesarean section.
Clinical signs and symptoms
Premonitory signs and symptoms (restlessness, abnormal behaviour, respiratory
distress and cyanosis) may occur before collapse (Knight et al 2010). There is maternal
hypotension and uterine hypertonus. The la er will induce fetal compromise and is in
response to uterine hypoxia. Cardiopulmonary arrest follows quickly. O nly minutes
may elapse before cardiac arrest. Blood coagulopathy develops following the initial
collapse (Dawson 2011). The key signs and symptoms are summarized in Box 22.5.
Box 22.5
K e y signs a nd sym pt om s of a m niot ic fluid e m bolism
• Respiratory
– Cyanosis
– Dyspnoea
– Respiratory arrest
• Cardiovascular
– Tachycardia
– Hypotension
– Pale clammy skin/shivering
– Cardiac arrest
• Haematological
– Haemorrhage from placental site
– Coagulation disorders, DIC
• Neurological
– Restlessness, panic
– Convulsions
• Fetal compromise
Emergency action
A ny one of the above symptoms is indicative of an acute emergency. A s the woman is
likely to be in a state of collapse, effective resuscitation needs to be commenced at
once. A n emergency team should be called since the midwife responsible for the care
of the woman will require immediate assistance. I f collapse occurs in a community
se ing, basic life support should be commenced prior to the arrival of emergency
services.
D espite improvements in intensive care, the outcome of this condition is poor if
A FE occurs outside a hospital se ing. S pecific management for the condition is life
support, with high levels of oxygen being required.
Complications of amniotic fluid embolism
D isseminated intravascular coagulation (D I C) is likely to occur within 30 minutes of
the initial collapse. I n some cases the woman bleeds heavily prior to developing
amniotic fluid embolism, which contributes to the severity of her condition. I t has also
been reported that the amniotic fluid has the ability to suppress the myometrium,
resulting in uterine atony.
A cute renal failure is a complication of the excessive blood loss and the prolonged
hypovolaemic hypotension. Prompt transfer to a critical care unit for specialized care
improves the outcome in AFE (Knight et al 2010; Dawson 2011).
Midwifery support and advice should be continued for the family. The woman
should be given the opportunity to talk about emergency treatment when she has
recovered sufficiently (Mapp 2005; Mapp and Hudson 2005).
Effect of amniotic fluid embolism on the fetus
Perinatal mortality and morbidity are high where amniotic fluid embolism occurs
before the birth of the baby. D elay in the time from initial maternal collapse to the
baby's birth needs to be minimal if fetal compromise or death is to be avoided.
However, maternal resuscitation may, at that time, be a priority. Box 22.6 summarizes
the key points relating to amniotic fluid embolism.
Box 22.6
K e y point s for a m niot ic fluid e m bolism
• Major cause of maternal death worldwide
• Universal features: maternal shock, dyspnoea and cardiovascular collapse
• Fetal compromise
• Can occur at any time: most commonly immediately after labour
• Suspected in cases of sudden collapse or uncontrollable bleeding
A ll cases of suspected or proven amniotic fluid embolism, whether fatal or not,
should be reported to the N ational A mniotic Fluid Embolism Register at the following
address:
United Kingdom Obstetric Surveillance System [UKOSS]
National Perinatal Epidemiology Unit [NPEU]
University of Oxford (Old Road Campus)
Old Road
Headington
Oxford
OX3 7LF
Acute inversion of the uterus
This is a rare but potentially life-threatening complication of the third stage of labour.
I t occurs in approximately 1 in 20 000 births (Wi eveen et al 2013). A midwife's
awareness of the precipitating factors enables her to take preventive measures to avoid
this emergency.
Classification of inversion
Inversion can be classified according to severity as follows:
• first-degree: the fundus reaches the internal os
• second-degree: the body or corpus of the uterus is inverted to the internal os (Fig.
22.11)
FIG. 22.11 Second-degree inversion of the uterus.
• third-degree: the fundus protrudes to or beyond the introitus and is visible
• fourth degree: this is total uterine and vaginal inversion where both the uterus and
vagina are inverted beyond the introitus.
Inversion is also classified according to the timing of the event:
• acute inversion: occurs within the first 24 hours
• subacute inversion: occurs after the first 24 hours, and within 4 weeks
• chronic inversion: occurs after 4 weeks and is rare (Bhalia et al 2009).
It is the first of these, acute inversion, that the remainder of this section considers.
Causes
Causes of acute inversion are associated with uterine atony and cervical dilatation, and
include:
• mismanagement in the third stage of labour, involving excessive cord traction to
manage the birth of the placenta
• combining fundal pressure and cord traction to expel the placenta
• use of fundal pressure to expel the placenta while the uterus is atonic
• pathologically adherent placenta
• spontaneous occurrence, of unknown cause
• primiparity
• fetal macrosomia
• short umbilical cord
• sudden emptying of a distended uterus.
(Momin 2009; Witteveen et al 2013)
Careful management of the third stage of labour is needed to prevent inversion of
the uterus. I n active management of the third stage of labour, palpation of the fundus
is essential to confirm that contraction has taken place, prior to undertaking controlled
cord traction.
Warning signs and diagnosis
The major sign of acute inversion of the uterus is profound shock and usually
haemorrhage. The blood loss is within a range of 800–1800 ml. I nversion of the uterus
will cause the woman severe abdominal pain. O n palpation of the uterus, the midwife
may feel an indentation of the fundus. W here there is a major degree of inversion the
uterus may not be palpable abdominally but may be felt upon vaginal examination or,
in a severe case, the uterus may be seen at the vulva.
The pain is thought to be caused by the stretching of the peritoneal nerves and the
ovaries being pulled as the fundus inverts. Bleeding may or may not be present,
depending on the degree of placental adherence to the uterine wall. The cause of the
symptoms may not be readily apparent and diagnosis may be missed if inversion is
incomplete.
Management
Immediate action
A swift response is needed to reduce the risks to the woman. Throughout the events
the woman and her partner should be kept informed of what is happening.
Assessment of vital signs, including level of consciousness, is of utmost importance.
1. Urgent medical help is summoned.
2. The midwife in attendance should immediately attempt to replace the uterus. If
replacement is delayed the uterus can become oedematous and replacement will
become increasingly difficult. Replacement may be achieved by pushing the fundus
with the palm of the hand, along the direction of the vagina, towards the posterior
fornix. The uterus is then lifted towards the umbilicus and returned to position with
a steady pressure known as Johnson's manoeuvre. If replacement cannot be achieved
immediately the foot of the bed can be raised to reduce traction on the uterine
ligaments and ovaries (Cunningham et al 2010; Witteveen et al 2013).
3. An intravenous cannula should be inserted and blood taken for cross-matching
prior to commencing an infusion.
4. Analgesia such as morphine may be given to the woman.
5. If the placenta is still attached, it should be left in situ as attempts to remove it at
this stage may result in uncontrollable haemorrhage.
6. Once the uterus is repositioned, the midwife or obstetrician should keep their hand
in situ until a firm contraction is palpated. Oxytocics should be given to maintain
the contraction (Cunningham et al 2010; Witteveen et al 2013).
Medical management
The hydrostatic method of replacement involves the instillation of several litres of
warm saline infused through a giving set into the vagina. The pressure of the fluid
builds up in the vagina and restores the uterus to the normal position, while the
midwife or obstetrician seals off the introitus by hand or using a soft ventouse cup.
I f the inversion cannot be replaced manually, a cervical constriction ring may have
developed. D rugs can be given to relax the constriction and facilitate the return of the
uterus to its normal position. S urgical correction via a laparotomy may be needed to
correct inversion. Full support and explanation of the emergency should be offered to
the woman in the postnatal period (Mapp 2005; Mapp and Hudson 2005; Witteveen
et al 2013).
Basic life support measures
Cardiac arrests are rare in maternity units but they can occur and their management is
sometimes suboptimal (CMA CE 2011 ). The midwife must undertake, record and act
on basic observations using the Modified Early O bstetric Warning S coring (MEO W S
system that contain triggers to identify symptoms and recognize any deterioration in
the woman's condition in order to prompt medical referral (CMACE 2011). A ll medical
and midwifery staff should be trained to a nationally recognized level: Basic Life
S upport (BLS ), I mmediate Life S upport (I LS ) or A dvanced Life S upport (A LS ),
appropriate (N ational Patient S afetyA gency 2007; Resuscitation Council UK [RCUK
2010; CMACE 2011; RCOG 2011).
Emergency drills for maternal resuscitation should be regularly practised in clinical
areas in all maternity units (N HS LA 2011 ). These drills should include the
identification of the equipment required and appropriate methods for ensuring that
cardiac arrest teams know the location of the maternity unit and theatres in order to
arrive promptly. S pecialized courses such as A dvanced Life S upport in O bstetrics
(A LS O ®) and Managing O bstetric Emergencies and Trauma (MO ET) provid
additional training for obstetric, midwifery and other staff employed in the area of
midwifery and obstetric care.
S tandards of basic life support have been agreed internationally for health
professionals and lay people (RCUK 2010). Basic life support refers to the maintenance
of an airway and support for breathing, without any specialist equipment other than
possibly a pharyngeal airway. Recent guidelines place greater emphasis on high
quality cardiopulmonary resuscitation (CPR) with minimal interruptions in chest
compressions. The basic principles are as follows:
A Airway
B Breathing
C Circulation
D Disability: assess consciousness
E Environment: keep safe
(RCUK 2010)
1. Check the surroundings to establish it is safe to proceed.
2. Establish the level of consciousness by shaking the woman's shoulders and
enquiring whether she can hear.
3. Summon urgent assistance by the most appropriate means if there is no response.
4. If the woman is already lying flat on her back, remove any pillows. A pregnant
woman should be further positioned with a left lateral tilt to prevent aortocaval
compression.
5. Tilt the woman's head back, lifting the chin upwards to open the airway (Fig. 22.12).
Any obstruction, such as mucus or vomit, should be cleared away.
FIG. 22.12 The airway is opened by tilting the head backwards and lifting the chin upwards.
6. Observe for chest movements, listen and feel for breath.
7. Commence chest compressions, if the pulse is absent or the breathing is absent or
abnormal.
8. Place the hands palm downwards one on top of the other with the fingers
interlinked, with the heel of the lower hand positioned over the lower part of the
sternum. With arms straight, compress the chest 100–120 times/min to a depth of
5 cm, releasing at the same rate as compression. The chest should recoil completely
after each compression.
9. Consider kneeling over the woman or find something to stand on to ensure a
suitable position to carry out resuscitation (Fig. 22.13). The surface under the
woman must be firm for compressions to succeed.
FIG. 22.13 Chest compression. The midwife leans well over the patient, with arms straight.
Hands are one on top of the other with fingers interlinked. The heel of the hand is used to
compress the chest.
10. Give two rescue breaths after 30 chest compressions, preferably by bag and mask but
mouth-to-mouth if necessary. Each breath should last for only 1 second. Ensure that
the woman's chest rises with each breath and is seen to fall again. If unhappy to
perform mouth-to-mouth breathing, continue chest compressions only.
11. Minimize any interruptions to chest compressions.
12. A change in rescuers should occur every 2 minutes where possible.
(RCUK 2010)
Chest compression and rescue breathing should be continued until help arrives
when those experienced in resuscitation are able to take over (Grady et al 2007; RCUK
2010). The exact sequences of resuscitation will depend on the training of staff and
their experience in assessment of breathing and circulation. These measures are
summarized in Box 22.7.
Box 22.7
K e y point s for ba sic life support
• Check safety of surroundings
• Gently shake the woman and shout
• Call for help
• Check the woman's breathing
• Check the woman's pulse
• Use 30 chest compressions to 2 breaths
• Continue resuscitative measures until help arrives
Adapted from RCUK (2010)
Shock
S hock is a complex syndrome involving a reduction in blood flow to the tissues that
may result in irreversible organ damage and progressive collapse of the circulatory
system (Mulryan 2011; Chandraharan and A rulkumaran 2013). I f left untreated it will
result in death. S hock can be acute but prompt treatment results in recovery, with
li le detrimental effect on the woman. However, failure to initiate effective treatment,
or inadequate treatment, can result in a chronic condition ending in multisystem
organ failure, which may be fatal (NICE 2007).
Shock can be classified as follows:
• hypovolaemic: the result of a reduction in intravascular volume such as in severe
haemorrhage during childbirth
• septic or toxic: occurs with a severe generalized infection
• cardiogenic: impaired ability of the heart to pump blood; in midwifery it may be
apparent following a pulmonary embolism or in women with cardiac defects
• neurogenic: results from an insult to the nervous system as in uterine inversion
• anaphylactic: may occur as the result of a severe allergy or drug reaction.
This section deals with the principles of hypovolaemic shock and septic shock, either of
which may develop as a consequence of childbirth.
Hypovolaemic shock
This is caused by any loss of circulating fluid volume as in haemorrhage, but may also
occur when there is severe vomiting. The body reacts to the loss of circulating fluid in
stages as follows.
Initial stage
The reduction in fluid or blood decreases the venous return to the heart. The ventricles
of the heart are inadequately filled, causing a reduction in stroke volume and cardiac
output. A s cardiac output and venous return fall, the blood pressure is reduced. The
fall in blood pressure decreases the supply of oxygen to the tissues and cell function is
affected.
Compensatory stage
The fall in cardiac output produces a response from the sympathetic nervous system
through the activation of receptors in the aorta and carotid arteries. Blood is
redistributed to the vital organs. Vessels in the gastrointestinal tract, kidneys, skin and
lungs constrict. This response is seen by the skin becoming pale and cool. Peristalsis
slows down, urinary output is reduced and exchange of gas in the lungs is impaired as
blood flow diminishes. The heart rate increases in an a empt to improve cardiac
output and blood pressure. The pupils of the eyes dilate. The sweat glands are
stimulated and the skin becomes moist and clammy. A drenaline (epinephrine) is
released from the adrenal medulla and aldosterone from the adrenal cortex.
A ntidiuretic hormone (A D H) is secreted from the posterior lobe of the pituitary. Their
combined effect is to cause vasoconstriction, increased cardiac output and a decrease
in urinary output. Venous return to the heart will increase but, unless the fluid loss is
replaced, this will not be sustained.
Progressive stage
This stage leads to multisystem organ failure. Compensatory mechanisms begin to
fail, with vital organs lacking adequate perfusion. Volume depletion causes a further
fall in blood pressure and cardiac output. The coronary arteries suffer lack of supply
and peripheral circulation is poor, with weak or absent pulses.
Final, irreversible stage of shock
Multisystem organ failure and cell destruction are irreparable and death ensues.
Effect of shock on organs and systems
The human body is able to compensate for loss of up to 10% of blood volume,
principally by vasoconstriction. W hen that loss reaches 20–25%, however, the
compensatory mechanisms begin to decline and fail. I n pregnancy the plasma volume
increases, as does the red cell mass. The increase is not proportionate, but allows a
healthy pregnant woman to sustain significant blood loss at birth as the plasma
volume is reduced with li le disturbance to normal haemodynamics. I n cases where
the increase in plasma volume is reduced or there has been an antepartum
haemorrhage, the woman is more susceptible to experience a pathological effect on
the body and its systems following a much lower blood loss during childbirth.
Individual organs are affected as below.
Brain
The level of consciousness deteriorates as cerebral blood flow is compromised. The
woman will become increasingly unresponsive to verbal stimuli and there is a gradual
reduction in the response elicited from painful stimulation.
Lungs
Gas exchange is impaired as the physiological dead space increases within the lungs.
Levels of carbon dioxide rise and arterial oxygen levels fall. I schaemia within the lungs
alters the production of surfactant and, as a result of this, the alveoli collapse. O edema
in the lungs, due to increased permeability, exacerbates the existing problem of
diffusion of oxygen. Atelectasis, oedema and reduced compliance impair ventilation
and gaseous exchange, leading ultimately to respiratory failure. This is known as adult
respiratory distress syndrome (ARDS).
Kidneys
The renal tubules become ischaemic owing to the reduction in blood supply. A s the
kidneys fail, urine output falls to less than 20 ml/hour. The body does not excrete
waste products such as urea and creatinine, so levels of these in the blood rise.
Gastrointestinal tract
The gut becomes ischaemic and its ability to function as a barrier against infection
wanes. Gram-negative bacteria are able to enter the circulation.
Liver
D rug and hormone metabolism ceases, as does the conjugation of bilirubin.
Unconjugated bilirubin builds up and jaundice develops. Protection from infection is
further reduced as the liver fails to act as a filter. Metabolism of waste products does
not occur, so there is a build-up of lactic acid and ammonia in the blood. D eath of
hepatic cells releases liver enzymes into the circulation.
Management
Urgent resuscitation is needed to prevent the woman's condition deteriorating and
causing irreversible damage (Chandraharan and A rulkumaran 2013). W omen who
decline blood products must have their wishes respected and a treatment plan in case
of haemorrhage should be discussed with them before labour (CMACE 2011).
The priorities are to:
1. Call for help: shock is a progressive condition and delay in correcting hypovolaemia
can lead ultimately to maternal death.
2. Maintain the airway: if the woman is severely collapsed she should be turned on to
her side and 40% oxygen administered at a rate of 4–6 l/min. If she is unconscious,
an airway should be inserted.
3. Replace fluids: two wide-bore intravenous cannulae should be inserted to enable
fluids and drugs to be administered swiftly. Blood should be taken for cross-
matching prior to commencing intravenous fluids. A crystalloid solution such as
normal saline, Hartmann's, or Ringer's lactate is given until the woman's condition
has improved. A systematic review of the evidence found that colloids were not
associated with any difference in survival and were more expensive than crystalloids
(Perel et al 2013). Crystalloids are, however, associated with loss of fluid to the
tissues, and therefore to maintain the intravascular volume colloids are
recommended after 2 l of crystalloid have been infused. No more than 1000–1500 ml
of colloid such as Gelofusine or Haemocel should be given in a 24 hours period.
Packed red cells and fresh frozen plasma are infused when the condition of the
woman is stable and these are available.
4. Arrest haemorrhage: the source of the bleeding needs to be identified and stopped.
Any underlying condition should be managed promptly and appropriately.
5. Warmth: it is important to keep the woman warm, but not over warmed or warmed
too quickly, as this will cause peripheral vasodilatation and result in hypotension.
Assessment of clinical condition
A n interprofessional team approach to management should be adopted to ensure that
the correct level of expertise is available. A clear protocol for the management of shock
should be used, with the midwife fully aware of key personnel required. O nce the
woman's immediate condition is stable, the midwife should continue to assess and
record the woman's condition or liaise with staff on the critical care unit if the woman
has been transferred there for subsequent care (Chandraharan and A rulkumaran
2013).
Hypovolaemic shock in pregnancy will reduce placental perfusion and oxygenation
to the fetus, resulting in fetal distress and possibly death. W here maternal shock is
caused by antepartum factors, the midwife should determine whether the fetal heart is
present, but as swift and aggressive treatment may be required to save the woman's
life, this should be the first priority.
D etailed MEO W S observation charts including fluid balance should be accurately
maintained. The extent of the woman's condition may require her to be transferred to
a critical care unit.
Observations and clinical signs of deterioration in hypovolaemic shock
1. Assess level of consciousness in association with the Glasgow Coma Score (GCS).
This is a reliable, objective tool for measuring coma, using eye opening, motor
response and verbal response. A total of 15 points can be achieved, and one of <12 is
cause for concern. Any signs of restlessness or confusion should be noted
(Dougherty and Lister 2011).
2. Assess respiratory status using respiratory rate, depth and pattern, pulse oximetry
and blood gases. Humidified oxygen should be used if oxygen therapy is to be
administered for any length of time.
3. Monitor blood pressure continuously, or at least every 30 minutes, with note taken
of any fall in blood pressure.
4. Monitor cardiac rhythm continuously.
5. Measure urine output hourly, using an indwelling catheter and urometer.
6. Assess skin colour including core and peripheral temperature hourly.
7. If a central venous pressure (CVP) line has been sited, haemodynamic measures of
pressure in the right atrium are taken to monitor infusion rate and quantities. The
fluid balance should be maintained and recorded accurately.
8. Observe for further bleeding, including lochia, or oozing from a wound or puncture
site.
9. Undertake venepuncture for haemoglobin and haematocrit estimation to assess the
degree of blood loss.
10. The woman is likely to be nursed flat in the acute stages of shock. Clinical
assessment will also include review and recording of pressure areas, with positional
changes made as necessary to prevent deterioration. A lateral tilt should be
maintained to prevent aortocaval compression if a gravid uterus is likely to
compress the major vessels.
Box 22.8 summarizes the key points relating to the management of hypovolaemic
shock.
Box 22.8
K e y point s for m a na ging hypovola e m ic shock
• Call for help
• Identify the source of bleeding and control temporarily if able
• Gain venous access using two wide-bore cannulae
• Rapidly infuse intravenous fluid to correct loss
• Assess for coagulopathy and correct
• Manage the underlying condition
Central venous pressure
I t is unlikely that a midwife will experience central venous pressure (CVP) being
measured outside of an intensive care unit (Fig. 22.14). CVP is the pressure in the right
atrium or superior vena cava and is an indicator of the volume of blood returning to
the heart, reflecting the competence of the heart as a pump and the peripheral
vascular resistance. N ormal CVP values will change with gestation, and can vary
between +5 and +10 cmH2O. Values within this range indicate that the vascular space is
well filled and red cell transfusion would not be necessary. However, in the presence
of acute peripheral circulatory failure, which accompanies severe shock, the
monitoring of CVP aids assessment of blood loss with a negative value indicating the
necessity for fluid replacement (S cales 2010). A n isolated CVP recording is of li le
clinical value. Trends in CVP results are more useful clinically and are interpreted in
conjunction with fluid balance and peripheral perfusion.
FIG. 22.14 Monitoring central venous pressure.
I t is extremely dangerous to base an intravenous regimen on guesswork, as
hypervolaemia or hypovolaemia, cardiac and renal failure may result.
Septic shock
D eath and serious illness from pregnancy-related sepsis are rare. This means that
many midwives will not have seen a case, and it is surprising and shocking when it
does happen. The last Confidential Enquiry (CMA CE 2011 ) reported a total of 26
women died over the triennium 2006–8 as a result of genital tract sepsis. W omen and
their families should be made aware of the importance of disclosing significant
symptoms to enable earlier interventions in treatment of any underlying infection
(Chapters 12 and 13).
S eptic shock is a distributive form of shock, where an overwhelming infection
develops. Certain organisms produce toxins that cause fluid to be lost from the
circulation into the tissues. The commonest form of sepsis causing death in
childbearing in the UK is reported to be that caused by beta-haemolytic Streptococcus
pyrogenes (Lancefield Group A) (CMA CE 2011 ). This is a Gram-positive organism,
responding to intravenous antibiotics, specifically those that are penicillin-based.
Gram-negative organisms such as Escherichia coli, Proteus or Pseudomonas pyocyaneus
are common pathogens in the female genital tract.
The placental site and perineal wounds are the main points of entry for an infection
associated with pregnancy and childbirth. This may occur following prolonged rupture
of fetal membranes, birth trauma, septic abortion or in the presence of retained
placental tissue.
Clinical signs
S epsis is often insidious in onset but requires prompt recognition and immediate
medical referral. Recognition is a particular challenge to the community midwife. The
woman may present with tachypnoea, tachycardia, pyrexia or extremely low
temperature, or rigors. However, a temperature recording may appear normal if the
woman has taken paracetamol as this will reduce pyrexia. The woman may seem
confused or anxious, exhibiting a change in her mental state. A bdominal pain and
gastrointestinal symptoms are common in pelvic sepsis. O ther symptoms, including
hypotension, develop in septic shock as the condition progresses. Haemorrhage may
be apparent, which could be a direct result of events due to childbearing, however, it
occurs in septic shock due to disseminated intravascular coagulation (D I C) (Chapter
12). I n hospital all observations should be recorded on a MEO W S chart to determine
any further deterioration in the woman's condition and subsequent prompt action.
Management
The advice of an anaesthetist and the critical care team should be sought at an early
stage.
Treatment is based on preventing further deterioration in the woman's condition by
restoring circulatory volume and then eradication of the infection. Rigorous treatment
with intravenous antibiotics is essential to halt the illness. Replacement of fluid
volume will restore perfusion of the vital organs. Fluid balance is essential but difficult
to manage in septic shock (especially when hourly urine output is low), as fluid
overload may lead to fatal pulmonary or cerebral oedema. The midwife must maintain
careful monitoring and clear, accurate documentation of the woman's condition
throughout (NMC 2012).
Measures are needed to identify the source of infection and to protect the woman
against re-infection by maintaining high standards of care in clinical procedures. A
full infection screening should be undertaken, including a high vaginal swab, throat
swab, midstream specimen of urine and blood cultures. Retained products of
conception can be detected on ultrasound, and these can then be removed if they are
apparent.
I n all situations where the woman requires to be transferred to a critical care unit,
relatives should be kept informed of her progress. The midwife may be the person
with whom the relatives have formed a relationship and therefore is relied upon to
give them information on the woman's condition and progress.
Drug toxicity/overdose
D rug toxicity and illicit drug overdose should be considered as a cause in all cases of
maternal collapse in any type of se ing. The principals of observation and
resuscitation already discussed in this chapter apply to such a scenario. Common
sources of drug toxicity in midwifery and obstetric practice are local anaesthetic agents
injected intravenously by accident and magnesium sulphate given in the presence of
renal impairment (RCOG 2011).
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Further reading
Draycott T, Winter C, Crofts J, et al. RCOG Press: London; 2008. PROMPT
PRactical Obstetric Multi-Professional Training Course Manual. Vol. 1.
Recommended training course for childbirth emergencies presenting current best
practice..
Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through
practical shoulder dystocia training. Obstetrics and Gynecology. 2008;112(1):14–
20.
The introduction of shoulder dystocia training for all maternity staff was associated
with improved management and neonatal outcomes of births complicated by shoulder
dystocia..
James A, Endacott R, Stenhouse E. Identifying women requiring maternity high
dependency care. Midwifery. 2011;27(1):60–66.
Key issues in the management of women who become critically ill during pregnancy,
labour and the postpartum period are discussed, with identification of recognition of
signs of clinical deterioration with subsequent referral for appropriate care..
National Institute for Health and Clinical Excellence. Acutely ill patients in
hospital: recognition of and response to acute illness in adults in hospital. Clinical
Guideline 50. NICE: London; 2007 http://publications.nice.org.uk/acutely-ill-
patients-in-hospital-cg50.
Provides guidance on the care and management of the acutely ill patient..
Raynor MD, Marshall JE, Jackson K. Midwifery practice: critical illness,
complications and emergencies case book. Open University Press: Maidenhead;
2012.
This text provides a case study approach to several critical conditions and emergencies
that can prove a challenge to all healthcare professionals working in midwifery
practice, with particular importance being placed on multiprofessional team working.
Each case explores and explains the pathology, pharmacology and care principles and
uses test questions and answers to assist learning..
Resuscitation Council UK. Resuscitation guidelines. RCUK: London;
2010 www.resus.org.uk.
Internationally agreed information and guidance on resuscitation and emergency life
support. The website contains a range of publications, information and posters that
can be downloaded to support clinical practice..
Robson SE, Waugh J J S. Medical disorders in pregnancy: a manual for midwives. 2nd
edn. John Wiley and Sons: London; 2013.
The need for joint medical and midwifery care is stressed in the latest CMACE report,
with a recommendation that contemporary midwifery education prepares midwives
for problems in pregnancy and adverse pregnancy outcome..
Royal College of Obstetricians and Gynaecologists. Maternal collapse in pregnancy
and the puerperium. Green-Top Guideline No. 56. Royal College of Obstetricians
and Gynaecologists: London; 2011 www.rcog.org.uk/files/rcog-corp/GTG56.pdf.
Provides up-to-date information and excellent reference material on maternal collapse
in pregnancy and the puerperium..
Useful websites
Erb's Palsy Group, for parents and health professionals.
www.erbspalsygroup.co.uk.
National Amniotic Fluid Embolism Register. www.npeu.ox.ac.uk/ukoss/current-
surveillance/amf.
National Institute for Health and Care (formerly Clinical) Excellence.
www.nice.org.uk.
NHS Improving Quality (formerly NHS Institute for Innovation and
Improvement). www.nhsiq.nhs.uk/.
Resuscitation Council UK. www.resus.org.uk.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
*
Axial traction is traction in line with the fetal spine, i.e. no lateral deviation.
S E CT I ON 5
Puerperium
OU T LIN E
Chapter 23 Physiology and care during the puerperium
Chapter 24 Physical health problems and complications in the puerperium
Chapter 25 Perinatal mental health
Chapter 26 Bereavement and loss in maternity care
Chapter 27 Contraception and sexual health in a global society
C H AP T E R 2 3
Physiology and care during the
puerperium
Mary Steen, Julie Wray
CHAPTER CONTENTS
The postnatal period 499
Historical background 500
Framework and regulation for postnatal care 501
Midwives and postpartum care 501
Public health care 501
The provision of and need for postnatal care 502
Midwifery postpartum contact and visits 503
Physiological changes and observations 504
Returning to non-pregnant status 504
Future health, future fertility 509
Record-keeping and documentation 509
Evidence and best practice 509
Transition to parenthood 509
References 510
Further reading 514
Useful websites 514
There is current evidence that postnatal care is often undervalued and
under-resourced even though it is an important and challenging time for a
mother who has recently given birth, her partner and family (Wray and Bick
2012). Current postnatal care in the United Kingdom (UK) can involve
several healthcare practitioners. Midwives are the lead health professional,
with support from maternity support workers, general practitioners, health
visitors and other practitioners depending on the mother's individual needs
and circumstances. Both public and voluntary services can work together to
support the mother, father, baby and other family members to cope and
adjust following the birth of a new baby (Department of Health [DH] 2005;
National Institute for Health and Clinical Excellence [NICE] 2006; Nursing
and Midwifery Council [NMC] 2012). This approach to postnatal care differs
from that offered to women in most other developed countries where the
provision for regular contact with midwives as the main healthcare
professional responsible for postnatal care is less well defined. (Potential
postnatal morbidity and in some cases mortality for the mother is discussed
in Chapter 24.)
The chapter aims to:
• review the historical background of postnatal care
• explore the role of the midwife in the assessment and care of women's postpartum
health and wellbeing
• review the current evidence for women's general health and wellbeing after childbirth
• discuss the contemporary challenges for the provision of maternity care during the
postnatal period
• explore women's and their partners views and experiences of postnatal care.
The postnatal period
Following the birth of a baby, placenta and membranes, the newly birthed mother
enters a period of physical and emotional/psychological recuperation (Buckley 2006;
W ray 2012). S kin-to-skin contact is advocated immediately following birth and during
the postnatal period as there is clear evidence of benefit to the mother and father
(Moore et al 2012). The puerperium starts immediately after birth of the placenta and
membranes and continues for 6 weeks. I n many cultures around the world 40 days for
recuperation is a time-honoured practice (Hundt et al 2000; Waugh 2011). A general
expectation is that by 6 weeks after birth a woman's body will have recovered
sufficiently from the effects of pregnancy and the process of parturition. However,
there has now been a recognition that the return to a non-pregnant state of health and
wellbeing can take much longer (W orld Health O rganization [W HO ], 2010 ; Bick et al
2011). S ome women continue to experience health problems related to childbirth that
extend well beyond the 6-week period defined as the puerperium (W HO 2010). I n
some cases, healing and recovery can take up to a year following birth (Bedwell 2006;
Wray and Bick 2012).
I t has been customary to refer to the first weeks after the birth as the postnatal
period, defined in the UK by the N MC as ‘a period after the end of labour during
which the a endance of a midwife upon a woman and baby is required, being not less
than 10 days and for such longer period as the midwife considers necessary’ ( NMC
2012: 6).
By no longer stating an endpoint in time until which midwifery care can still be
made available to women, it is envisaged that offering more flexibility to the provision
of midwifery care will make a positive impact on the health and wellbeing of women
(Cattrell et al 2005; Redshaw and Heikkila 2010).
The N ational Childbirth Trust (N CT) makes clear on its website that it is the quality
of postnatal care provided to women and families in the first days and weeks after
birth that can have a huge impact and affect mothers' and families' experiences of the
transition to parenthood (NCT 2012).
However, in this present climate, when there is an ever-increasing birth rate, a
shortage of midwives and ongoing financial constraints, this is an extremely
challenging task for maternity service providers.
Historical background
Postnatal care in the UK has been an integral part of the midwife's role since the
beginning of the last century following the introduction of the Midwives A ct in 1902.
This was instigated by the high maternal mortality rates. D espite a decline in death
rates among all age groups in the general population, maternal mortality rates
remained high. The majority of maternal deaths were caused by puerperal infection
(interestingly, the latest triennial report on the Confidential Enquiries into Maternal
D eaths in the UK cites sepsis as currently the leading cause of maternal mortality
[CMACE 2011]).
This had a marked effect on what constituted important aspects of postnatal care.
Routine observations, such as temperature, pulse, respirations, blood pressure, breast
examination, uterine involution and observation of lochia, were introduced as well as a
set pattern of postnatal visits.
Midwives were expected to visit twice a day for the first three days and then daily
until day 10, commonly referred to as the ‘lying in period’ ( Leap and Hunter 1993).
Two further Midwives A cts extended the regulatory maximum duration of postnatal
care from 10 to 14 days in 1936 and then this was increased to 28 days in 1962. This
approach to postnatal care was considered appropriate to meet the needs of women at
that time. However, a considerable decline in maternal mortality rates began in the
1930s and has continued up to the present day. A traditional pa ern and content of
postnatal care continued until the 1980s. Then, two major changes happened that
affected the pa ern of postnatal care, those being the woman returning home much
earlier following childbirth and the introduction of ‘selective visiting’ rather than
specified days in 1986 by the former midwifery governing body, the United Kingdom
Central Council (UKCC 1986). A postal survey undertaken in England in 1991 reported
that most maternity services had changed from the daily home visits up to the tenth
postnatal day to selective home visits, but there was wide variation in pa erns of
selective visiting (Garcia et al 1994). This may be due to the fact that li le guidance
was given on how to plan and implement this change and there was no evaluation with
regard to the implications for women. A House of Commons Health Commi ee report
(Winterton 1992) highlighted, among other things, that postnatal care was neglected
and there was a lack of research in this area. This was followed by the establishment of
the Expert Maternity Commi ee, whose remit was to examine policy and make
recommendations for the maternity services in England and Wales. Their report
‘Changing Childbirth’ (D H 1993) recommended that the maternity services should
offer women more choice, greater continuity of care, more involvement in the
planning of their care and should be midwifery-led, and more recently the ‘Maternity
Matters’ report (DH 2007a) reiterated these recommendations.
Today, a partnership approach, where the woman is encouraged to explore how she
is feeling physically and emotionally and to seek the advice and support of the
midwife, is advocated (W ray and Bick 2012). The importance of all newly birthed
mothers having access to postnatal care that will meet their individual needs is
underpinned by the N MC (2012) Midwives Rules and S tandards and by a national
guideline defining core care, and what should be provided for the mother and baby in
the days and weeks following birth (NICE 2006).
Framework and regulation for postnatal care
The initial framework for hospital postnatal care in the early 20th century involved a
regimented approach, with the newly birthed mother being viewed as a patient; a
period of prescribed bed rest, compliance with hospital regimens such as vulval
swabbing, binding of legs and separation from her baby were thus routine procedures.
A gradual shift in this ‘sickness’ framework of care as described by Parsons (1951)
started to occur during the 20th century. Renfrew (2010) describes how mothers in the
late 1970s and early 1980s were still kept in postnatal wards for a week or more after
birth and their babies were kept in nurseries with their feeds timed and measured,
regardless of whether they were being breastfed or formula-fed. I n the 1990s the
provision of postpartum care was reviewed with regard to its content, purpose or
effectiveness (Marsh and S argent 1991; Garcia and Marchant 1993; Twaddle et al 1993);
this led to research that investigated and challenged regimented and ritual pa erns of
postpartum care (Bick et al 2002; Shaw et al 2006; Wray 2006).
N owadays, mothers have the choice to return home in a few hours after the birth, as
it is considered both safe and acceptable by society at large. The newly birthed mother
can recuperate in her own familiar surroundings with the support of her family and
friends.
The recent Health and S ocial Care A ct 2012 will continue to support mothers to
make their own choices about who and what services/care best meet their individual
needs. I ndependent sector providers as well as N ational Health S ervice (N HS
maternity service providers will be free to innovate to deliver quality services.
Midwives and postpartum care
I t is vitally important that midwives have the knowledge and skills to determine when
to be proactive and undertake specific observations when there are indications to do
so. Therefore, the midwife needs to be able to acknowledge and recognize what are
normal expected outcomes following birth and also be able to identify signs of what is
not normal and when to instigate care that will involve further investigation, tests and
the support of other health professionals. I t is the midwife's responsibility to ensure
she is competent and to undertake any further necessary education and training if
required to provide extended care (see Box 23.1).
Box 23.1
T he m idwife 's skills a nd knowle dge
The UK's N ursing and Midwifery Council states inThe Code: Standards of
Conduct, Performance and Ethics for Nurses and Midwives:
Keep your skills and knowledge up to date:
▪ You must have the knowledge and skills for safe and effective practice when
working without direct supervision.
▪ You must recognise and work within the limits of your competence.
▪ You must keep your knowledge and skills up to date throughout your working
life.
▪ You must take part in appropriate learning and practice activities that maintain
and develop your competence and performance.
Source: NMC 2008: 38–41
Public health care
I t has long been recognized that poverty and being socially disadvantaged is society
leads to increased risk of poor health and wellbeing (Hart 1971; A cheson 1998). I n
England, the D epartment of Health has acknowledged that ‘Healthy mothers are key
for giving healthy babies a healthy start in life’ ( DH 2004). I t is important that mothers
and their family receive information and advice about healthy lifestyles. Midwives
have a vital role to address public health targets and are ideally situated to promote
healthy lifestyles to the mother, her partner and extended family during the postnatal
period. However, midwives cannot address public health issues alone and working
collaboratively with other professionals and local communities and signposting to
other services needs to occur. Models of care to give more intense care and support to
disadvantaged groups have been developed. S ure S tart centres were set up to provide
accessible community-based services that would enable families with young children
to improve their health and wellbeing (DH 1999). Targets were linked to public health
issues such as smoking cessation, breastfeeding rates and reaching disadvantaged
groups (N ational Evaluation of S ure S tart [N ES S ] 2004
). The government's Every Child
M a ers: Change for Children agenda (D fES 2004) supported the S ure S tart goals and
aimed to increase the support for children and young people up to the age of 19. These
centres became S ure S tart Children's Centres, where family healthcare and parenting
skills from midwives and health visitors were delivered with support from other
professionals (DCSF 2009).
Positive benefits for mothers and their families who live within the designated
postcode for Children's Centre services have been reported (Tanner et al 2012).
However, a sustained commitment to service provision and funding is essential for
this to benefit mothers and their families. I n 2009, Children's Centres became a
statutory requirement under the A pprenticeships, S kills, Children andLearning A ct
(HM Government 2009; D fE 2010). I n 2010, the Coalition government offered
protection from spending cuts to enable Children's Centres to continue to provide a
range of services to local communities but at the time of writing there are concerns in
the present economic climate with budget reductions; the government is interested in
developing community management models such as cooperatives and social
enterprises (DfE 2012).
W orking in tandem with Children's Centres is the Family N urse Partnership (FN P
Programme as developed in the US A and recently piloted in selected areas of high
deprivation in England. I t has been reported that teenage first-time mothers, their
partners and family find this approach acceptable (Barnes et al 2011). Further work is
being undertaken to see if a group approach is of any benefit to families who are not
eligible for the FN P programme (B arnes and Henderson 2012). Early indications show
that there are some benefits and peer support is valuable. A n holistic maternal health
and wellbeing programme, specifically designed to raise awareness of the general
health and wellbeing of mothers, their babies and families also reported how
beneficial group and peer support is to postnatal mothers (Steen 2007b) (see Box 23.2).
Box 23.2
E x a m ple s of post na t a l wom e n's vie ws
Postnatal workshops:
‘I needed to talk about my birth as I was disappointed I had been induced,
but I can understand why now.’
‘I didn’t know that most breast cancer is detected by the woman herself,
I will start checking now.’
‘I feel guilty about smoking and now I have my daughter to think about I
will seriously think about stopping.’
‘I 'm finding being a mum hard. I 'm always tired and feeling weepy but I
feel a lot better once I have come to the class.'
Postnatal exercise classes:
‘I couldn’t do my pelvic floor exercises properly before. I can now.’
‘I did some of the exercises in early labour and used the positions I was
shown, it really helped.’
‘I had a section in the end but I wasn’t too disappointed as I coped really
well during labour and used the Pilates and relaxation techniques.’
‘I have a bit of weight to lose and this will help me get back into shape.’
‘I'm steadily getting my figure back. The exercises appear to be helping.'
‘I really enjoyed the exercises and intend to continue to do Pilates.’
Postnatal general comments:
‘I always go home feeling good about myself and fit and healthy.’
‘I love the company as well as being able to exercise.’
‘I t’s great that you can bring your baby with you. I love being able to
exercise with him on a mat next to me.’
‘I bring my mum as well. We both have enjoyed it.’
‘I'm going to come to the gym and get my boyfriend to come as well.'
‘I t will be difficult for me to a end classes when I go back to work but I
intend to walk more and exercise on a weekend.’
‘I have enjoyed coming to the sessions and I 've loved being able to meet
other mums.'
Source: Steen 2007b: 119
Recently, the Health and S ocial Care A ct 2012 gives a new focus to public health
(HM Government 2012). This A ct provides the underpinnings for Public Health
England, a new body to drive improvements in public health.
The provision of and need for postnatal care
The provision of midwifery care and support to newly birthed mothers needs to be
woman-focused and family-orientated. Good communication to explain what is
considered to be normal physical, emotional/psychological, occurrences during the
postnatal period will reassure a mother that she is going through a normal
physiological process. Building a trusting, caring relationship will give a mother
confidence to ask questions when she has concerns and is anxious about her health
and wellbeing.
A recent survey undertaken on behalf of the N ational Childbirth Trust N ( CT 2010)
involving 1260 first-time mothers reported that these mothers felt that midwives were
always or mostly kind and understanding (80%) and treated them with respect (83%) .
However, there were still gaps in the provision and satisfaction with regards to
postnatal care reported. O nly 4% of mothers reported being involved in the
development of a postnatal care plan to meet their individual needs as recommended
by NICE (2006). Mothers who had undergone either an operative or surgical procedure
to aid their birth were reported to be the least satisfied with their postnatal care.
A lthough this survey does not represent the whole of the UK maternal population and
socially disadvantaged mothers' voices were not represented, it does give an insight
into areas where improvements in postnatal care provision should be targeted.
A social model of care that encompasses aspects of observing and monitoring the
health and wellbeing of the mother, father and their baby initially, in a hospital and
then home se ing, will support both parents to adjust to their new parenting role.
Guidance and reassurance is an important aspect of midwifery care. W orking in
partnership with the mother and father will assist them to develop confidence in their
ability to be parents and care for their baby. There is growing evidence that when
fathers are included this is beneficial to both the mother's and the baby's health and
wellbeing (Flouri and Buchanan 2003; Bo orff et al 2006; Tohotoa et al 2009). For
example, fathers can play an important role in breastfeeding support (W ol erg et al
2004; Piscane et al 2005). Therefore, it is vital that they are included in discussions and
pathways of care. Yet, there is also evidence that many fathers feel excluded unsure
and fearful (S teen et al 2012). A recent publication entitled ‘Reaching out: involving
fathers in maternity care’ ( Royal College of Midwives [RCM] 2011 : 3) has highlighted
that ‘to provide effective support fathers themselves need to be supported, involved
and prepared’.
I n the UK, it is still usual for a midwife to ‘a end’ a postpartum woman on a regular
basis for the first few days regardless of whether the mother is in hospital or at home
(N MC 2012). D uring the course of contact visits, midwifery practice has been to
undertake a routine physical examination to assess the new mother's recovery from
the birth (Rowan and Bick 2006; Bick 2012; W ray and Bick 2012). From an international
perspective this practice is unusual; it is only comparatively recently that postpartum
home visits, and postpartum support programmes, have been initiated in A merica,
Canada and Australia (Boulvain et al 2004; Peterson et al 2005; Vernon 2007) and that
women in these countries have recognized a need for and their satisfaction with
current services (D e Clerc 2006). I n the UK, the role of maternity support worker
(MS W ) has been introduced to support midwives to provide care to mothers and their
families. However, the development of MS Ws can be inconsistent (K ings Fund 2011).
T he RCM (2010) Position S tatement on maternity support workers reports that there
should be a clear framework which defines their role, responsibility and arrangements
for supervision. A study reviewed the involvement of maternity support workers in the
community over an extended postnatal period and found no differences in health
outcomes but reported that mothers found benefit in the extra support (Morrell et al
2000).
A common reference to postnatal services being the ‘Cinderella’ of the maternity
service provision as a whole has led to repeated reports from women of poor support,
disappointment in the services and in some cases evidence of negligence as a result of
sub-standard care (Wray 2006; Lewis 2007; Redshaw and Heikkila 2010; WHO 2010).
The framework for assessing resources released from the N HS costs would appear
to be based on a measurement of clinical need resulting in the main providers of
health services having to make comparisons between postpartum women's needs and
other members of the population who are suffering from acute or chronic illnesses
(O 'S ullivan and Tyler 2007). The birth of a baby does not a ract the same level of
funding as the needs of those with long-term conditions or terminal diseases.
However, there has been an increasing awareness that there are important aspects
around promoting good health and wellbeing of the newly birthed mother and baby as
this has implications for the nation's healthcare costs (N I CE 2006; N CT 2010). The
postnatal care pathway recommended by N I CE (2006) is divided into three ‘time
bands’ which cover the postnatal period, these are:
• the first 24 hours after birth
• the first 2–7 days
• the period from day 8 to around 6–8 weeks.
During these postnatal time bands a midwife will need to advise women about some
health problems that she may be at risk of developing and to discuss any symptoms or
concerns she may have. Contact numbers and how to summon help and advice need to
be made readily available and issuing regular reminders to encourage and enable a
mother to do this if she has any concerns is paramount.
Midwifery postpartum contact and visits
The majority of postnatal care in the UK now occurs either in the family or a relative's
home. Expectations of mothers about the purpose of home visits by the midwife may
vary according to their cultural backgrounds and individual needs. S ome faiths hold
important ceremonies for the newborn baby and a home visit from a midwife will
need to be mutually arranged to fit around these. N ewly birthed mothers who have
experienced motherhood before may feel that they need minimal support from a
midwife and this can also be mutually arranged. I n contrast, a first-time mother or a
mother who has had complications will more likely need further support and contact.
The concept of postpartum care is one that aims to assist the mother, her baby and
family towards a aining an optimum health status. W here the visit from the midwife
can be seen as supportive and useful to the mother and her family, this purpose is
more likely to be achieved. Research that has explored the experiences of women from
different ethnic backgrounds has demonstrated marked inequalities in both the
provision of services as well as the actual direct contact with caregivers (Hirst and
Hewison 2002). I n contrast, where the timing of midwifery postpartum care is
extended beyond 28 days, there is greater opportunity for midwives to continue
midwifery support where this might be appropriate, and this has been welcomed as
progress although the focus would appear to be more on social or psychological
outcomes, or for breastfeeding support than overt clinical or physical morbidity
(Winter et al 2001; Bick et al 2002). I n the United S tates a woman can choose to employ
a doula to help her during her transition to motherhood. A doula can provide physical,
emotional and social support (S imkin 2008). This option is becoming more readily
available in the UK (Gibbon and Steen 2012).
Physiological changes and observations
Regardless of place of birth, the midwife is primarily concerned with the observation
of the health of the postpartum mother and the new baby. A s such, it has been
common practice to have an overall framework upon which to base the assessment of
the mother's state of health and for the observations contained within the examination
to link with pre-stated categories in the postnatal midwifery records. This formalized
approach to the postpartum review might be an appropriate tool to use if there is
concern about a woman who is feeling unwell and there is a need for a comprehensive
picture of the woman's state of health (see Chapters 13 and 24). W here this is not the
case such an approach might be less useful from the viewpoint of the needs of a
healthy woman who has recently given birth (Redshaw and Heikkila 2010). The
concern focuses on whether in the time taken to complete a ‘top to toe’ examination as
a thorough review of someone who is generally well, the midwife might ignore or give
less a ention to what the mother really wants to talk about ( Ridgers 2007). However,
W ray (2011: 158 ) highlights that women want to be ‘checked over’ (physically) as a
means to obtain contact and feedback from the midwife about their bodies and
recovery separate from their baby. A s one new mother pointed out: ‘it was only when
she [the midwife] checked me over that you could think about yourself and talk about
how you were healing and getting sorted’.
The skill of the midwife's care is to achieve a balance when deciding which
observations are appropriate so that she does not fail to detect potential aspects of
morbidity. The next part of this chapter identifies areas of physiology that are likely
either to cause women the most anxiety or to have the greatest outcome with regard to
morbidity. These descriptions relate to observations undertaken for women who have
had vaginal births and uncomplicated pregnancies.
Returning to non-pregnant status
I n the postnatal period, all of the mother's body systems have to adjust from the
pregnant state back to the pre-pregnant state. Mothers go through a transitional
period and the period of physiological adjustment and recovery following birth is
closely related to the overall health status of the mother. The intricate relationships
between physiological, emotional/psychological and cultural and sociological factors
are all encompassed in the remit of caring for the postnatal woman and her newborn
(MaGuire 2000; Wiggins 2000; Bick 2012).
Vital signs: general health and wellbeing
The following information is based on the premise that the midwife is exploring the
health of the postpartum woman from a viewpoint of confirming normality. ‘Common
sense’, although a concept that is very difficult to define, is probably a well-
understood paradigm and taking such an approach is an important part of midwifery
care with regard to addressing the issues that are visible before seeking out the less
obvious. I n this instance, an overall assessment of the woman's physical appearance
will add considerably to the management of what will be undertaken prior to
continuing any further investigation for either the woman or her baby.
Observations of temperature, pulse, respiration (TPR) and blood pressure (BP)
D uring the first 6 hours postnatal care observations to record vital signs will need to
be taken and these should be within a normal range before a woman returns home if
she has opted for an early transfer. A n Early Warning S core has recently been
introduced in some maternity units (Lewis 2007). I f the woman has had a home birth
the midwife must not leave the new mother's home until she is satisfied that vital
signs are stable.
I t is not necessary to undertake observations of temperature routinely for women
who appear to be physically well and who do not complain of any symptoms that
could be associated with an infection. However, where the woman complains of feeling
unwell with flu-like symptoms, or there are signs of possible infection or information
that might be associated with a potential environment for infection, the midwife
should undertake and record the temperature. This will enhance the amount of clinical
information available where further decisions about potential morbidity may need to
be made.
Making a note of the pulse rate is probably one of the least invasive and most cost-
effective observations a midwife can undertake. I f undertaken when seated alongside
or at the same level as the woman, it can create positive feelings of care while also
obtaining valuable clinical information. W hile observing the pulse rate, particularly if
this is done for a full minute, the midwife can also observe a number of related signs
of wellbeing: the respiratory rate, the overall body temperature, any untoward body
odour, skin condition and the woman's overall colour and complexion, as well as just
listening to what the woman is saying.
Blood pressure
Following the birth of the baby, a baseline recording of the woman's blood pressure
will be made. I n the absence of any previous history of morbidity associated with
hypertension, it is usual for the blood pressure to return to a normal range within 24
hours after the birth. Routinely undertaking observations of blood pressure without a
clinical reason is therefore not required once a baseline recording has been taken.
NICE (2006) suggest this should be within 6 hours of the birth.
Circulation
The body has to reabsorb a quantity of excess fluid following the birth and for the
majority of women this results in passing large quantities of urine, particularly in the
first day, as diuresis is increased ( Cunningham et al 2005). W omen may also
experience oedema of their ankles and feet and this swelling may be greater than that
experienced in pregnancy. These are variations of normal physiological processes and
should resolve within the puerperal time scale as the woman's activity levels also
increase. A dvice should be related to taking reasonable exercise, avoiding long periods
of standing, and elevating the feet and legs when si ing where possible. S wollen
ankles should be bilateral and not accompanied by pain; the midwife should note
particularly if this is present in one calf only as it could indicate pathology associated
with a deep vein thrombosis.
Skin and nutrition
W omen who have suffered from urticaria of pregnancy or cholestasis of the liver
should experience relief once the pregnancy is over. The pace of life once the baby is
born might lead to women having a reduced fluid intake or eating a different diet than
they had formerly (Tuffery and S criven 2005). This in turn might affect their skin and
overall physiological state. W omen should be encouraged to maintain a balanced fluid
intake and a diet that has a greater proportion of fresh food in it (Tuffery and S criven
2005; DH 2007b). This will improve gastrointestinal activity and the absorption of iron
and minerals, and reduce the potential for constipation and feelings of fatigue.
Breast care
I t is essential that midwives offer support and advice on common breast and
breastfeeding problems. With a woman's permission a midwife needs to check for any
physical problems such as engorgement, cracked or bleeding nipples, mastitis, or
signs of thrush. Engorgement on postnatal day 3 and 4 is a common problem for most
mothers regardless of whether they have chosen to breast- or formula-feed. I t is
important that mothers are aware of this and this needs to be discussed antenatally so
it does not come as a complete surprise. I f breastfeeding and engorged, advise the
mother to feed on demand, perform breast massage from under her axilla and towards
the nipple, to hand express, take analgesia if necessary, and to wear a well-fi ing bra.
For further content on complications see Chapters 24 and 34.
The uterus
A fter the birth, oxytocin is secreted from the posterior lobe of the pituitary gland to
act upon the uterine muscle and assist separation of the placenta. Following the birth
of the placenta and membranes, the uterine cavity collapses inwards; the now opposed
walls of the uterus compress the newly exposed placental site and effectively seal the
exposed ends of the major blood vessels. The muscle layers of the myometrium act
like ligatures that compress the large sinuses of the blood vessels exposed by placental
separation. These occlude the exposed ends of the large blood vessels and contribute
further to reducing blood loss. I n addition, vasoconstriction in the overall blood
supply to the uterus results in the tissues receiving a reduced blood supply; therefore,
de-oxygenation and a state of ischaemia arise. Through the process of autolysis,
autodigestion of the ischaemic muscle fibres by proteolytic enzymes occurs resulting
in an overall reduction in their size. There is phagocytic action of polymorphs and
macrophages in the blood and lymphatic systems upon the waste products of
autolysis, which are then excreted via the renal system in the urine. Coagulation takes
place through platelet aggregation and the release of thromboplastin and fibrin
(Cunningham et al 2005).
W hat remains of the inner surface of the uterine lining apart from the placental site,
regenerates rapidly to produce a covering of epithelium. Partial coverage occurs within
7–10 days after the birth; total coverage is complete by the 21st day (Cunningham et al
2005).
O nce the placenta has separated, the circulating levels of oestrogen, progesterone,
human chorionic gonadotrophin and human placental lactogen are reduced. This
leads to further physiological changes in muscle and connective tissues as well as
having a major influence on the secretion of prolactin from the anterior lobe of the
pituitary gland.
A bdominal palpation of the uterus is usually performed soon after placental
expulsion to ensure that the physiological processes are beginning to take place
(Chapter 18). O n abdominal palpation, the fundus of the uterus should be located
centrally, its position being at the same level or slightly below the umbilicus, and
should be in a state of contraction, feeling firm under the palpating hand. The woman
may experience some uterine or abdominal discomfort, especially where uterotonic
drugs have been administered to augment the physiological process (A nderson et al
1998).
Uterine involution
T he process of involution is essential background knowledge for midwives monitoring
the physiological process of the return of the uterus to its non-pregnant state.
I nvolution involves the gradual return and reduction in size of the uterus to a pelvic
organ until it is no longer palpable above the symphysis pubis (S tables and Rankin
2011). This process is usually assessed by measuring the symphysio-fundal height (S -
FD ). This is the distance from the top of the uterine fundus to the symphysis pubis
and is commonly assessed by anthropometry (abdominal palpation) (Bick et al 2009).
N I CE (2006) has concluded that there is insufficient evidence to recommend the
routine measurement of fundal height and how often this should take place as the
process of involution is highly variable between individual women. Therefore,
involution of the uterus should be placed into context alongside the colour, amount
and duration of the woman's vaginal fluid loss and her general state of health at that
time. Uterine involution in combination with other observations such as a raised or
lowered temperature abdominal tenderness and offensive lochia can be helpful to
detect any maternal morbidity, e.g. sepsis (CMACE 2011).
Assessment of postpartum uterine involution
There are several aspects to the abdominal palpation of the postpartum uterus that
contribute to the observation as a whole. The first is to identify height and location of
the fundus (the upper parameter of the uterus). A ssessment should then be made of
the condition of the uterus with regard to uterine muscle contraction and finally
whether palpation of the uterus causes the woman any pain. W hen all these
dimensions are combined, this provides an overall assessment of the state of the
uterus and the progress of uterine involution can be described. Findings from such an
assessment should clearly record the position of the uterus in relation to the umbilicus
or the symphysis pubis, the state of uterine contraction and the presence of any pain
during palpation. A suggested approach to how this is undertaken in clinical practice
can be found in Box 23.3.
Box 23.3
S ugge st e d a pproa ch t o unde rt a king post pa rt um
a sse ssm e nt of ut e rine involut ion
• Discuss the need for uterine assessment with the woman and obtain her
agreement to proceed. She should have emptied her bladder within the
previous 30 min.
• Ensure privacy and an environment where the woman can lie down on her
back with her head supported. Locate a covering to put over her lower
body.
• The midwife should have clean, warm hands and should help the woman
to expose her abdomen; the assessment should not be done through
clothing.
• The midwife places the lower edge of her hand at the umbilical area and
gently palpates inwards towards the spine until the uterine fundus is
located.
• The fundus is palpated to assess its location and the degree of uterine
contraction. Any pain or tenderness should be noted.
• Once the midwife has completed the assessment she should help the
woman to dress and to sit up.
• The midwife should then ask the woman about the colour and amount of
her vaginal loss and whether she has passed any clots or is concerned
about the loss in any way.
• Following the assessment, the woman should be informed about what has
been found and any further action that is required, and then a record of
the assessment is made in the midwifery notes.
‘Afterpains’
‘A fterpains’ are caused by involutionary contractions and usually last for two to three
days after childbirth. These cramping type of pains are more commonly associated
with multiparity and breastfeeding. The production of the oxytocin in relation to the
let-down response that initiates the contraction in the uterus and causes pain. W omen
have described the pain as equal to the severity of moderate labour pains and women
require analgesia (Marchant et al 2002). A recent systematic analysis has concluded
that non-steroidal anti-inflammatory drugs (N S A I D s) were be er than placebo at
relieving ‘afterpains’ and N S A I D s were be er than paracetamol, but there were
insufficient data to make conclusions regarding the effectiveness of opioids at
relieving ‘afterpains’ (Deussen et al 2011).
I t is helpful to explain the cause of ‘afterpains’ to women and that they might
experience a heavier loss at this time, even to the extent of passing clots. Pain in the
uterus that is constant or present on abdominal palpation is unlikely to be associated
with ‘afterpains’ and further enquiry should be made about this. W omen might also
confuse ‘afterpains’ with flatus pain, especially after an operative birth or where they
are constipated. I dentifying and treating the cause is likely to relieve the symptoms or
raise concern about a more complex condition that needs further attention.
Postpartum vaginal blood loss
Blood products constitute the major part of the vaginal loss immediately after the
birth of the baby and expulsion of the placenta and membranes. A s involution
progresses the vaginal loss reflects this and changes from a predominantly fresh blood
loss to one that contains stale blood products, lanugo, vernix and other debris from
the unwanted products of the conception. This loss varies from woman to woman,
being a lighter or darker colour, but for any woman the shade and density tends to be
consistent (Marchant et al 2002).
Lochia is a Latin word traditionally used to describe the vaginal loss following the
birth (Cunningham et al 2005). Medical and midwifery textbooks have described three
phases of lochia and have given the duration over which these phases persist.
Research has explored the relevance of these descriptions for women and raised
questions about the use of these descriptions in clinical practice. Marchant et al (2002)
reported that not all women are aware they will have a vaginal blood loss after the
birth and that women experience a wide variation in the colour, amount and duration
of vaginal loss in the first 12 weeks' postpartum. This suggests that, overall,
descriptions of normality ascribed to the traditional descriptions of lochia are
outdated and unhelpful to women and midwives in accurately describing a clinical
observation.
Most women can clearly identify colour and consistency of vaginal loss if asked and
will be able to describe any changes. I t is important for a midwife to ask direct
questions about the woman's vaginal loss: whether this is more or less, lighter or
darker than previously and whether the woman has any concerns. I t is of particular
importance to record any clots passed and when these occurred. Clots can be
associated with future episodes of excessive or prolonged postpartum bleeding (see
Chapters 18, 24).
A ssessment that a empts to quantify the amount of loss or the size of clot is
problematic. However, the use of descriptions that are common to both woman and
midwife can improve accuracy in these assessments – for example, asking the mother
how often she has to change her maternity pad and describing her blood loss in her
own words.
Continence after birth
The majority of women will revert back to their non-pregnant status during the
puerperium without any major urinary or bowel problems. A ny minor changes to
women's urinary and bowel habits should resolve within the first few days of giving
birth. W omen suffering from perineal injury may need extra reassurance that having
their bowels open may be uncomfortable but will not disrupt and dislodge any
stitches in the perineal region (Chapter 15). A systematic review has reported that
there is sufficient evidence to suggest that pelvic floor exercise training during
pregnancy and after birth can prevent and treat urinary incontinence (Mørkved and Bø
2013). NICE (2006) recommends that pelvic floor muscle exercises should be taught as
first line treatment for urinary incontinence.
I t is important that women are given opportunities to discuss any urinary or bowel
problems as it is often a taboo subject. Some women may find it embarrassing and will
not seek help and advice whilst others may put up with urinary and bowel problems
believing that it is an accepted outcome following childbirth. Therefore, it is essential
that a midwife build a trusting, caring relationship to encourage a woman to disclose
any urinary or bowel problems.
Usually, urinary and bowel symptoms resolve within the first two weeks following
birth but some problems do persist. I f a woman continues to notice a change to her
pre-pregnant urinary and bowel pattern by the end of the puerperal period, she should
be advised to have this reviewed (S teen 2013). I nitially, conservative management is
advocated and then if the symptoms are persistent a referral to a specialist may be
required (RCM/CSP 2013) (see Chapter 24).
Perineal trauma
Perineal and vaginal injury during childbirth continues to affect the majority of
women (A lbers et al 2006; East et al 2012b). Morbidity associated with perineal injury
and repair is a major health problem for women throughout the world. The Royal
College of O bstetricians and Gynaecologists (RCO G) (2004)reported that perineal
trauma can have long-term social, psychological and physical health consequences for
women. Perineal pain and discomfort associated with trauma may disrupt
breastfeeding, family life and sexual relationships.
I n the UK, it is estimated that 1000 women per day will require perineal repair
(Ke le and Fenner, 2007). I t is therefore important that midwives are firstly educated
and trained to recognize the extent of perineal and vaginal trauma, and secondly, have
gained the confidence and clinical skills to suture competently as failure to do so can
contribute to negative consequences for women in both the short and long term (Steen
2010). I n addition, it is important to consider how to alleviate the associated pain and
discomfort attributed to perineal injuries following birth.
Up-to-date knowledge and an understanding of the negative consequences for
women will help midwives to advise women on how to alleviate perineal pain, prevent
further trauma and promote healing (Steen 2012).
Perineal pain
Regardless of whether the birth resulted in actual perineal trauma, women are likely to
feel swollen and bruised around the vaginal and perineal tissues for the first few days
after a vaginal birth. W omen who have undergone any degree of actual perineal injury
will experience pain for several days until healing takes place (East et al 2012b). I t is
essential that women are offered adequate pain relief initially following birth and then
for them to be advised on how to alleviate the inflammation associated with perineal
injuries and any pain felt during the postnatal period. I n the first few days after the
birth all women should be asked if they have any pain or discomfort in the perineal
area regardless of whether there is a record of actual perineal trauma (Bick and Basse
2013).
W here women appear to have no discomfort or anxieties about their perineum, it is
not essential for the midwife to examine this area and arguably it is an intrusion on
the woman's privacy to do so. The basic principles of morbidity or infection
(Cunningham et al 2005) indicate that it is unusual for morbidity to occur without
inflammation and pain although these factors are also integral to the healing process
(S teen 2007a); therefore, although the area might be causing discomfort from the
original trauma, where this is unchanged or absent a pathological condition should
not be developing. There may be occasions, however, where the midwife might
consider that the woman is declining this observation because she is embarrassed or
anxious. I n such cases, the midwife should use her skills of communication to explore
whether there is a clinical need for this observation to be undertaken and, if so, to
advise the woman accordingly. Examining the perineal area is undertaken to assess
healing after birth. S tandardized scales to assist the midwife are not readily available
and formal evaluation appears to be an ongoing neglected area of women's health care
(S teen 2010). Fortunately, for the majority of women, the perineal wound gradually
becomes less painful and initial healing should occur by 10–14 days after the birth
(Steen 2007a).
Alleviating perineal pain and discomfort
Evidence suggests that a combination of systemic and localized treatments may be
necessary to achieve adequate pain relief which will meet individual women's needs
(Steen and Roberts 2011).
There is some evidence that oral analgesia, bathing, diclofenac suppositories,
lidocaine gel and localized cooling treatment can alleviate perineal pain. N o adverse
effects on healing have been reported when localized cooling is applied (East et al
2012a).
The treatments that appear to achieve pain relief are summarized in Box 23.4.
Box 23.4
S um m a ry of e vide nce t o a lle via t e pe rine a l pa in a nd
discom fort
• Oral analgesia, self-administered, effective for mild to severe pain (Moffat
et al 2006; Steen and Marchant 2007; Chou et al 2010).
• Bathing (Sleep and Grant 1988; Greenshields and Hulme 1993; Steen and
Marchant 2007).
• Voltarol suppositories – effective in first 24–48 hr, some relief (Yoong et al
1997; Searles and Pring 1998; Hedayati et al 2005).
• Lignocaine gel – effective in first 48 hr (Harrison and Brennan 1987a,
1987b; Corkill et al 2001).
• Localized cooling (Steen et al 2000; Steen 2002; Steen and Marchant 2007;
Navviba et al 2009; East et al 2012a)
Tiredness and fatigue
Most women will complain of tiredness and fatigue during the first few weeks
following birth, and lack of sleep at the end of pregnancy, giving birth and
establishing feeding can take its toll. I t is therefore vitally important that a newly
birthed mother is advised to consciously make time to rest and sleep during the
postpartum period. For example, she should be advised to take the opportunity to
have a ‘nap’ during the day when her baby is sleeping and not to feel guilty about
doing this. A midwife may need to reassure a mother that household chores can wait
and it takes time to adjust to caring for a newborn. Tiredness and fatigue can have an
adverse effect on a mother's health and wellbeing status. Being tired and fatigued will
inevitably have a negative effect on a woman's ability to care for her newborn (Troy
and D algas-Pelish, 2003). Tiredness and fatigue can lead to maternal exhaustion and
has been associated with maternal depression (Taylor and J ohnson 2010) (see Chapter
25). However, it has been reported that the meaning of tiredness and fatigue are
subjective and difficult to define and ‘there is a lack of authoritative research on
postnatal tiredness and fatigue’ ( McQ ueen and Mander 2003: 464). N evertheless,
midwives can play a vital role in supporting a woman to have realistic expectations
about life after birth and advising her to nurture herself and on the importance of
finding time to rest and recuperate.
Expectations of health
I t is reasonable for women to look forward to regaining their body for themselves once
the baby is born (MaGuire 2000; S teen 2007b). However, this is not the immediate
outcome for many women and, once again, individual women will have their own
expectations about the nature and speed at which they would like this recovery to
occur. The role of the midwife at this point is to assist the woman to identify actual
symptoms of disorder from the gradual process of reorder and advise what action the
woman can do for herself in the way of progressive recovery. Advice for new parents in
the ma er of recovery from the birth is limited and often superficial; also women may
feel they should know what to do, or have unrealistic expectations of motherhood and
their ability to cope with these new experiences (Bartell 2004). This is one area where
taking the time to talk about what might seem to the midwife a range of peripheral or
even superficial issues that might be worrying the otherwise healthy new mother
could be of more benefit that day than a range of routine clinical observations
(Redshaw et al 2007).
Balancing exercise and healthy activity with rest and relaxation
I ncreasing the understanding in the general population about the value of different
forms of exercise and health has been shown to be of psychological as well as physical
benefit (A rmstrong and Edwards 2004). There is substantial evidence that suggests
exercising during the postnatal period has many positive effects (Goodwin et al 2000;
Berk 2004; Steen 2007b). For example, women who exercise regularly are more likely to
recover more quickly after the birth (Clapp 2001) (see Box 23.3).
Exploring each person's level of activity will encourage advice in relation to
appropriate exercise and, by association, nutritional intake and rest or relaxation and
sleep. Undertaking regular pelvic floor exercises is of benefit to women's long-term
health (Mørkved and Bø 2013).
Future health, future fertility
Advice on managing fertility is within the sphere of practice of the midwife and it is an
important aspect of postpartum care (see Chapter 27). Midwives need to be aware of a
range of different needs with regard to women's sexuality and should be able to offer
sensitive and appropriate advice on contraception where this is needed.
Record-keeping and documentation
A midwife has to provide high standards of practice and care at all times (N MC 2008).
Clear and accurate records of any observations and discussions that have taken place
during the postnatal period are a key tool in safeguarding the health and wellbeing of
the mother and her baby. I n its Code, the N ursing and Midwifery Council N ( MC 2008)
clearly states that a midwife must keep clear and accurate records (Box 23.5).
Box 23.5
T he m idwife 's re cord- ke e ping
The UK's N ursing and Midwifery Council states inThe Code: Standards of
Conduct, Performance and Ethics for Nurses and Midwives:
Keep clear and accurate records:
▪ You must keep clear and accurate records of the discussions you have, the
assessments you make, the treatment and medicines you give and how effective
these have been.
▪ You must complete records as soon as possible after an event has occurred.
▪ You must not tamper with original records in any way.
▪ You must ensure any entries you make in someone's paper records are clearly
and legibly signed, dated and timed.
▪ You must ensure any entries you make in someone's electronic records are clearly
attributable to you.
▪ You must ensure all records are kept securely.
Source: NMC 2008: 42–7
Evidence and best practice
The midwife should gain a considerable amount of information during her contact
with the mother and baby. The wide range for normality and the individuality within
this can make it difficult for the midwife to decide whether an observation is related to
morbidity. I t is more likely to be the relationship between several observations that
raises cause for concern and, where these appear to be more related to abnormality
than normality, the midwife has a responsibility to make appropriate referral to a
medical practitioner or other appropriate healthcare professional. I n the UK the
midwife's statutory framework (N MC 2012) is different from the overall guidance and
frameworks for care provision developed under the auspices of various D epartments
of Health. This is an important distinction with regard to the professional
accountability of the midwife and her obligation as an employee (NMC 2008).
Transition to parenthood
The transition to parenthood involves major adjustments within a family and some
mothers will welcome and actively seek help and support from a midwife during the
postnatal period, but some women, for a range of reasons, may not. W omen from
different cultural backgrounds may have traditions that conflict with the current
management of postpartum care (O ckleford et al 2004), or consider that they already
have sufficient skills and experience. N ot being able to speak or understand English
may also prevent a woman from seeking help.
A lthough a visit to the home might have been planned, there will also be times
when women are not at home when the midwife visits. I t is important to keep in mind
individual circumstances and whether these might have any bearing on a no-access
visit. For example, parents with a disability such as hearing loss or poor mobility
might not hear a doorbell. I t is, therefore, important to make arrangements for contact
to be made by alternative means (e.g. using a visual alarm or telephone to alert the
woman of the visit beforehand) (D isability Pregnancy and Parenthood I nternational
2007).
The midwife needs to recognize situations where the mother perceives she has
different priorities from those routinely provided by the healthcare services. The
option of a ending a postnatal clinic/drop-in centre has been introduced in some
areas of the UK to meet maternity services local needs and offers some flexibility
around postnatal follow-up care (Gibbon and Steen 2012).
A recent meta-synthesis has reported that fathers cannot support their partner
effectively in achieving a positive parenthood experience unless they are themselves
supported, included and prepared for parenthood (S teen et al 2012). A study has
reported that inadequate preparation remains a concern to both women and their
partners and concluded that there is an urgent need for an improvement in parents'
preparation for parenthood (D eave and J ohnson 2008). Becoming a parent is often a
stressful event and can contribute to relationship difficulties and a achments within
the family. Both parents have reported in studies that they would have benefited from
some early warning and education (D eave and J ohnson 2008; S teen et al 2011). The
midwife has an important role in supporting both parents during the transition to
parenthood as there are clear health and wellbeing benefits for the mother and baby
(DfE 2010). In addition, the midwife may have an important role with regard to referral
and support for women who are in abusive relationships (Steen and Keeling 2012).
W here there are concerns about the safety or protection of the newborn infant, the
supervisor of midwives should be informed and advice sought from the local social
services (the S afeguarding Children Board). Children's Centres offer a range of
services to assist disadvantaged groups and local communities during the transition to
parenthood. Family nurse practitioners (FN Ps) can also offer further support. I n
addition, there is good evidence that new parents benefit from the support that their
families, friends and other parents can offer.
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Further reading
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Hale, Cheshire; 1994.
Baston H, Hall J. Midwifery essentials: postnatal. Churchill Livingstone/Elsevier:
Edinburgh; 2009.
Brown S, Lumley J, Small R, et al. Missing voices: the experiences of motherhood.
Oxford University Press: Melbourne; 1994.
Byrom S, Edwards G, Bick D. Essential midwifery practice: postnatal care. Wiley–
Blackwell: Oxford; 2009.
Choi P, Henshaw C, Baker S, et al. Supermum, superwife, supereverything:
performing femininity in the transition to motherhood. Journal of Reproductive
and Infant Psychology. 2005;23:167–180.
Dykes F. A critical ethnographic study of encounters between midwives and
breast-feeding women in postnatal wards in England. Midwifery. 2005;21:241–
252.
Gibbon K, Steen M. Postnatal care. Caring for women during a homebirth. Steen
M. Supporting women to give birth at home. A practical guide for midwives.
Routledge: London; 2012:148–154.
Lunt K. How to undertake a postnatal examination. RCM Magazine. 2013;4:32–33.
Miller T. Making sense of motherhood: a narrative approach. Cambridge University
Press: Cambridge; 2005.
Useful websites
Made for Mums. www.madeformums.com/breast-and-bottlefeeding/how-to-
breastfeed-your-baby/19342.html.
Maternity Action. www.maternityaction.org.uk/.
Mums net. www.mumsnet.com/.
National Childbirth Trust. www.nct.org.uk/professional/research/pregnancy-
birth-and-postnatal-care/postnatal-care.
National Institute for Health and Care [formerly Clinical] Excellence.
http://pathways.nice.org.uk/pathways/postnatal-care.
Royal College of Midwives. http://www.rcm.org.uk/midwives/by-
subject/postnatal-care/.
C H AP T E R 2 4
Physical health problems and
complications in the puerperium
Julie Wray, Mary Steen
CHAPTER CONTENTS
The need for women-focused and family-centred postpartum care 516
Potentially life-threatening conditions and morbidity after the birth 516
Immediate untoward events for the mother following the birth of the
baby 516
Maternal collapse within 24 hours of the birth without overt bleeding 517
Postpartum complications and identifying deviations from the normal 517
The uterus and vaginal loss following vaginal birth 518
The uterus and vaginal loss following operative delivery 519
Wound problems 520
Circulation 522
Headache 523
Backache 523
Urinary problems 523
Bowel problems 524
Anaemia 524
Breast problems 525
Practical skills for postpartum midwifery care after an operative birth 525
Emotional wellbeing: psychological deviation from normal 526
Self care and recovery 526
Talking and listening after childbirth 526
References 527
Further reading 529
Useful websites 529
This chapter reviews the care of women who either entered the postpartum
period having experienced obstetric or medical complications, including
those who did not undergo a vaginal birth, or whose postpartum recovery,
regardless of the mode of birth, did not follow a normal pattern. It includes
the care for women with signs and symptoms of life-threatening conditions
and those with obvious risks for increased postpartum physical morbidity.
(The effects of morbidity related to psychological trauma are covered in
Chapter 25.)
The chapter aims to:
• discuss the role of midwifery care in the detection and management of life-threatening
conditions and postpartum morbidity
• review best practice in the management of problems associated with trauma and
pathology arising from pregnancy and childbirth
• review the role of the midwife (and family) where postpartum health is complicated by
an instrumental or operative birth.
The need for women-focused and family-centred
postpartum care
A women-focused approach to care in the postpartum period alongside individualized
care planning developed with the woman and her family will assist physical and
psychological recovery (N I CE [N ational I nstitute for Health and Clinical Excellence
2006a). W hat is important is to focus upon the needs of women as individuals rather
than fi ing women into a routine care package ( D H [D epartment of Health] 2004; Bick
et al 2009; W ray and Bick 2012). The midwife needs to be familiar with the woman's
background and antenatal and labour history irrespective of the care se ing (NICE
2006a) when assessing whether or not the woman's progress is following the expected
postpartum recovery pattern (Garcia et al 1998; DH 2004; Redshaw and Heikkila 2010).
A ll women should be offered appropriate and timely information with regard to
their own health and wellbeing (and their babies) including recognition of, and
responding to, problems (N I CE 2006a; Bick et al 2011). The effects of obstetric or
medical complications will be assessed for and reviewed within the context of the
immediate and ongoing care by the midwife of the woman's health over the postnatal
period. The role of the midwife in these cases is first to identify whether a potentially
life-threatening condition exists and, if so, to refer the woman for appropriate
emergency investigations and care (N MC (N I CE 2006a, CMA CE [Centre for Materna
and Child Enquiries] 2011; N MC [N ursing and Midwifery Council] 2012 ). W here the
birth involves obstetric or medical complications, a woman's postpartum care is likely
to differ from those women whose pregnancy and labour are considered
straightforward. However, it must also be considered that some women have a
perception of the whole birth experience as traumatic, although to the obstetric or
midwifery staff no untoward events occurred ( S ingh and N ewburn 2000; Marchant
2004).
Potentially life-threatening conditions and morbidity after
the birth
D espite the apparent advances in medication and practice, women still die
postpartum. The discovery of penicillin and the provision of a blood transfusion were
major contributions to saving women's lives over the past century (Loudon 1986, 1987),
and maternal death after childbirth where there has been no preceding antenatal
complication is now a rare occurrence in the United Kingdom (UK) L ( ewis 2007;
CMACE 2011). Thrombosis or thromboembolism and haemorrhage were major causes
of direct maternal deaths in the UK but these have declined (Lewis 2007). Cardiac
disease is the most common cause of indirect death; the indirect maternal mortality
rate has not changed significantly since 2003–2005 (CMA CE 2011 ). However, sepsis is
now the most common cause of direct maternal death in the triennium 2006–2008
associated with genital tract infection, particularly from community-acquired Group A
streptococcal (GA S ) infection (C MA CE 2011 ). The mortality rate related to sepsis
increased from 0.85 deaths per 100 000 maternities in 2003–2005 to 1.13 deaths in 2006–
2008 (CMACE 2011).
Being aware of this information is vital for all those involved in giving postnatal care
as good quality care can contribute to the prevention as well as the detection and
management of potentially fatal outcomes (Wray and Bick 2012).
From research, it became clear that maternal morbidity after childbirth was typically
under-reported by women (Bick and MacA rthur 1995; Marchant et al 1999). The extent
of postnatal morbidity was remarkable in the extensive nature of the problems and the
duration of time over which such problems continued to be experienced by women
(MacA rthur et al 1991; Garcia and Marchant 1993; Glazener et al 1995; Brown and
Lumley 1998; Glazener and MacArthur 2001; Waterstone et al 2003; Bick et al 2009).
The midwife has a duty to undertake midwifery care for at least the first 28 days, and
according to N I CE (2006a)all women should receive essential core routine care in the
first 6–8 weeks after birth. The activities of the midwife are to support the new mother
and her family unit by monitoring her recovery after the birth and to offer her
appropriate information and advice as part of the statutory duties of the midwife
(NMC 2012).
Immediate untoward events for the mother following the
birth of the baby
I mmediate (primary) postpartum haemorrhage (PPH) is a potentially life-threatening
event which occurs at the point of or within 24 hours of expulsion of the placenta and
membranes and presents as a sudden, and excessive vaginal blood loss (see Chapter
18). S econdary, or delayed PPH is where there is excessive or prolonged vaginal loss
from 24 hours after birth and for up to 6 weeks' postpartum (Cunningham et al 2005a).
Unlike primary PPH, which includes a defined volume of blood loss (>500 ml) as part
of its definition, there is no volume of blood specified for a secondary PPH and
management differs according to apparent clinical need (A lexander et al 2002; Bick
et al 2009).
Regardless of the timing of any haemorrhage, it is most frequently the placental site
that is the source. A lternatively, a cervical or deep vaginal wall tear or trauma to the
perineum might be the cause in women who have recently given birth. Retained
placental fragments or other products of conception are likely to inhibit the process of
involution, or reopen the placental wound. The diagnosis is likely to be determined
more by the woman's condition and pa ern of events (Hoveyda and MacKenzie 2001;
J ansen et al 2005) and is also often complicated by the presence of infection
(Cunningham et al 2005b; see Chapter 18). The recent CMA CE (2011 : 13) report states
that, ‘there remains an urgent need for the routine use of a national modified early
obstetric warning score (MEO W S ) chart in all pregnant or postpartum women who
become unwell and require either obstetric or gynaecology services’. Usage of this
score will help in providing timely recognition, treatment and referral of women who
have or are developing a critical illness after birth and postnatal.
Maternal collapse within 24 hours of the birth without
overt bleeding
W here no signs of haemorrhage are apparent other causes need to be considered (see
Chapter 13). Management of all these conditions requires ensuring the woman is in a
safe environment until appropriate treatment can be administered by the most
appropriate health professionals, and meanwhile maintaining the woman's airway,
basic circulatory support as needed and providing oxygen. I t is important to
remember that, regardless of the apparent state of collapse, the woman may still be
able to hear and so verbally reassuring the woman (and her partner or relatives if
present) is an important aspect of the immediate emergency and ongoing care.
Postpartum complications and identifying deviations from
the normal
Following the birth of their baby, women recount feelings that are, at one level, elation
that they have experienced the birth and survived, and at another, the reality of pain or
discomfort from a number of unwelcome changes as their bodies recover from
pregnancy and labour (Gready et al 1997; W ray 2011a). W omen may experience
symptoms that might be early signs of pathological events. These might be presented
by the woman as ‘minor’ concerns, or not actually be in a form that is recognized as
abnormal by the woman herself. W here the postpartum visit is undertaken as a form
of review of the woman's physical and psychological health, led by the woman's needs,
the midwife is likely to obtain a random collection of information that lacks a specific
structure. W omen will probably give information about events or symptoms that are
the most worrying or most painful to them at that time. At this point the midwife
needs to establish whether there are any other signs of possible morbidity and
determine whether these might indicate the need for referral. Figure 24.1 suggests a
model for linking together key observations that suggest potential risk of, or actual,
morbidity.
FIG. 24.1 Diagrammatic demonstration of the relationship between deviation from normal
physiology and potential morbidity.
The central point, as with any personal contact, is the midwife's initial review of the
woman's appearance and psychological state. This is underpinned by an assessment of
the woman's vital signs, where any general state of illness is evident, including signs of
infection. I t is suggested that a pragmatic approach be taken with regard to evidence
of pyrexia as a mildly raised temperature may be related to normal physiological
hormonal responses, for example the increasing production of breastmilk. However,
infection and sepsis are important factors in postpartum maternal morbidity and
mortality and the midwife should not make an assumption that a mildly raised
temperature is part of the normal health parameters (Lewis 2007; CMA CE 2011 ; Bick
2012). The accumulation of a number of clinical signs will assist the midwife in making
decisions about the presence or potential for morbidity. W here there is a rise in
temperature above 38 °C it is usual for this to be considered a deviation from normal
and of clinical significance. I f puerperal infection is suspected, the woman must be
referred back to the obstetric services as soon as possible (CMA CE 2011 ). A dherence
to local infection control policies and awareness of the signs and symptoms of sepsis
in postnatal women is important for all practitioners caring for women. This is
particularly the case for community midwives, who may be the first to pick up any
potentially abnormal signs during their routine postnatal observations for all women,
not just those who have had a caesarean section (CS) (CMACE 2011).
The pulse rate and respirations are also significant observations when accumulating
clinical evidence. A lthough there may be no evidence of vaginal haemorrhage, for
example, a weak and rapid pulse rate (>100 bpm) in conjunction with a woman who is
in a state of collapse with signs of shock and a low blood pressure (systolic <90 mmHg)
may indicate the formation of a haematoma, where there is an excessive leakage of
blood from damaged blood vessels into the surrounding tissues. A rapid pulse rate in
an otherwise well woman might suggest that she is anaemic but could also indicate
increased thyroid or other dysfunctional hormonal activity.
The midwife needs to be alert to any possible relationship between the observations
overall and their potential cause with regard to common illnesses, e.g. that the woman
has a common cold, and that the morbidity is associated with or affected by having
recently given birth. W here the midwife is in conversation with the woman as part of
the postpartum assessment, if she receives information that suggests the woman has
signs deviating from what is expected to be normal, it is important that a range of
clinical observations are undertaken to refute or confirm this, followed by timely and
appropriate referral.
Following an innovative research study into extended midwifery care of women
beyond the conventional 10–14-day period, a set of guidelines were compiled to assist
midwives make decisions about the need for referral (Bick et al 2009). A s part of the
N I CE (2006a) process compiling guidelines for core care, it was recognized that
midwives develop skills and processes from their experience to accumulate evidence
from their observations and conversations about the overall wellbeing of the mother
and the baby. However, this process was mainly covert and difficult to adapt in any
formal way to help less experienced midwives or even explain the course of action to
the women themselves (Marchant et al 2003; Marchant 2006). To clarify the actions
necessary, when the NICE guidelines were published, a quick guide was also produced
providing a table of the action required for possible signs/symptoms of complications
and common health problems in women (NICE 2006a).
The uterus and vaginal loss following vaginal birth
I t is expected that the midwife will undertake assessment of uterine involution at
intervals throughout the period of midwifery care (see Chapter 23). I t is recommended
that this should always be undertaken where the woman is feeling generally unwell,
has abdominal pain, a vaginal loss that is markedly brighter red or heavier than
previously, is passing clots or reports her vaginal loss to be offensive ( Hoveyda and
MacKenzie 2001; Marchant et al 2006; Bick et al 2009; CMACE 2011).
W here the palpation of the uterus identifies that it is deviated to one side, this
might be as a result of a full bladder. W here the midwife has ensured that the woman
had emptied her bladder prior to the palpation, the presence of urinary retention must
be considered. Catheterization of the bladder in these circumstances is indicated for
two reasons: to remove any obstacle that is preventing the process of involution taking
place and to provide relief to the bladder itself. I f the deviation is not as a result of a
full bladder, further investigations need to be undertaken to determine the cause.
Morbidity might be suspected where the uterus fails to follow the expected
progressive reduction in size, feels wide or ‘boggy’ on palpation and is less well
contracted than expected. This might be described as subinvolution of the uterus,
which can indicate postpartum infection, or the presence of retained products of the
placenta or membranes, or both (Khong and Khong 1993; Howie 1995).
Treatment is by antibiotics, oxytocic drugs that act on the uterine muscle, hormonal
preparations or evacuation of the uterus (ERPC), usually under a general anaesthetic.
Vulnerability to infection, potential causes and prevention
I nfection is the invasion of tissues by pathogenic microorganisms; the degree to which
this results in ill-health relates to their virulence and number. Vulnerability is
increased where conditions exist that enable the organism to thrive and reproduce and
where there is access to and from entry points in the body. O rganisms are transferred
between sources and a potential host by hands, air currents and fomites (i.e. agents
such as bed linen). Hosts are more vulnerable where they are in a condition of
susceptibility because of poor immunity or a preexisting resistance to the invading
organism. The body responds to the invading organisms by forming antibodies, which
in turn produce inflammation initiating other physiological changes such as pain and
an increase in body temperature.
A cquisition of an infective organism can be endogenous, where the organisms are
already present in or on the body – e.g. Streptococcus faecalis (Lancefield group B),
Clostridium welchii (both present in the vagina) or Escherichia coli (present in the bowel)
– or organisms in a dormant state are reactivated, notably tuberculosis bacteria. O ther
routes are exogenous, where the organisms are transferred from other people (or
animal) body surfaces or the environment. O ther transfer mechanisms include droplets
– inhalations of respiratory pathogens on liquid particles (e.g. β-haemolytic
streptococcus and Chlamydia trachomatis) , cross-infection and nosocomial (hospital-
acquired) transfer from an infected person or place to an uninfected one (e.g.
Staphylococcus aureus).
The bacteria responsible for the majority of puerperal infection arise from the
streptococcal or staphylococcal species, with community acquired GA S infection
causing most serious problems (CMA CE 2011 ). The Streptococcus bacterium has a
chain-like formation and may be haemolytic or non-haemolytic, and aerobic or
anaerobic; the most common species associated with puerperal sepsis is the β-
haemolytic S. pyogenes (Lancefield group A) although other strains of the streptococcal
bacteria have also been identified as the source of serious morbidity (Muller et al
2006). The Staphylococcus bacterium has a grape-like structure, of which the most
important species is S. aureus or pyogenes. S taphylococci are the most frequent cause of
wound infections; where these bacteria are coagulase-positive they form clots on the
plasma which can lead to more widely spread systemic morbidity. There is additional
concern about their resistance to antibiotics and subsequent management to control
spread of the infection. Regardless of the location of care, postpartum women and
healthcare professionals should be aware of how infection can be acquired and should
pay particular a ention to effective hand-washing techniques. They should adhere to
the accepted practice for aseptic technique such as local infection control policies
when in contact with wound care, including the use of gloves for this, and where there
is direct contact with areas in the body where bacteria of potential morbidity are
prevalent. Avoiding the spread of infection is especially necessary when the woman or
her family or close contacts have a sore throat or upper respiratory tract infection
(CMA CE 2011 ). Educating women and their family about the basic principles of good
hand hygiene is a key public health role of the midwife in staving off infection.
The uterus and vaginal loss following operative birth
A lower segment caesarean section (CS ) will have involved cu ing of the major
abdominal muscles and damage to other soft tissues. Palpation of the abdomen is
therefore likely to be very painful for the woman in the first few days after the
operation. The woman who has undergone a CS will have a very different level of
physical activity from the woman who has had a vaginal birth. I t may be some hours
after the operation until the woman feels able to sit up or move about. Blood and
debris will have been slowly released from the uterus during this time and, when the
woman begins to move, this will be expelled through the vagina and may appear as a
substantial fresh-looking red loss. Following this initial loss, it is usual for the amount
of vaginal loss to lessen and for further fresh loss to be minimal. A ll this can be
observed without actually palpating the uterus. For women who have undergone an
operative birth, once 3 or 4 days have elapsed, abdominal palpation to assess uterine
involution can be undertaken by the midwife where this appears to be clinically
appropriate. By this time, the uterus or area around the uterus should not be overly
painful on palpation.
W here clinically indicated, e.g. where the vaginal bleeding is heavier than expected,
the uterine fundus can be gently palpated. I f the uterus is not well contracted then
medical intervention is needed. Uterine stimulants (uterotonics) are usually
prescribed in the form of an intravenous infusion of oxytocin or an intramuscular
injection of syntometrine/ergometrine, if not contraindicated (Chapter 18). I f the
bleeding continues where such treatment has been commenced, further investigations
might include obtaining blood for clo ing factors, or the woman might need to return
to theatre for further exploration of the uterine cavity. The emergence of ultrasound
scans (US S ) in the postpartum period has led to some conflictingreports of the state
of the normal postpartum uterus and the value of US S in distinguishing potentially
pathological conditions (Her berg and Bowie 1991). More recent studies appear to
support greater use of US S to assist diagnosis and clinical management of problems of
uterine sub-involution (Shalev et al 2002; Deans and Dietz 2006).
Wound problems
Perineal problems
I t is important that the midwife has an understanding of the effect of trauma as a
physiological process and the normal pa ern for wound healing (S teen 2007).
Knowledge and an understanding of the physiological process and the nutrients that
are necessary to promote healing will assist a midwife to recognize when there is a
delay in healing and also enable her to advise a woman on her dietary requirements.
(See Fig. 24.2 and Table 24.1.)
FIG. 24.2 The phases of wound healing. Reproduced with permission from Steen 2007.
Table 24.1
Nutrients and their contribution to healing
Nutrient Contribution
Carbohydrates Energy for leucocyte, macrophage and fibroblast function
Proteins Immune response, phagocytosis, angiogenesis, fibroblast proliferation, collagen synthesis, wound
maturation
Fats Provision of energy, formation of new cells
Vitamins
Vitamin A Collagen synthesis and cross-linking, tensile strength
Vitamin B Immune response, collagen cross-linking, tensile strength
(complex)
Vitamin C Collagen synthesis tensile strength, neutrophil function, macrophage migration, immune response
Vitamin E Reduce tissue damage from free radical formation
Minerals
Copper Collagen synthesis, leucocyte formation
Iron Collagen synthesis, oxygen delivery
Zinc Increases cell proliferation, epithelialization, collagen strength
Perineal pain is a result of perineal injury, which can be surgically or naturally
induced. W omen complain of varying degrees of severity of perineal pain. There is
some evidence to suggest that the severity of the perineal injury is linked to the
severity of perineal pain (Kenyon and Ford 2004). Perineal injury that requires
suturing predisposes women to an increased risk of severe perineal pain (Chapter 15).
This might be as a result of the analgesia no longer being effective, the presence of
inflammation in the surrounding tissues or, more seriously, the formation of a
haematoma. Haematoma usually develops deep in the perineal fascia tissues and may
not be easily visible if the perineal tissues are already inflamed. I nadequate perineal
repair or a traumatic vaginal birth can increase the risk of a haematoma. The blood
contained within a haematoma can exceed 1000 ml and may significantly affect the
overall state of the woman, who can present with signs of acute shock. Treatment is by
evacuation of the haematoma and resuturing of the perineal wound, usually under a
general anaesthetic.
Perineal pain that is severe and is not caused by a haematoma might arise as a result
of inflammation causing the stitches to feel excessively tight. Local application of cold
packs can bring relief as they reduce the immediate oedema and continue to provide
relief over the first few days following the birth (S teen et al 2006). The use of oral
analgesia as well as complementary therapies such as arnica and lavender oil is said to
be beneficial, although the effectiveness of such therapies has to date not been
confirmed by research findings ( Bick et al 2009). Midwives should undertake
appropriate training in complementary therapies before advocating their use.
Factors that are associated with poor healing include poor diet, obesity, preexisting
medical disorders and negative social conditions such as poor housing, increased
stress and smoking (S teen 2007). W here pain in the perineal area occurs at a later
stage, or re-occurs, this might be associated with an infection. The skin edges are likely
to have a moist, puffy and dull appearance; there may also be an offensive odour and
evidence of pus in the wound. A swab should be obtained for microorganism culture
and referral made to a General Practitioner (GP). A ntibiotics might be commenced
immediately when there is specific information about any infective agent. W here the
perineal tissues appear to be infected, it is important to discuss with the woman about
cleaning the area and making an a empt to reduce constant moisture and heat.
W omen might be advised about using co on underwear, avoiding tights and trousers
and frequently changing sanitary pads. They should also be advised to avoid using
perfumed bath additives or talcum powder.
I f the perineal area fails to heal, or continues to cause pain, a referral should be
made and resuturing or refashioning might be advised (a Cochrane S ystematic Review
on this topic is currently being undertaken to influence best practice guidelines).
There is evidence to suggest that a substantial proportion of women continue to have
problems during the first 12 months following birth and do not report these to
healthcare professionals (Bedwell 2006). Therefore, it is important to advise women to
seek help and encourage them to discuss any problems with their GP. Most women
should be pain-free and be able to resume sexual intercourse within a few weeks after
the birth; this will vary in individual women. S ome women may still complain of
discomfort, depending on the severity of trauma experienced and the healing process.
D yspareunia (painful sexual intercourse) can be related to perineal trauma (Chapter
15) and this can in the long-term affect the woman's relationship with her partner. I n
the first 3 months post-birth, approximately, 23% of women report dyspareunia
(RCO G 2004). A lthough high levels of sexual morbidity after childbirth have been
identified, the approach to discussion and management of this area appears to be
problematic (Barre et al 2000). W hen giving health advice and support, healthcare
professionals are advised to identify an appropriate time, not to make assumptions
with regard to sexual activity after childbirth and to be conversant with support
agencies relevant to a range of cultural and sexual diversities and associated individual
women's needs (Barrett et al 2000; NICE 2006a).
Caesarean section wounds
I t is now common practice for women undergoing an operative birth to have
prophylactic antibiotics at the time of the surgery (S maill and Hofmeyr 2002). This has
b e e n demonstrated to significantly reduce the incidence of subsequent wound
infection and endometritis. I n addition, it is now usual for the wound dressing to be
removed after the first 24 hours, as this also aids healing and reduces infection. A dvice
needs to be offered to the woman about care of her wound and adequate drying when
taking a bath or shower, or for more obese women where abdominal skin folds are
present and are likely to create an environment that is constantly warm and moist. For
these women, a dry dressing over the suture line might be appropriate.
A wound that is hot, tender and inflamed and is accompanied by a pyrexia is highly
suggestive of an infection. W here this is observed, a swab should be obtained for
microorganism culture and medical advice should be sought. Haematoma and
abscesses can also form underneath the wound and women may identify increased
pain around the wound where these are present. Rarely a wound may need to be
probed to reduce the pressure and allow infected material to drain, reducing the
likelihood of the formation of an abscess. With the hospital stay now being much
shorter than previously, these problems increasingly occur after the woman has left
hospital.
Circulation
Pulmonary embolism remains a major cause of maternal deaths in the UK and
midwives and GPs need to be more alert to identify high-risk women and the
possibility of thromboembolism in puerperal women with leg pain and breathlessness
(Lewis 2007; CMA CE 2011 ). W omen who have a previous history of pulmonary
embolism, a deep vein thrombosis (D VT), are obese or who have varicose veins have a
higher risk of postpartum problems. Postpartum care of women who have preexisting
or pregnancy-related medical complications relies on prophylactic precautions and
should be undertaken for women who undergo surgery and have these preexisting
factors. Thromboembolitic D (TED ) stockings should be provided during, or as soon
as possible after, the birth and prophylactic heparin prescribed until women a ain
normal mobility. A ll women who undergo an epidural anaesthetic, are anaemic, or
have a prolonged labour or an operative birth are slightly more at risk of developing
complications linked to blood clots. W omen with preexisting problems are at higher
risk because of their overall health status and environment of care postpartum. For
example, women who undergo a CS as a result of maternal illness are more likely to
spend longer in bed, thereby reducing their mobility and increasing their risk of
morbidity.
Clinical signs that women might report include the following (from the most
common to the most serious). The signs of circulatory problems related to varicose
veins are usually localized inflammation or tenderness around the varicose vein,
sometimes accompanied by a mild pyrexia. This is superficial thrombophlebitis, which
is usually resolved by applying support to the affected area and administering anti-
inflammatory drugs, where these are not in conflict with other medication being taken
or with breastfeeding. Unilateral oedema of an ankle or calf accompanied by stiffness
or pain and a positive Homan's sign might indicate a D VT that has the potential to
cause a pulmonary embolism. Urgent medical referral must be made to confirm the
diagnosis and commence anticoagulant or other appropriate therapy. The most
serious outcome is the development of a pulmonary embolism. The first sign might be
the sudden onset of breathlessness, which may not be associated with any obvious
clinical sign of a blood clot. W omen with this condition are likely to become seriously
ill and could suffer a respiratory collapse with very little prior warning.
S ome degree of oedema of the lower legs and ankles and feet can be viewed as being
within normal limits where it is not accompanied by calf pain (especially unilaterally),
pyrexia or a raised blood pressure.
Hypertension
W omen who have had previous episodes of hypertension in pregnancy may continue
to demonstrate this postpartum for several weeks after the birth (Tan and D e S wiet
2002). There is still a risk that women who have clinical signs of pregnancy-induced
hypertension can develop eclampsia in the hours and days following the birth
although this is a relatively rare outcome in the normal population (A erbury et al
1998; Tan and D e S wiet 2002). I n addition, some women appear to develop eclampsia
postpartum where there has been no previous history of raised blood pressure or
proteinuria (Chames et al 2002; Ma hys et al 2004). S ome degree of monitoring of the
blood pressure should be continued for women who were hypertensive antenatally,
and postpartum management should proceed on an individual basis (Tan and D e
S wiet 2002). For these women, the medical advice should determine optimal systolic
and diastolic levels, with instructions for treatment with antihypertensive medication
if the blood pressure exceeds these levels. A s women can develop postnatal pre-
eclampsia without having antenatal problems associated with this, because the
symptoms can be fairly non-specific, such as a headache or epigastric pain or
vomiting, the woman may delay or fail to contact a healthcare professional for advice.
W here they do seek advice, the healthcare professional may not be alert to the
possibility of the development of postpartum eclampsia (Chames et al 2002). Failure to
detect symptoms at this initial stage may lead to more serious outcomes as the disease
develops untreated (Chames et al 2002; Tan and D e S wiet 2002; Ma hys et al 2004).
Therefore, if a postpartum woman presents with signs associated with pre-eclampsia,
the midwife should be alert to this possibility and undertake observations of the blood
pressure and urine and obtain medical advice.
For women with essential hypertension, the management of their overall medical
condition will be reviewed postpartum by their usual caregivers. Undertaking clinical
observation of blood pressure for a period after the birth is advisable so that
information is available upon which to base the management of this for the woman in
the future (Tan and De Sweit 2002).
Headache
This is a common ailment in the general population; concern in relation to postpartum
morbidity should therefore centre around the history of the severity, duration and
frequency of the headaches, the medication being taken to alleviate them and how
effective this is. A s this is also associated with hypertension, a recording of the blood
pressure should be undertaken to exclude this as a primary factor. I n taking the
history, if an epidural analgesic was administered, medical advice should be sought.
Headaches from a dural tap typically arise once the woman has become mobile after
the birth and they are at their most severe when standing, lessening when the woman
lies down. They are often accompanied by neck stiffness, vomiting and visual
disturbances. These headaches are very debilitating and are best managed by stopping
the leakage of cerebral spinal fluid by the insertion of 10–20 ml of blood into the
epidural space; this should resolve the clinical symptoms. W here women have
returned home after the birth, they would need to return to the hospital to have this
procedure.
Headaches might also be precursors of psychological distress and it is important
that other issues related to the birth event are explored, taking the time and
opportunity to do this in a sensitive manner. Factors that might be overlooked include
dehydration, sleep loss and a greater than usual stressful environment (see Chapter
25). However, the midwife should take time to discuss the woman's feelings and offer
advice or reassurance about these where possible.
Backache
Many women experience pain or discomfort from backache in pregnancy as a result of
separation or diastasis of the abdominal muscles (rectus abdominis diastasis [RA D ]).
W here backache is causing pain that affects the woman's activities of daily living,
referral can be made to local physiotherapy services. Pelvic girdle pain experienced in
pregnancy should resolve in the weeks after the baby is born but it may continue for a
much longer period (Aslan and Fynes 2007).
Urinary problems
Urinary problems can have short- and long-term social, psychological and physical
health consequences for women (W HO [W orld Health O rganization] 2010 ).
A pproximately 19% of women will have urinary problems following birth (Laperriere
2000). S tress incontinence appears to be the most common form of urinary
incontinence reported following birth but some women may also suffer from
frequency, urgency and urge incontinence ( Birch et al 2009). S ome women who have
had a complicated birth may be susceptible to the risk of urinary infections, which
may lead to cystitis and in some severe cases pyelonephritis (S tables and Rankin 2010).
W here a woman has undergone an epidural or spinal anaesthetic, this can have an
effect on the neurological sensors that control urine release and flow, which may cause
acute retention. The main complication of any form of urine retention is that the
uterus might be prevented from effective contraction, which leads to increased vaginal
blood loss. There is also increased potential for the woman to contract a urine
infection with possible kidney involvement and long-term effects on bladder function.
I n addition, women who have sustained pelvic floor damage during birth may suffer
from continence problems in the short and long term. S tress and urge incontinence of
urine, utero-vaginal prolapse, cystocele, rectocele and dyspareunia are associated with
pelvic floor damage (Stables and Rankin 2010). Very rarely, urinary incontinence might
be a result of a urethral fistula following complications from the labour or birth.
Management of urine output has been shown to lack consistency and recognition of
its potential importance (Zaki et al 2004). A midwife will need to be alert to any
urinary problems a woman may have as sometimes these can be missed. Being alert to
the risks and being able to recognize ongoing urinary problems is an essential
component of care (S teen 2013). A bdominal tenderness in association with other
urinary symptoms, for example a poor output, dysuria or offensive urine and a raised
temperature or general flu-like symptoms, might indicate a urinary tract infection
(UTI ). A mid-stream urine sample will be required to confirm a UTI and the infection
can be treated with antibiotics (NICE 2006b).
W omen might feel embarrassed about having urinary problems and midwives may
need to consider appropriate ways of encouraging women to talk about any problems
so that they can inform them about their future management. S pecific enquiry about
these issues should be made when women a end for their 6–8-week postnatal
examination; further investigations should be made for women who are encountering
these problems. Keeping a bladder diary can be a useful aid. N I CE (2006b) have
suggested that women should complete a bladder diary for three consecutive days to
allow for variation in day-to-day activities to be captured.
Recently it has been reported that women with ongoing urinary incontinence
following birth are nearly twice as likely to develop postnatal depression (S word et al
2011). Therefore, it is essential that midwives have knowledge and an understanding
of the risks and symptoms of urinary problems and are able to ask sensitive questions
to identify women at risk as failure to do so can lead to poor mental health. These
women will need additional social and psychological support (Steen 2013).
Bowel problems
Bowel problems can have short- and long-term social, psychological and physical
health consequences for women (W HO 2010). I t is estimated that about 3–10% of
women will suffer from faecal incontinence (RCO G 2004; Van Brummen et al 2006).
Faecal incontinence is associated with primiparity, instrumental birth and severe
perineal injury (Thornton and Lubowski 2006; Guise et al 2007). Constipation and
haemorrhoids can be a problem for some women. I t is estimated that about 44% of
women will suffer from constipation and 20–25% of women will suffer from
haemorrhoids following birth. S ymptoms such as flatus incontinence, passive leakage,
urge and faecal incontinence can be caused by a neurological or muscular dysfunction
or both (Pollack et al 2004) (see Chapter 15). The prevalence of bowel problems maybe
higher as many women may suffer in silence and be too embarrassed to ask for help
(Steen 2013).
Therefore, a midwife will need to be alert to any bowel problems and to ask a
woman sensitively about her bowel habits. Being alert to the risks and being able to
recognize ongoing bowel problems is an essential component of care. Enquiring about
the pa ern and frequency of bowel movements and comparing this to the woman's
previous experience is likely to assist a midwife in identifying whether or not there is a
problem. Factors such as dietary intake, a degree of dehydration during labour and
concern about further pain from any perineal trauma can contribute to bowel
problems. A diet that includes soft fibre, increased fluids and the use of prophylactic
aperients that are non-irritant to the bowel can be prescribed to alleviate constipation,
the most common and apparently effective of these being lactulose (Eogan et al 2007).
W omen need advice that any disruption to their normal bowel pa ern should resolve
within days of the birth, taking into consideration the recovery required by the
presence of perineal trauma. They should also be reassured about the effect of a bowel
movement on the area that has been sutured as many women may be unnecessarily
anxious about the possibility of tearing their perineal stitches. W here women have
prolonged difficulty with constipation, anal fissures can result ( Corby et al 1997).
These are painful and difficult to resolve and therefore advice about bowel
management is important in avoiding this situation. W omen who have haemorrhoids
should also be given advice on following a diet high in fibre and fluids, preferably
water and the use of appropriate aperients to soften the stools as well as topical
applications to reduce the oedema and pain.
I t is also of concern where women might experience loss of bowel control and
whether this is faecal incontinence. I t is important to determine the nature of the
incontinence and distinguish it from an episode of diarrhoea. I t might be helpful to
ask whether the woman has taken any laxatives in the previous 24 hours and explore
what food was eaten. W here the problems do not seem to be associated with other
factors the woman should first be advised to see her GP.
The role of the midwife is to encourage women to talk about these problems by
being proactive in asking women about any bowel problems. W here women identify
any change to their pre-pregnant bowel pa ern by the end of the puerperal period,
they should be advised to have this reviewed further, whether it is constipation or loss
of bowel control.
Anaemia
I ron-deficiency during pregnancy is extremely common even among well-nourished
women and this can be a predisposing risk factor for anaemia in the postnatal period.
The main cause of anaemia is iron deficiency and severe anaemia can have serious
health and functional consequences (Goddard et al 2011). W hilst severe anaemia
(haemoglobin <7 g/dl) is rare in resource-rich countries, it is a serious problem for
many women in resource-poor countries. The impact, however, of the events of the
labour and birth may leave many women looking pale and tired for a day or so
afterwards. W here it is evident that a larger than normal blood loss has occurred, it
can be valuable to obtain an overall blood profile within which the red blood cell
volume, haemoglobin and ferritin levels can be assessed so as to provide appropriate
treatment to reduce the effects of the anaemia; these include blood transfusions and
iron supplements (D odd et al 2004; Bhandal and Russell 2006). The degree to which
the haemoglobin level has fallen should determine the appropriate management and
this is particularly important in the presence of preexisting haemoglobinopathies,
sickle cell and thalassaemia.
W here the haemoglobin level is <9 g/dl and women are symptomatic, a blood
transfusion might be appropriate. Blood transfusions should be considered if a
woman is at risk of cardiovascular instability because of their degree of anaemia
(Goddard et al 2011). Body-store iron deficiency is diagnosed by a low serum ferritin
level and this can indicate that the woman has a longstanding problem of iron
deficiency. A cut-off ferritin level varies between 12 and 15 µg/l to confirm iron
deficiency (Todd and Caroe 2007). However, ferritin levels can be raised if infection or
inflammation is present, even if iron stores are low (Goddard et al 2011). O ral iron and
appropriate dietary advice are advocated where the level is <11 g/dl. Usually, ferrous
sulphate 200 mg twice daily is recommended; however, a lower dose may be effective
and be er tolerated. A lternatively, ferrous fumarate, ferrous gluconate or iron
suspensions may be be er tolerated and oral iron should be continued for 3 months
after the iron deficiency is corrected to replenish the woman's stores of iron. A scorbic
acid (250–500 mg) twice daily may be prescribed to enhance iron absorption but to
date there are no data to support its effectiveness (Goddard et al 2011). W omen should
be advised not to have milk (including hot beverages with milk added) at the time of
having iron as it can interfere with its absorption.
W here the woman has returned home soon after the birth, the postpartum woman's
haemoglobin values might not have been undertaken where there was no history of
anaemia prior to labour and the blood loss at birth was not assessed as excessive. I f
there is no clinical information to hand, the midwife needs to rely on the woman's
clinical symptoms; if these include lethargy, tachycardia and breathlessness as well as
a clinical picture of pale mucous membranes, it would be prudent to arrange for the
blood profile to be reviewed. S ome researchers have questioned blood loss estimation
after childbirth as well as the timing of blood tests taken to assess the physiological
impact of this (Jansen et al 2007). Thus the postnatal day when the haemoglobin test is
taken might have a clinically significant bearing on the subsequent management.
Breast problems
Regardless of whether women are breastfeeding, they may experience tightening and
enlargement of their breasts towards the 3rd or 4th day as hormonal influences
encourage the breasts to produce milk (see Chapter 34). For women who are
breastfeeding the general advice is to feed the baby and avoid excessive handling of
the breasts. S imple analgesics may be required to reduce discomfort. For women who
are not breastfeeding, the advice is to ensure that the breasts are well supported but
that this is not too constrictive and, again, that taking regular analgesia for 24–48
hours should reduce the discomfort. Heat and cold applied to the breasts via a shower
or a soaking in the bath may temporarily relieve acute discomfort as well as the use of
chilled cabbage leaves (Nikodem et al 1993; Roberts 1995).
Practical skills for postpartum midwifery care after an
operative birth
I n the immediate period after an operative birth the a endant will be closely
monitoring recovery from the anaesthetic used for CS (see Chapter 21). Regular
observation of vaginal loss, leakage on to wound dressings and fluid loss in any
‘redivac’ drain system should also be undertaken.
O nce the woman has fully recovered from the operation she should be transferred
to a ward environment. Midwifery care involves the overall framework of core care (see
Chapter 23). A ppropriate care is to assess the needs of the individual woman and to
formalize this within a documented postnatal care plan so that she and caregivers
have a clear framework by which to promote recovery (DH 2004; N I CE 2006a). W omen
who have undergone an operative birth need time to recover from a major physical
shock to the systems of the body, for optimal conditions to allow tissue repair to take
place as well as psychological adjustment to the events of the birth (Mander 2007).
W omen who have undergone an operative birth will require assistance with a
number of activities they would otherwise have done themselves. D uring their
hospital stay, they will need help to maintain their personal hygiene, to get out of bed
and mobilize and to start to care for their baby. The rate at which each woman will be
able to regain control over these areas of activity is highly individual. I t is strongly
suggested that caregivers should not expect all women to have reached a certain level
of recovery in line with their ‘postnatal day’. Using such a framework to assess the
degree to which a woman is recovering from a major operation leads to a tendency to
become judgemental and unrealistic (W ray 2011a). W omen may view undergoing a
caesarean section or any complication in the birth in different ways depending on
their social and cultural background and this might have associations to their ongoing
psychological health and wellbeing (Chien et al 2006; McCourt 2006).
I t is now common for women to have a much shorter period in hospital after birth;
some women might return home 48–72 hours after a major operation with very
minimal support (Wray and Bick 2012). Practical advice about the management of their
recovery and self-care at home is also within the remit of midwifery postpartum care.
For example; the midwife might suggest that the woman identifies the ways in which
she could reduce the need to go upstairs. A longside this, women can be encouraged to
go out with their baby when someone is available to help with all the baby
transportation equipment; this will encourage venous return and cardiac output at a
level that is beneficial rather than exhausting. At the same time, ge ing ‘out and
about’ can provide a sense of feeling good and improved wellbeing (Wray 2011b: 2).
The benefits of mobility after surgery are well known and although women may be
supplied with thromboembolitic stockings prior to the operation and be prescribed an
anticoagulant regimen such as heparin, women need to be encouraged to mobilize as
soon as practicable after the operation to reduce the risk of circulatory problems.
W omen need an explanation that mobility is of benefit soon after the birth, but it is
also an important part of care to recognize when the woman has reached her limit with
regard to physical activity and may need to rest (W ray 2011a). Regular use of
appropriate analgesia should be made available to women where this is required
(Mander 2007). Good information about self-care and recovery is important to every
woman and the midwife has a key role to play in this process. Each woman is an
individual and unique so her recovery from surgery alongside her adaptation to
motherhood needs to be borne in mind and tailored to meet her own needs (Wray
2011a, 2011b).
Emotional wellbeing: psychological deviation from
normal
Psychological distress and psychiatric illness in relation to childbirth are covered in
depth in Chapter 25. However, it is relevant to reflect here on the possible importance
of the relationship that develops between the woman and the midwife during their
contact postpartum (Hunter 2004). Clearly, such relationships are enriched where
there has been antenatal contact or a degree of continuity postpartum, or both, and
women have commented positively where such continuity has been achieved (Singh
and Newburn 2000; Bhavnani and Newburn 2010). This prior knowledge can mean that
the midwife might detect or be concerned about a change in the woman's behaviour
that has not been noticed by her family. A ny initial concerns of the mother or the
family should be explored by the midwife making use of open questions and listening
skills during the postnatal contact either in the home or in the hospital se ing (NICE
2007; Bick et al 2011). Behavioural changes may be very subtle, but, however small,
they might be of importance in the woman's overall psychological state; it is the
balance between the woman's physical condition and her psychological state that
might influence an eventual decision to refer for expert advice.
A lthough the woman and her partner are likely to have an expectation of reduced
sleep once the baby is born, the actual experience of this can have very varied effects
on individual women (Wray 2012). The cause of the lack of sleep or tiredness is what is
important – is the being unable to get to sleep a result of anxiety about the future and
what is, as yet, unknown? This might include fears about the possibility of a cot death,
or a lack of confidence in coping as a mother, financial or relationship worries. The
opportunity to sleep might be reduced because the feeding is not yet established or
the baby is not in a se led environment and so the mother is constantly disturbed
when she tries to sleep. I n addition, other people may not be allowing the mother to
sleep when the baby does not need her a ention. Tiredness and fatigue can adversely
affect women's health and interfere with their adaptation to motherhood (Troy and
D algas-Pelish 2003), however the terms fatigue and tiredness are subjective and
difficult to define postnatally. S eeking to unravel the issues can help the midwife and
the women to determine what is the underlying cause and whether simple
interventions could improve the situation. A s a result of this enquiry, women who
come into the category where chronic fatigue or anxiety prevents them from sleeping
when the opportunity arises may benefit from interagency referral and support.
A lternatively, where there is a physiological reason for the tiredness, as a result of
anaemia for example, the situation can be managed clinically (J ansen et al 2007). The
midwife is an important member of the primary health care team and should practise
within an interagency context (see Chapter 25). Enabling women to plan and set
realistic goals as part of their own recovery from childbirth is ongoing and extends
beyond 28 days and 6 weeks (Bick et al 2011; Wray 2012).
Self-care and recovery
S elf-care and managing one's own health following childbirth requires women to take
some ownership of their own health and wellbeing (W ray 2011a). The pace at which
women recover is highly variable, and notions of a set time period (6 weeks) do not
apply to all women (N I CE 2006a). W omen need guidance and sound information to
enable them to recover so that they are clear about what they can expect and what to
do when they are concerned. Good rapport and positive feedback from midwives are
known to help women in their recovery as well as support from partners, family and
friends (Beake et al 2010; W ray 2011a). Central to self-care is robust information from
the midwife from the outset, so that women can feel confident in their own
assessments of themselves.
Talking and listening after childbirth
The essence of the contact between the woman and the midwife after the birth event is
to strive to maintain a therapeutic relationship – one of support and advice that builds
on the relationship formed ideally antenatally. Within the current provision of care, it
is not always possible to achieve the objective of continuity of carer postnatally, and
some women will have postnatal home visits from several different midwives, possibly
previously unknown to them. I ndeed other healthcare workers such as maternity
support workers (MS Ws) may form part of the postnatal care-giving process under the
supervision of midwives.
O nce the birth is over and the woman has returned to her home environment there
may be aspects of the birth that she does not understand or that even distress her to
think about. W here appropriate, a midwife undertaking postnatal care in the woman's
home might be able to help the woman review and reflect on the birth by talking
about it and listening to her concerns. W here necessary, the midwife can facilitate
referral to the key people involved in order that the woman can discuss the birth or see
the records of the birth and clarify any outstanding issues (Charles and Curtis 1994;
A llen 1999; N I CE 2006a). O ther forms of support, for instance specific counselling for
those with traumatic emotional experiences, might also be appropriate under
professional guidance (NICE 2007) (see Chapter 25).
References
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Further reading
Bhavnani V, Newburn M. Left to your own devices: the postnatal care experiences of
1260 first-time mothers. NCT: London; 2010.
A useful read to help inform postnatal care..
National Childbirth Trust. Postnatal care – still a Cinderella story?. NCT: London;
2010.
An important insight into why postnatal care is still a neglected issue..
Romano M, Cacciatore A, Giordano R, et al. Postpartum period: three distinct but
continuous phases. Journal of Prenatal Medicine. 2010;4(2):22–
25 www.ncbi.nlm.nih.gov/pmc/articles/PMC3279173/.
Useful websites
National Childbirth Trust. www.nct.org.uk/parenting/you-after-birth.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
A new Quality Standard for postnatal care was introduced in July 2013 – see
http://publications.nice.org.uk/postnatal-care-qs37.
Postnatal Care HEAT module – Lab space, Open University.
http://labspace.open.ac.uk/file.php/6632/HEAT_PNC_Final_Print_Output_cropp
Health Education and Training (HEAT) is an online educational series of modules
launched in 2011 by the Open University with the aim to educate and train
approximately 250 000 frontline healthcare workers across sub-Saharan Africa by
2016..
Royal College of Midwives (RCM). www.rcm.org.uk/midwives/by-
subject/postnatal-care/.
World Health Organization.
www.who.int/maternal_child_adolescent/topics/newborn/postnatal_care/en/.
C H AP T E R 2 5
Perinatal mental health
Maureen D Raynor, Margaret R Oates
CHAPTER CONTENTS
Part A: Pregnancy, childbirth, puerperium: the psychological context 532
Stress/anxiety 532
Fear of giving birth (tocophobia) 533
Tocophobia 533
Transition to parenthood 534
Role change/role conflict 534
Communication 534
The ideology of motherhood 534
Social support 535
Normative emotional changes during pregnancy, labour and the puerperium 535
Pregnancy 535
Labour 535
The puerperium 536
Postnatal ‘blues’ 536
Distress or depression? 537
Emotional distress associated with traumatic birth events 537
Conclusion 537
Part B: Perinatal psychiatric disorder 537
Introduction 537
Types of psychiatric disorder 538
Psychiatric disorder in pregnancy 539
Mild–moderate conditions 539
Serious conditions 540
Psychiatric disorder after birth 541
Puerperal (postpartum) psychosis 541
Postnatal depressive illness 542
Treatment of perinatal psychiatric disorders 545
The role of the midwife 545
Psychological treatments 545
Social support 545
Pharmacological treatment 546
Service provision 548
Prevention and prophylaxis 549
Prevention 549
Prophylaxis 549
The Confidential Enquiries into Maternal Deaths: psychiatric causes of
maternal death 550
Conclusion 550
References 551
Further reading 553
Useful websites 553In psychological terms, pregnancy, childbirth and the
puerperium are major life events or life crises. Having children is associated
with an immense increase in individual life changes that may lead to anxiety
and chronic stressors, for example a new baby may result in a change of
housing and brings increased financial demands. Pregnant women in
employment will inevitably take maternity leave and may return to work in a
different capacity or even on a part-time basis. A new baby may cause
disruption to the family unit. Roles and responsibilities alter with changes to
the dynamics of family relationships. Having a child may place strains on
relationships and there is a higher rate of relationship discord and
breakdown around this time. Many women find coping with the physiological
adaptation to pregnancy, the plethora of antenatal screening tests and
advice, issues around choice, control and communication emotionally
draining. Therefore, while many women and their partners experience
pregnancy and childbirth as a joyous, exciting and life-affirming event, the
transition to parenthood is an emotionally charged time bringing common
anxieties, a certain degree of loss and periods of self-doubt. This can
culminate in pregnancy and postpartum being a fragile time of physical,
psychological and social upheavals. Like other stressful life events
childbirth can be associated with depression and anxiety. However, it is also
known to be associated with an increased risk of serious psychiatric illness.
Pregnancy provides a wealth of opportunities for promoting emotional
health while predicting and preventing mental illness. It is important for
midwives to be able to identify normal adjustment reactions to motherhood
and distinguish them from the early warning signs of emotional distress or
indeed mental illness.This chapter is formed of two distinct but inter-related
parts:
The aim of Part A is to:
• explore the psychological context of pregnancy, childbirth and the puerperium by
examining the full range of human emotions that may affect women as they adjust to
change and make the transition to motherhood
• emphasize that awareness of the multiplicity of psychosocial factors and what
constitutes normal emotions and behaviours are key components in enhancing
understanding of perinatal mental health.
The aim of Part B is to:
• explore the range of perinatal disorders, i.e. psychiatric conditions, that pre-exist or co-
exist with pregnancy as well as those conditions presenting with the puerperium
• emphasize, by using a defined nomenclature, their recognition and management
(including relevant pharmacology and the implications for breastfeeding and mother–
baby relationship)
• highlight key recommendations from NICE and relevant triennial reports on the
Confidential Enquiries into Maternal Deaths in the United Kingdom
Part A: Pregnancy, childbirth, puerperium: the
psychological context
Maureen D Raynor
Stress/anxiety
Pregnancy, labour and the puerperium are normal life events, yet they are periods in a
woman's life when her vulnerability exposes her to a significant amount of stress and
anxiety. S tress and anxiety are the psychopathology of humans' existence and a part of
normal human emotion. A degree of stress during pregnancy is both essential and
normal for the psychological adjustment of pregnant women. The ‘worry work’ that
women encounter assists in their psychological adaptation to the emotional demands
and changes of pregnancy. Conversely, elevated levels of stress hormones and
unnecessary anxiety will stretch coping reserves, and could prove disabling. S tress is
the body's psychophysical response to any type of demand or threat, whether good or
bad. A nxiety on the other hand is a state of angst, worry or unease, often triggered by
an element of perceived threat or an event where there is an uncertain outcome, such
as a wri en examination or when important decisions have to be made. The brain
plays a key role in how an individual responds and processes the perception of a
threat. This is realized via a neurohormonal response by both the neocortex and limbic
system. The ‘fight or flight’ reflex is produced when there is a threat to the self.
A nxiety and fear causes the individual to become stressed, releasing stress response
hormones namely catecholamines (adrenaline/noradrenaline) and cortisol. A host of
psycho-physical symptoms can manifest, such as hyperalertness, tension, sense of
unease, restlessness, insomnia, fear and forgetfulness. Gastrointestinal upset and
marked changes in the cardiovascular system, e.g. sweating, palpitations, tachycardia,
shortness of breath, dizziness, dry mouth and nausea, can also feature. S tress and
anxiety therefore have a cognitive, somatic, emotional, physiological and behavioural
component.
A nxiety disorders, on the other hand, are a group of mental illness that cause such
marked distress that they disrupt normal function, overwhelm or impair the
individual's ability to lead a normal life. Examples of anxiety disorders such as
obsessional–compulsive and phobic anxiety states are discussed in more detail in Part
B of the chapter.
A lthough many studies have raised the profile of elevated levels of stress hormones
during the antenatal period having the potential to lead to deleterious effects on the
fetus (Teixeira et al 1999; Evans et al 2001; Miller et al 2005; Glover and O 'Connor 2006;
Talge et al 2007; O 'D onnell et al 2009) or persistent antenatal anxiety acting as a
possible precursor to maternal mental illness postpartum, this is still an emerging
field. The mechanism by which raised levels of stress hormones may affect fetal
development is not yet fully understood. Furthermore, the research studies have
provided very li le data to help guide midwifery practice on how antenatal stress can
be alleviated in pregnant women.
Thus it can be concluded that there are many factors in women's lives that can
impact on their happiness (Fig. 25.1) and affect their emotional health and wellbeing.
Understanding the root cause and expression of anxiety, stress and mental distress in
women is complex, as the social circumstances in which women live and into which
children are born play a major role in their health and wellbeing.
FIG. 25.1 Vulnerability factors and mental health.
Fear of giving birth (tocophobia)
The fear of childbirth has grown in prominence over recent years, as demonstrated by
the emergent studies mainly from S candinavian countries. The exact incidence of this
psychological condition is unknown but it is estimated that approximately 5–20% of
pregnant women within Western society are fearful of childbirth (Waldenstrom et al
2006; Rouhe et al 2009; A dams et al 2012). The picture within developing and more
resource-poor countries is unreported. Understanding tocophobia is challenging as
there is an array of complex social factors a ributed to the roots of its expression, such
as domestic abuse, communication difficulties, previous traumatic birth experience,
poor socioeconomic status, lack of social support, nulliparity and pre-existing mental
illness (Rouhe et al 2009, 2011). A study by A dams et al (2012) suggests that
tocophobia might result in longer duration of labour and therefore more risk of
obstetric intervention during childbirth. I t is postulated that the fear and anxiety
generated in the presence of tocophobia increases catecholamine levels, which can
affect the frequency, strength and duration of uterine contractions. This can affect
women's satisfaction with their birth experience and lead to maternal distress.
Transition to parenthood
Postnatally, parents may find coping with the demands of a new baby, e.g. infant
feeding, financial constraints, the whole process of lifestyle adjustments and role
changes, a real strain. For new mothers, this will involve diverse emotional responses
ranging from joy and elation to sadness and u er exhaustion. Fatigue, pain and
discomfort commonly result once the elation that follows the safe arrival of the baby
wears off. D isturbed sleep is inevitable with a new baby. Mothers who are trying to
establish breastfeeding, older women, women who are recovering from a caesarean
section or those who have had a long and difficult labour/birth, twins or higher
multiples, may feel wretched and constantly weary for months following childbirth.
S oreness and pain being experienced from perineal trauma will affect libido, so too
will feelings of exhaustion, despair and unhappiness that may be associated with the
round-the-clock demands of caring for a new baby. W omen may be left feeling bereft
and quite miserable after giving birth.
Role change/role conflict
Having a baby, and particularly the transition to parenthood that accompanies the first
child, leads to a significant shift in a couple's relationship; social networks are
disrupted, especially those of the mother, and the quality and quantity of social
support such networks can and do provide. There is a strong possibility that old
relationships, particularly with those who are childless or single, may be weakened,
leading to a sense of social isolation. However, some relationships are strengthened or
even replaced gradually by new contacts established with other parents. The dynamics
of relationships with family members are also altered during this process of transition
and change. The relationship with the woman's parents for example alters as the
daughter becomes a mother herself and her parents develop new roles as
grandparents. The competing demands on time of caring for a new baby may lead to
role conflict and confusion for parents. Mothers may find that there is li le time for
them to pursue other activities, which can diminish any opportunity for contact with
and support from others (Raynor and England 2010). Partners, especially young
fathers, can also experience a sense of isolation as the dynamic within the couple's
relation alters, becoming more baby-centred. Postnatal care is therefore essential to
women's emotional wellbeing and should be a continuation of the care given during
pregnancy. I ts contribution plays a significant part in the positive adjustment to
parenthood, as it assists in the acquisition of confident and well-informed parenting
skills (DH [Department of Health] 2004; Barlow et al 2011).
Communication
Effective communication during pregnancy and the puerperium is essential. Yet poor
communication is still the single most common factor that is associated with women's
dissatisfaction with their care. A survey by the N ational Perinatal Epidemiology Unit
(N PEU) reports that communication remains a ma er of concern within the maternity
service (Redshaw and Heikkila 2010). Being provided with adequate information will
serve to:
• diminish women's anxiety levels and allay emotional distress
• facilitate choice
• enable women to maintain control over decision-making.
The ideology of motherhood
Motherhood, it is thought, ensures that a woman has fulfilled her biological destiny,
confirms a woman's femininity and raises her status in society, but without financial
gain (Cri enden 2001; Winson 2009). I nstead of feeling elated by motherhood some
women experience displeasure, harbour feelings of unhappiness and feel dismayed or
even disappointed in their role as new mothers (Grabowska 2009). Many may be afraid
to speak out about their feelings in case they are judged a ‘bad’ or not a ‘good enough’
mother. Painful emotions may be internalized, magnifying difficulties with coping and
sleeping, leading many women to suffer in silence. D istress may then manifest as
mothers rage against their impossible situation. S ome women may even grieve for the
loss of their former lifestyle, career or status. N icholson (1998) contends that
healthcare professionals have defined women's postnatal experience through
proposing that well-adjusted, ‘normal’ and therefore ‘good’ mothers are those who are
happy and fulfilled, but those who are unfulfilled, anxious or distressed are ‘ill’ and
may be perceived as ‘bad’ mothers. This may lead to feelings of isolation, inadequacy
and confusion. The ideology of motherhood is therefore an assumption and a paradox
with inherent dichotomies as the woman strives to be ‘super mum, super wife, super
everything’ (Choi et al 2005). Midwives have a pivotal role to play in assisting women
and their partners to prepare for the physical, social, emotional and psychological
demands of pregnancy, labour, the puerperium and, perhaps more importantly,
parenthood (Barlow et al 2011; DH 2011).
Social support
D uring periods of stress, supportive and holistic care from midwives will not only
assist in promoting emotional wellbeing of women, but will also help to ameliorate
threatened psychological morbidity in the postnatal period (Oakley et al 1996; Webster
et al 2000; Wessely et al 2000; Hodne et al 2010). W omen who are socially isolated or
who have poor socioeconomic circumstances are particularly vulnerable to mental
health problems and need additional help and support. This includes women from
minority ethnic groups who do not speak English, and often have problems accessing
health care (CMA CE 2011 ) . Bick et al (2009) provide evidence regarding the
psychosocial benefits of midwifery care well beyond the historical boundaries of the
traditionally defined postnatal period. The restructuring of postnatal care means there
is now a social expectation that midwives will respond flexibly and responsively to
women's emotional needs on an individual basis (Brown et al 2002; D H 2004, 2007a,
2007b; NICE [National Institute for Health and Clinical Excellence] 2006). This calls for
skilled multidisciplinary and multi-agency collaboration as well as effective teamwork,
taking into account the diversity within teams, for example the D epartment of Health
(D H 2003a, 2003b) acknowledges the contribution of the maternity support worker in
maternity care. Social support is further explored in Part B.
Normal emotional changes during pregnancy, labour and
the puerperium
Pregnancy
S ince many decisions have to be made it is perfectly normal for women to have
periods of self-doubt and crises of confidence. Box 25.1 outlines the many and varied
emotions women may experience during the different trimesters of pregnancy. The
reality for many women will encompass fluctuations between ambivalence to positive
and negative emotions.
Box 25.1
N orm a l e m ot iona l cha nge s during pre gna ncy
First trimester
• pleasure, excitement, elation
• dismay, disappointment
• ambivalence emotional lability (e.g. episodes of weepiness exacerbated by
physiological events such as nausea, vomiting and tiredness)
• increased femininity
Second trimester
• a feeling of wellbeing, especially as physiological effects of tiredness,
nausea and vomiting start to abate
• a sense of increased attachment to the fetus; the impact of ultrasound
scanning generating images for the prospective parents may intensify the
experience
• stress and anxiety about antenatal screening and diagnostic tests
• increased demand for knowledge and information as preparations are
now on the way for the birth
• feelings of the need for increasing detachment from work commitments
Third trimester
• loss of or increased libido
• altered body image
• psychological effects from physiological discomforts such as backache
and heartburn
• anxiety about labour (e.g. pain)
• anxiety about fetal abnormality, which may disturb sleep or cause
nightmares
• increased vulnerability to major life events such as financial status,
moving house, or lack of a supportive partner
Labour
D uring labour, midwives must facilitate choice to help women maintain control.
Factors that induce stress should be prevented, or at least minimized, as the woman's
long-term emotional health may be severely compromised by an adverse birth
experience (Lyons 1998; Redshaw and Heikkila 2010). Choice and control are important
psychological concepts to mental health and wellbeing. Evidence from Green et al's
(1998) prospective study of women's expectations and experiences of childbirth
suggests that having choice in pregnancy and childbirth, and a sense of being in
control, lead to a more satisfying birth experience. I n England, the publication of
‘Maternity Ma ers’ (D H 2007a) epitomizes a real philosophical shift in maternity care
in terms of the guaranteed choices for women. Redshaw and Heikkila (2010) identify
key factors related to women's perception of control during labour, these are:
• continuity of care with carer
• one-to-one care in labour
• not being left for long periods
• being involved in decision-making.
O ngoing research to determine the relationship between women's perception of
control during childbirth and postnatal outcomes is needed in order to measure
factors such as postnatal depression, positive parenting relationships and self-esteem.
Common emotional responses during labour are detailed in Box 25.2.
Box 25.2
E m ot iona l cha nge s during la bour
• Ranging from great excitement and anticipation, to utter dread
• Fear of the unknown
• Fear of technology, intervention and hospitalization
• Tension, fear and anxiety about pain and the ability to exercise control
during labour
• Concerns about the wellbeing of the baby and ability of the partner to
cope
• Fear of death: hospitals may be construed as places of illness, death and
dying; the magnitude of such feelings may intensify if the woman
experiences life-threatening complications or even an emergency
caesarean section
• The process of birth thrusts a lot of private data into the realms of the
public, so there could be a fear of lack of privacy or utter embarrassment
The puerperium
The puerperium is hailed as the ‘fourth trimester’ – an emotionally complex
transitional phase. By definition, it is the period from birth to 6–8 weeks postpartum,
when the woman is readjusting physiologically, socially and psychologically to
motherhood. Emotional responses may be just as intense and powerful for
experienced as well as for new mothers. The major psychological changes are therefore
emotional. The woman's mood appears to be a barometer, reflecting the baby's needs
of feeding, sleeping and crying pa erns. N ew mothers tend to be easily upset and
oversensitive. A sense of proportion is easily lost, as women may feel overwhelmed
and agitated by minor mishaps. The woman might start to regain a sense of
proportion and ‘normality’ between 6 and 12 weeks. Exhaustion is also a major factor
of women's emotional state. Perhaps the most important factor in regaining any
semblance of normality is the mother's ability to sleep throughout the night. A
woman's sexual urges, emotional stability and intellectual acuity may take months, if
not longer, to return. N ormal emotional changes in the puerperium are summarized
in Box 25.3.
Box 25.3
N orm a l e m ot iona l cha nge s during t he pue rpe rium
• Immediately following birth, the woman might experience relief. The
woman might convey a cool detachment from events, especially if labour
was protracted, complicated and difficult
• Contradictory and conflicting feelings ranging from satisfaction, joy and
elation to exhaustion, helplessness, discontentment and disappointment
as the early weeks seem to be dominated by the novelty and
unpredictability of the new baby
• A feeling of closeness to partner or baby; equally the woman may feel
disinterested in the baby
• Early skin-to-skin contact and breastfeeding will help to nurture the early
stages of relationship building between mother and baby
• Being very attentive towards the baby; equally the woman may show
disinterest in the baby
• Fear of the unknown and sudden realization of overwhelming
responsibility
• Exhaustion and increased emotionality
• Pain (e.g. perineal, in nipples)
• Increased vulnerability, indecisiveness (e.g. in feeding), loss of libido,
disturbed sleep and anxiety
Postnatal ‘blues’
Childbirth is an emotionally intense experience. Mood changes in the early days
postpartum are particularly common. The postnatal ‘blues’ is a transitory state,
experienced by 50–80% of women depending on parity (Harris et al 1994). I t has been
identified as an antecedent to depression following childbirth (Gregoire 1995; Cooper
and Murray 1997). The onset typically occurs between day 3 and 5 postpartum, but
may last up to 1 week or more, though rarely persisting longer than 48 hours. The
main features are mild and may include:
• a state whereby the woman experiences labile emotions (e.g. tearfulness, despair,
irritability to euphoria and laughter)
• a state whereby the woman feels overwhelmed by the sudden realization of the
relentless responsibility of the baby's 24-hour dependency and vulnerability.
The actual aetiology is unclear but hormonal influences (e.g. changes in oestrogen,
progesterone and prolactin levels) seem to be implicated as the period of increased
emotionality appears to coincide with the production of milk in the breasts. This state
of heightened emotionality is self-limiting and will resolve spontaneously, assisted by
support from loved ones. The midwife should be vigilant during this time as
persistent features could be indicative of depressive illness.
Distress or depression?
Repeated contact with women during pregnancy and puerperium afford a wealth of
opportunity to explore feelings, experience and emotions, and for midwives to provide
clear explanations to women about the differences between distress – a normal
reaction to major life events – and depressive illness. However, midwives should be
mindful of over-reliance on the medical model to describe women's moods as such an
approach may serve to pathologize or medicalize normal emotional changes
(Nicholson 1998).
Emotional distress associated with traumatic birth events
Understanding the root cause and expression of mental distress associated with
pregnancy and childbirth is complex. I t is important to recognize the inter-
relationship between traumatic life events and women's mental health. Vulnerability
factors such as a history of childhood sexual abuse or a morbid fear of childbirth can
negate a woman's experience of childbirth. W hat is intended to be one of the happiest
days in a woman's life can quickly turn into anguish and distress. Furthermore,
environmental factors may lead to a sense of loss of control, for example effects of
intense pain, use of technological interventions, insensitive and disrespectful care or
an emergency caesarean section (CS ) may prove very distressing and frightening.Post-
traumatic stress disorder (PTS D ), a term most commonly associated with individuals
who have suffered the onslaught of war, has emerged in the literature around
maternity care (Lyons 1998). O bstetric PTS D occurs when women feared they or their
baby were in danger of dying. N ot surprisingly it is commonest after emergency CS or
obstetric emergencies, particularly involving intensive care. I t is estimated 6% of
emergency CS are followed by obstetric PTS D Beck
( 2009). Box 25.4 highlights some of
the reported symptoms of obstretric PTSD.
Box 25.4
R e port e d sym pt om s of obst re t ric P T S D
Features of obstetric PTS D – applies where symptoms are present for more
than 1 month (Lyons 1998; Beck 2009)
• Intrusive thoughts or images resulting in nightmares, panic attacks or
‘flashbacks’ about the birth
• Detachment from loved ones and difficulty with mother–baby
relationship (attachment)
• Avoidance especially of issues relating to pregnancy/birth
• Hypervigilance/increased arousal – having a sense of imminent disaster
• Sleep disturbances
• Irritability or angry outbursts
• Anxiety/depression
O ther features are not dissimilar to those previously discussed in the text
relating to stress and anxiety.
Unlike mild to moderate depression in the postpartum period, which seems to have
its roots in the biophysical and psychosocial domains, obstetric distress after
childbirth appears to be directly linked to the stress, fear and trauma of birth, yet its
prevalence is unrecognized (Lyons 1998). Psychological interventions such as
‘debriefing’ have been suggested to manage immediate symptomatology but there is
no reliable evidence that it is a useful intervention in reducing psychological
morbidity (A lexandra 1998; Wessely et al 2000; Bick et al 2009). Moreover, clinical
guidelines from N I CE (2007) have stated that following a traumatic birth, women
should not routinely be offered ‘single-session formal debriefing focused on the birth’.
I nstead midwives and other healthcare professionals should support women who wish
to talk about their experience and draw on the love and support of family and friends.
Neither should midwives overlook the impact of birth on the partner.
Conclusion
Conclusion
A plethora of significant social and health policies and clinical guidelines have
resulted in wider consideration being given to the social and psychological context of
pregnancy and the puerperium. Midwives need to have knowledge and understanding
of how they influence care provision. Box 25.5 provides a summary of key points.
Box 25.5
S um m a ry of ke y point s
• In the UK pregnancy and the postnatal period are unparalleled periods
when women engage with health care and have repeated contact with
healthcare professionals
• Women during pregnancy, labour and puerperium are in a state of
transition punctuated by heightened emotions and anxiety. Family life
and daily routines become disrupted by the arrival of a new baby
• Vulnerability factors such as domestic abuse, poverty and social isolation,
can impact on the mother–baby relationship with consequences for child
development
• Risk identification of vulnerable groups of women antenatally presents a
unique opportunity for multidisciplinary and multi-agency collaboration
in promoting mental health and wellbeing
Part B: Perinatal psychiatric conditions
Margaret R Oates
Introduction
Perinatal psychiatric disorder is now an accepted term used both nationally and
internationally. I t emphasizes the importance of psychiatric disorder in pregnancy as
well as following childbirth and the variety of psychiatric disorders that can occur at
this time, not just the ubiquitously known postnatal depression (PN D ). I t also places
emphasis on the significance of psychiatric disorders that were present before
conception as well as those that arise during the perinatal period (Box 25.6).
Box 25.6
W ha t is pe rina t a l psychia t ric disorde r?
• Psychiatric disorders that complicate pregnancy, childbirth and the
postnatal period
• Includes not only those illnesses that develop at this time but also pre-
existing disorders such as schizophrenia, bipolar illness and depression
• Care involves consideration of the effects of the illness itself and of its
treatment on the developing fetus and infant
• Care involves multidisciplinary and multi-agency working, especially
close relationships with Maternity Mental Health and Children's Services
The emotional wellbeing of women is of primary importance to midwives. N ot only
can mental illness affect obstetric outcomes but also the transition to parenthood and
emotional wellbeing and health problems in the infant. O ver the last 15 years
psychiatric disorder in pregnancy and the postpartum period has been a leading cause
of maternal mortality, as highlighted in the ‘W hy Mothers D ie in the UK’ O( ates 2001,
2004) and ‘Saving Mothers’ Lives' (Oates 2007; Oates and Cantwell 2011) reports. These
reports of the Confidential Enquiry into Maternal D eaths recommend that midwives
routinely ask at early pregnancy assessment about previous mental health problems,
their severity and care. These recommendations have also been made by the Royal
College of Psychiatrists (RCPC 2000), the W omen's Mental Health S trategy (part of the
Mental Health N ational S ervice Framework;D H 1999), Maternity S tandard 11 of the
Children, Young Peoples and Maternity N ational S ervice Framework D ( H 2004), the
N I CE Guidelines (2007)on the management of antenatal and postnatal mental health
and the Clinical N egligence S tandards for Trusts N ( HS LA [N ational Health S ervice
Litigation Authority] 2011). I n addition, N I CE (2007) recommends that midwives
should ask questions (the W hooley questions) on at least two occasions – antenatally
and following birth – about women's current mental health. S ystems should be in
place locally to ensure that women with mental health problems and those at risk of
developing them receive the appropriate care.
I t is therefore essential that all midwives have education and training to be familiar
with normal emotional changes, commonplace distress and adjustment reactions as
well as the signs and symptoms of more serious psychiatric illnesses.
Types of psychiatric disorder
The term ‘mental health problem’ is commonly used to describe all types of emotional
difficulties from transient and temporary states of distress, often understandable, to
severe and uncommon mental illness. I t is also used frequently to describe learning
difficulties, substance misuse problems and difficulties coping with the stresses and
strains of life. I t is therefore too general and too non-specific to be of use to the
midwife. The term does not discriminate between severity and need and does not help
the midwife distinguish between those conditions that she can manage and those that
require specialist a ention. For this reason, in this chapter, the term ‘psychiatric
disorder’ is preferred as it can be further categorized and the different types can be
described aiding recognition and the planning of care.
Psychiatric disorders are conventionally categorized into:
Serious mental illnesses
These include schizophrenia, other psychotic conditions, bipolar illness and severe
depressive illness. Previously, these conditions were called psychotic disorders.
Mild to moderate psychiatric disorders
These were previously known as ‘neurotic disorders’. These include non-psychotic
mild to moderate depressive illness, mixed anxiety and depression, anxiety disorders
including phobic anxiety states, panic disorder, obsessive–compulsive disorder and
post-traumatic stress disorder.
Adjustment reactions
These would include distressing reactions to life events, including death and adversity.
Substance misuse
This includes those who misuse or who are dependent upon alcohol and other drugs
of dependency, including both prescription and legal/illegal drugs.
Personality disorders
This is a term that should be used only to describe people who have persistent severe
problems throughout their adult life in dealing with the stresses and strains of normal
life, maintaining satisfactory relationships, controlling their behaviour, foreseeing the
consequences of their own actions and which persistently cause distress to themselves
and other people.
Learning disability
This is a term used to describe people who have a lifetime evidence of intellectual and
cognitive impairment, developmental delay and consequent learning disabilities. This
is usually graded as mild, moderate or severe.
O verall psychiatric disorders are very common in the general population. The
General Household S urvey 2000, as reported by the O ffice of N ational S tatistics ONS
(
2002), reveals a prevalence of over 20% of these disorders. Recent figures from ONS
(2012) have shown li le change in this trend in the adult population in the UK,
reporting that in 2007, approximately 1 : 6 adults had a common mental disorder such
as anxiety or depression.
They are commoner in women than in men with the exception of substance misuse
problems. However, the majority of psychiatric disorders in the community are mild to
moderate conditions, particularly general anxiety and depression. Mild to moderate
depressive illness and anxiety disorders are at least twice as common in women than
in men, and are particularly common in young women with children under the age of
5. The majority of these disorders are managed in primary care and do not require the
a ention of specialist psychiatric services. Mild to moderate depressive illness and
anxiety states respond to psychological treatments. D espite this, perhaps because of
shortage of such treatments, prescription of antidepressants is widespread in the
community, particularly among women.
S erious mental illnesses are less common. Both schizophrenia and bipolar illness
affect approximately 1% of the population. Bipolar illness affects men and women
equally. However, schizophrenia, particularly the more severe chronic forms, is
commoner among men. These conditions require the a ention of specialist psychiatric
services and require medical treatments as well as psychological care.
I n the UK psychiatric services are usually organized separately for adult mental
health (serious mental illnesses), substance misuse (drug and alcohol treatment
services) and learning disability. There are also, but not relevant to this chapter,
separate services for psychiatric disorders in the elderly.
Psychiatric disorder in pregnancy
I n general, psychiatric disorder is not associated with a decrease in fertility. Therefore
all the previously described psychiatric disorders can and do complicate pregnancy
and the postpartum period. The prevalence of psychiatric disorder in young women
means that at least 20% of women will have current or previous psychiatric disorder in
early pregnancy, many of whom will be taking psychiatric medication at the time of
conception. However, it can be seen that only a small number will have a past history
of a serious mental illness and an even smaller number will be currently suffering
from such an illness. Pregnancy is not protective against a recurrence or relapse of a
previous psychiatric disorder, particularly if the medication for these disorders is
stopped when pregnancy is diagnosed. W omen with a previous history of serious
illness are at increased risk of a recurrence of that illness following birth. I t is for these
reasons that it is so important for midwives to enquire into women's current and
previous mental health at early pregnancy assessment. Table 25.1 highlights the
incidence of perinatal psychiatric disorders.
Table 25.1
Incidence of perinatal psychiatric disorders
Psychiatric disorder (%)
'Depression’ 15–30
PND (postnatal depression) 10
Moderate/severe depressive illness 3–5
Referred psychiatry 2
Admitted to hospital 0.4
Admitted psychosis 0.2
Births to schizophrenic mothers 0.2
Mild–moderate conditions
The incidence (new onset) of psychiatric disorder in pregnancy is mostly accounted for
by mild depressive illness, mixed anxiety and depression or anxiety states. These
disorders present most commonly in the early weeks of pregnancy, becoming less
common as the pregnancy progresses. They are probably predominantly of
psychosocial aetiology, and for some women they will represent a recurrence of a
previous episode, of depression, anxiety, panic or obsessional disorders particularly if
they have suddenly stopped their antidepressant medication. W omen may also be
vulnerable at this time because of:
• previous fertility problems
• previous obstetric loss
• anxieties about the viability of their pregnancy
• social and relationship problems
• ambivalence towards the pregnancy
• other reasons for personal unhappiness.
I n the past, it was often assumed that hyperemesis gravidarum (severe vomiting)
was a psychosomatic manifestation of personal unhappiness and psychological
disturbance. This condition is less common than in the past and usually resolves by 16
weeks of pregnancy. Psychological factors, anxiety and cognitive misattribution remain
a significant factor in some women.
Prognosis and management
Most of the conditions are likely to improve as the pregnancy progresses.
Psychological treatments and psychosocial interventions are effective for these
conditions and caution needs to be exercised before pharmacological interventions are
initiated during pregnancy, although medication may be necessary for the more severe
illnesses.
For others, particularly those who develop a psychiatric illness in the later stages of
pregnancy, their condition is likely to continue and worsen in the postpartum period.
Serious conditions
This term refers to schizophrenia, other psychoses, bipolar illness (manic depressive
illness) and severe depressive illness.
Incidence
W omen are at a lower risk of developing a serious mental illness for the first time
during pregnancy than at other times in their lives. This is in marked contrast to the
elevated risk of suffering from such a condition in the first few months following
childbirth (Kendell et al 1987). W hile these conditions are uncommon, they require
urgent and expert treatment, particularly as an acute psychosis in pregnancy can pose
a risk to the mother and developing fetus, both directly because of the disturbed
behaviour and indirectly because of the treatments. There is a possibility that such an
illness can interfere with proper antenatal care.
Prevalence
W hile new onset psychosis in pregnancy is relatively rare, the prevalence of these
illnesses (pre-existing) at the beginning of pregnancy will be the same as at other
times. W omen suffering from schizophrenia or bipolar illness are as likely to become
pregnant as the rest of the general population. This means that approximately 2% of
women in pregnancy will either have had such an illness in the past or be currently
suffering from one. I t is important to realize that these women may range from
women who are well and stable, leading normal lives through to those who are
disabled, chronically symptomatic and on medication. The management of these
women in pregnancy therefore has to be individualized and plans made on a case-by-
case basis. Nonetheless, there are three broad groups of women.
Group 1
The first group includes women who have had a previous episode of bipolar illness or
a psychotic episode earlier in their lives. They are usually well, stable not on
medication and may not be in contact with psychiatric services. These women, if their
last episode of illness was more than 2 years ago, may not be at an increased risk of a
recurrence of their condition during pregnancy but face at least a 50% risk of
becoming psychotic in the early weeks postpartum. The most important aspect of their
management is therefore a proactive management plan for the first few weeks
following birth.
Group 2
The second broad group of women are those who have had a previous and/or recent
episode of a serious mental illness, who are relatively well and stable but whose health
is being maintained by taking medication. This may be antipsychotic medication or in
the case of bipolar illness, a mood stabilizer (lithium or an anticonvulsant). These
women are at risk of a relapse of their condition during pregnancy. This risk is
particularly high if they stop their medication at the diagnosis of pregnancy. A s some
of these medications may have an adverse effect on the development of the fetus and
yet an acute relapse of the illness also is hazardous, it is important that these women
have access to expert advice on the risks and benefits of continuing the treatment or
changing it as early as possible in pregnancy.
Group 3
The third broad category includes women who are chronically mentally ill with
complex social needs, persisting symptoms and on medication. These women will
usually be in contact with psychiatric services. Midwifery and obstetric care needs to
be closely integrated into the case management of these women and there needs to be
a close working relationship between maternity, psychiatric and social services.
I deally, all women who have a current or previous history of serious mental illness
should have advice and counselling before embarking upon a pregnancy. They should
be able to discuss the risk to their mental health of becoming pregnant and becoming
a parent as well as the risks to the developing fetus of continuing with their usual
medication and perhaps the need to change it. However, in the general population, at
least 50% of all pregnancies are unplanned at the point of conception. Midwives
should therefore enquire at early pregnancy assessment about the women's previous
and current psychiatric history and alert psychiatric services as soon as possible about
the pregnancy so that relapses of the psychiatric illness during pregnancy and
recurrences postpartum can be avoided wherever possible.
Psychiatric disorder after birth
The majority of postpartum onset psychiatric disorders are affective (mood) disorders.
However, symptoms other than those due to a disorder of mood are frequently
present. Conventionally three postpartum disorders are described:
• the ‘blues’
• puerperal (postpartum) psychosis
• postnatal depression.
The ‘blues’ is a common dysphoric, self-limiting state, occurring in the first week
postpartum (see Part A).
Puerperal (postpartum) psychosis
Globally, puerperal psychosis, the most severe form of postpartum affective (mood)
disorder has been recognized and described since antiquity. I t leads to 2 in 1000
women being admi ed to a psychiatric hospital following childbirth, mostly in the
first few weeks postpartum. A lthough a relatively rare condition, there is a marked
increase in the risk of suffering from a psychotic illness following childbirth (Kendell
et al 1987; Munk-O lsen et al 2012). I t is also remarkably constant across nations and
cultures.
Risk factors
Most women who suffer from this condition will have been previously well, without
obvious risk factors, and the illness comes as a shock to them and their families.
However, some women will have suffered from a similar illness following the birth of
a previous child, some may have suffered from a non-postpartum bipolar affective
disorder from which they have long recovered or they may have a family history of
bipolar illness. For others there may be marked psychosocial adversity. I t is generally
accepted that biological factors (neuroendocrine and genetic) are the most important
aetiological factors for this condition. This implies that puerperal psychosis can and
does strike without warning, women from all social and occupational backgrounds –
those in stable marriages with much-wanted babies as well as those living in less
fortunate circumstances.
Clinical features
Puerperal psychosis is an acute, early onset condition. The overwhelming majority of
cases present in the first 14 days postpartum. They most commonly develop suddenly
between day 3 and day 7, at a time when most women will be experiencing the ‘blues’.
D ifferential diagnosis between the earliest phase of a developing psychosis and the
‘blues’ can be difficult. However, puerperal psychosis steadily deteriorates over the
following 48 hours while the ‘blues’ tends to resolve spontaneously.
D uring the first 2–3 days of a developing puerperal psychosis there is a fluctuating
rapidly changing, undifferentiated psychotic state. The earliest signs are commonly of
perplexity, fear – even terror – and restless agitation associated with insomnia. O ther
signs include: purposeless activity, uncharacteristic behaviour, disinhibition, irritation
and fleeting anger, and resistive behaviour and sometimes incontinence.
A woman may have fears for her own and her baby's health and safety, or even
about its identity. Even at this early stage, there may be, variably throughout the day,
elation and grandiosity, suspiciousness, depression or unspeakable ideas of horror.
W omen suffering from puerperal psychosis are among the most profoundly
disturbed and distressed found in psychiatric practice (D ean and Kendell 1981). I n
addition to the familiar symptoms and signs of a manic or depressive psychosis,
symptoms of schizophrenia (delusions and hallucinations) may occur. D epressive
delusions about maternal and infant health are common. The behaviour and motives
of others are frequently misinterpreted in a delusional fashion. A mood of perplexity
and terror is often found, as are delusions about the passage of time and other bizarre
delusions. W omen can believe that they are still pregnant or that more than one child
has been born or that the baby is older than it is.
W omen often seem confused and disorientated. I n the very common mixed affective
psychosis, along with the familiar pressure of speech and flight of ideas, there is often
a mixture of grandiosity, elation and certain conviction alternating with states of
fearful tearfulness, guilt and a sense of foreboding. The sufferers are usually restless
and agitated, resistive, seeking senselessly to escape and difficult to reassure.
However, they are usually calmer in the presence of familiar relatives.
The woman may be unable to a end to her own personal hygiene and nutrition and
unable to care for her baby. Her concentration is usually grossly impaired and she is
distractible and unable to initiate and complete tasks. O ver the next few days her
condition deteriorates and the symptoms usually become more clearly those of an
acute affective psychosis. Most women will have symptoms and signs suggestive of a
depressive psychosis, a significant minority a manic psychosis and very commonly a
mixture of both – a mixed affective psychosis.
Relationship with the baby
S ome women are so disturbed, distractible and their concentration so impaired that
they do not seem to be aware of their recently born baby. O thers are preoccupied with
the baby, reluctant to let it out of their sight and forever checking on its presence and
condition. A lthough delusional ideas frequently involve the baby and there may be
delusional ideas of infant ill health or changed identity, it is rare for women with
puerperal psychosis to be overtly hostile to their baby and for their behaviour to be
aggressive or punitive. The risk to their baby lies more from an inability to organize
and complete tasks, and to inappropriate handling and tasks being impaired by their
mental state. These problems, directly a ributable to the maternal psychosis, tend to
resolve as the mother recovers.
Management
Most women with psychotic illness following childbirth will require admission to
hospital, which should be to a specialist mother and baby unit, the only se ing in
which the physical needs of the mother who has recently given birth can be met and
where specialist psychiatric nursing is available. This ensures that the physical and
emotional needs of both mother and baby are met and the developing relationship
with the baby promoted.
Prognosis
I n spite of the severity of puerperal psychoses, they frequently resolve relatively
quickly over 2–4 weeks. However, initial recovery is often fragile and relapses are
common in the first few weeks. A s the psychosis resolves, it is common for women to
pass through a phase of depression and anxiety and preoccupation with their past
experiences and the implications of these memories for their future mental health and
their role as a mother. S ensitive and expert help is required to assist women through
this phase, to help them understand what has happened and to acquire a ‘working
model’ of their illness. The overwhelming majority of women will have completely
recovered by 3–6 months postpartum. However, they face at least a 50% risk of a
recurrence should they have another child and some may go on to have bipolar illness
at other times in their lives (Robertson et al 2005).
Postnatal depressive illness
A pproximately 10% of all postnatal women will develop a depressive illness. The
studies, from which this figure is derived, are usually community studies using the
Edinburgh Postnatal D epression S cale (EPD S ) either as a diagnostic tool or as a screen
prior to the use of other research tools. S tudies using a cut-off point of 14 usually give
an incidence of 10%; those using lower scores will give a higher incidence. A score on a
screening instrument is not the same as a clinical diagnosis. N onetheless a score of 14
is said to correlate with a clinical diagnosis of major depression and the lower scores
with that of major and minor depression (Elliot 1994). The incidence of women who
would meet the diagnostic criteria for moderate to severe depressive illness is lower,
probably between 3% and 5% (Cox et al 1993). D epression following childbirth has the
same range of severity and subtypes as depression at other times. A ccording to the
symptomatology, duration and severity, they may be graded as mild to moderate or
severe, and subtypes may have prominent anxiety and obsessional phenomena.
Postnatal depressive illness of all types and severities is therefore relatively common
and represents a considerable burden of disability and distress in these women.
A lthough postnatal depressive illness is popularly accepted, with the exception of the
most severe forms, it is no more common than during pregnancy or in non-
childbearing women of the same age (O 'Hara and S wain 1996). However, this does not
detract from its importance. D epressive illness of any severity occurring at a time
when the expectation is of happiness and fulfillment and when major psychological
and social adjustments are being made together with caring for an infant, creates
difficulties not found at other times in the human lifespan.
The term ‘postnatal depression’ is often used as a generic term for all forms of
psychiatric disorder presenting following birth. W hile in the past this has
undoubtedly been helpful in raising the profile of postpartum psychiatric disorders,
improving their recognition and reducing stigma, it has also become problematic. Use
of the term in this way can diminish the perceived seriousness of other illnesses, and
has led to a ‘one size fits all’ view of diagnosis and treatments ( O ates 2001). The term
postnatal depression should only be used for a non-psychotic depressive illness of
mild to moderate severity which arises within 3 months of childbirth.
Severe depressive illness
S evere depressive illness affects at least 3% of all women who have given birth, with a
seven-fold increase in risk in the first 3 months (Cox et al 1993). A gain, the majority of
women who suffer from this condition will have been previously well. However,
women with a previous history of severe postnatal depressive illness or severe
depression at other times or a family history of severe depressive illness or postnatal
depression are at increased risk. Psychosocial factors are more important in the
aetiology of this condition than in puerperal psychosis, although biological factors
play an important role in the most severe illnesses. N onetheless, severe postnatal
depression can affect women from all backgrounds not just those facing social
adversity.
Like puerperal psychosis, severe depressive illness is an early onset condition in
which the woman commonly does not regain her normal emotional state following
birth. However, unlike puerperal psychosis, the onset tends not to be abrupt; rather,
the illness develops over the next 2–4 weeks. The more severe illnesses tend to present
early, by 4–6 weeks postpartum, but the majority present later, between 8 and 12
weeks postpartum. These later presentations may be missed. This is partly because
some of the symptoms may be misa ributed to the adjustment to a new baby and
partly because the mother may ‘put on a brave face’, concealing how she feels from
others.
Risk factors
A variety of risk factors for postnatal depressive illness have been identified and
include those associated with depressive illness at other times. To these can be added
ambivalence about the pregnancy, high levels of anxiety during pregnancy and adverse
birth experiences, previous perinatal death to name but a few. Many of these risk
factors, though statistically significant are so common as to have li le positive
predictive value. However a clustering of these risk factors might lead to those caring
for the woman to be extra vigilant. O f more use are those risk factors that have a
higher positive predictive value. These include a family history of severe affective
disorder, a family history of severe postnatal depressive illness, developing a
depressive illness in the last trimester of pregnancy and the loss of the previous infant
(including stillbirth). There may also be an increased risk in those women who have
conceived through IVF.
Clinical features
The familiar symptoms of severe depressive illness are often modified by the context
of early maternity and the relative youth of those suffering from the condition:
The ‘somatic syndrome’ ( biological features) of broken sleep and early morning
wakening, diurnal variation of mood, loss of appetite and weight, slowing of mental
functioning, impaired concentration, extreme tiredness and lack of vitality can easily
be misa ributed to a crying baby, understandable tiredness and the adjustment to
new routines.
The all-pervasive anhedonia or loss of pleasure in ordinary everyday tasks, the lack of
joy and fearfulness for the future may be misa ributed by the woman herself to ‘not
loving the baby’ or ‘not being a proper mother’ and all too easily described as
‘bonding problems’ by professionals. A nhedonia is a particularly painful symptom at
a time when most women would expect to feel overwhelmed with joy and happiness
and in turn contributes to feelings of guilt, incompetence and unworthiness that are very
prominent in postnatal depressive illness. These overvalued ideas can verge on the
delusional.
I t is also common to find overvalued morbid beliefs and fears for the woman's own
health and mortality and that of her baby. S he may misa ribute normal infant
behaviour to mean that the baby is suffering or does not like her. A baby that se les
in the arms of more experienced people may confirm the mother's belief that she is
incompetent. Commonplace problems with establishing breastfeeding may become
the subject of morbid rumination.
S ome women with severe postnatal depressive illness may be slowed, withdrawn
and retreat easily in the face of offers of help, avoid the tasks of motherhood and their
relationship with the baby. O thers may be agitated, restless and fiercely protective of
their infant, resenting the contribution of others.
Anxiety and obsessive–compulsive symptoms
A lthough women with pre-existing anxiety and panic disorder or obsessional–
compulsive disorder (O CD ) frequently experience relapses or recurrences postpartum,
it is not known whether there is an increase in incidence (new onset) of these
conditions following birth. N onetheless, severe anxiety, panic a acks and obsessional
phenomena are common following birth. These symptoms may dominate the clinical
picture or accompany a postnatal depressive illness. They frequently underpin mental
health crises, calls for emergency a ention and maternal fears for the infant.
Repetitive intrusive, and often deeply repugnant, thoughts of harm coming to loved
ones, particularly the infant, are commonplace, often leading to repetitive doubting
and checking. The woman may doubt that she is safe as a mother and believe that she
is capable of harming her infant. Crescendos of anxiety and panic a acks may result
from the baby's crying or being difficult to se le and may lead the mother to be
frightened to be alone with her child. This is easily misinterpreted by professionals
who may fear that the child is at risk.
O bsessional, vacillating indecisiveness is also common and contributes to an
overwhelming sense of being unable to cope with everyday tasks in marked contrast to
premorbid levels of competence. W hile complex obsessive–compulsive behavioural
rituals are relatively rare, obsessive cleaning, housework and checking are common.
I ntrusive obsessional thoughts and the typical catastrophic cognitions associated with
panic attacks frequently lead to a fear of insanity and loss of control.
Relationship with the baby
S evere depressive symptomatology, particularly when combined with panic and
obsessional phenomena, can have a profound effect on the relationship with the baby,
in many, but by no means all women. Most women who suffer from severe postnatal
depressive illness maintain high standards of physical care for their infants. However,
many are frightened of their own feelings and thoughts and few gain any pleasure or
joy from their infant. They may find smiling and talking to their babies difficult. Most
affected women feel a deep sense of guilt and incompetence and doubt whether they
are caring for their infant properly. N ormal infant behaviour is frequently
misinterpreted as confirming their poor views of their own abilities. W hile a fear of
harming the baby is commonplace, overt hostility and aggressive behaviour towards
the infant is extremely uncommon. I t should be remembered that the majority of
mothers who harm small babies are not suffering from a serious mental illness. The
speedy resolution of maternal illness usually results in a normal mother–infant
relationship. However, prolonged chronic depressive illness can interfere with
a achment, social and cognitive development in the longer term, particularly when
combined with social and mental problems (Cooper and Murray 1997).
Management
These conditions need to be speedily identified and treated, preferably by a specialist
perinatal mental health team. The value of early contact with professionals who
recognize and validate the symptoms and distress, and can re-a ribute the overvalued
ideas of the mother and instill hope for the future cannot be underestimated. The
treatment of the depressive illness is the same as the treatment of depressive illness at
other times. The use of antidepressants together with good psychological care should
result in an improvement of symptoms within 2 weeks and the resolution of the illness
between 6 and 8 weeks.
Prognosis
With treatment, these women should fully recover. Without, spontaneous resolution
may take many months and up to one-third of women can still be ill when their child
is 1 year old.
W omen who have had a severe depressive illness face a 1 : 2 to 1 : 3 risk of a
recurrence of the illness following the birth of subsequent children (Cooper and
Murray 1995). They are also at elevated risk from suffering from a depressive illness at
other times in their lives. However, the long-term prognosis would appear to be be er
than when the first episode is in non-childbearing women, both in terms of the
frequency of further episodes and in their overall functioning (Robling et al 2000).
Mild postnatal depressive illness
This is the commonest condition following childbirth, affecting up to 10% of all
women postpartum. I t is in fact no commoner after childbirth than among other non-
childbearing women of the same age.
Risk factors
S ome women who suffer from this condition will be vulnerable by virtue of previous
mental health problems or psychosocial adversity, unsatisfactory marital or other
relationships or inadequate social support. O thers may be older, educated and
married for a long time, perhaps with problems conceiving, previous obstetric loss or
high levels of anxiety during pregnancy. Unrealistically high expectations of
themselves and motherhood and consequent disappointment are commonplace. A lso
common are stressful life events such as moving house, family bereavement, a sick
baby, experience of special care baby units and other such events that detract from the
expected pleasure and harmony of this stage of life.
Clinical features
The condition has an insidious onset in the days and weeks following childbirth but
usually presents after the first 3 months postpartum. The symptoms are variable, but
the mother is usually tearful, feels that she has difficulty coping and complains of
irritability and a lack of satisfaction and pleasure with motherhood. S ymptoms of
anxiety, a sense of loneliness and isolation as well as dissatisfaction with the quality of
important relationships are common. A ffected mothers frequently have good days and
bad days and are often be er in company and anxious when alone. The full biological
(somatic subtype) syndrome of the more severe depressive illness is usually absent.
However, difficulty ge ing to sleep and appetite difficulties, both over-eating and
under-eating, are common.
Relationship with the baby
D issatisfaction with motherhood and a sense of the baby being problematic are often
central to this condition, particularly when compounded by difficulty in meeting the
needs of older children. Lack of pleasure in the baby, combined with anxiety and
irritability, can lead to a vicious circle of a fractious and unsettled baby, misinterpreted
by its mother as critical and resentful of her and thus a deteriorating relationship
between them. However, it should also be remembered that the direction of causality
is not always mother to infant. S ome infants are very unse led in the first few months
of their life. A baby who is difficult to feed and cries constantly during the day or is
difficult to se le at night can just as often be the cause of a mild postnatal depressive
illness as the result of it. Even mild illnesses, particularly when combined with
socioeconomic deprivation and high levels of social adversity, can lead to longer-term
problems with mother–infant relationships and subsequent social and cognitive
development of the child (Cooper and Murray 1997). A very small minority of sufferers
from this condition may experience such marked irritability and even overt hostility
towards their baby that the infant is at risk of being harmed.
Management
Early detection and treatment is essential for both mother and baby. For the milder
cases, a combination of psychological and social support and active listening from a
health visitor will suffice. For others, specific psychological treatments, such as
cognitive behavioural psychotherapy and interpersonal psychotherapy, are as
effective, if not more than, antidepressants as outlined in A ntenatal and Postnatal
Mental Health guidelines (NICE 2007).
Prognosis
With appropriate management, postnatal depression should improve within weeks
and recover by the time the infant is 6 months old. However, untreated there may be
prolonged morbidity. This, particularly in the presence of continuing social adversity,
has been demonstrated to have an adverse effect not only on the mother–infant
relationship but also on the later social, emotional and cognitive development of the
child.
Breastfeeding
There is no evidence that breastfeeding increases the risk of developing significant
depressive illness, nor that its cessation improves depressive illness. Continuing
breastfeeding may protect the infant from the effects of maternal depression and
improve maternal self-esteem.
Treatment of perinatal psychiatric disorders
The role of the midwife
Midwives need knowledge and understanding of the different management strategies
for perinatal psychiatric disorder and of the use of psychiatric drugs in pregnancy and
lactation. This knowledge is required because the women themselves may wish for
advice, because the midwife may have to alert other professionals, for example general
practitioners and psychiatrists, to ask for a review of the woman's medication and
because in case of serious mental illness, the midwife will be part of a
multiprofessional team caring for the women.
Midwives should routinely ask all women at antenatal booking clinic whether they
have had an episode of serious mental illness in the past and whether they are
currently in contact with psychiatric services. Those women who have a previous
episode of serious mental illness (schizophrenia, other psychoses, bipolar illness and
severe depressive illness) should be referred to a psychiatric team during pregnancy
even if they have been well for many years. This is because they face at least a 50% risk
of becoming ill following birth. The midwife should also urgently inform the
psychiatric team if the woman is currently in contact with psychiatric services. The
psychiatric team may not be aware of the pregnant woman who is taking psychiatric
medication at the time when the midwife first sees her should be advised not to
abruptly stop her medication. The midwife should urgently seek a review of the
woman's medication from the general practitioner, obstetrician or psychiatrist as
appropriate. This may result in the woman being advised to reduce, change or
undertake a supervised withdrawal of her medication.
There are three components to the management of perinatal psychiatric disorder:
psychological treatments and social interventions, pharmacological treatments and the
skills, resources and services needed.
Those who are seriously mentally ill will require all three. Those with the mildest
illnesses may require only psychological and social interventions, which can be carried
out in primary care (NICE 2007).
Psychological treatments
A ll illnesses of all severities and indeed those who are not ill but experiencing
commonplace episodes of distress and adjustment need good psychological care. This
can only be based upon an understanding of the normal emotional and cognitive
changes and common concerns of pregnancy and the puerperium. I t also requires a
familiarity with the symptoms and clinical features of postpartum illnesses.
For most women with mild depressive illness or emotional distress and difficulties
adjusting, extra time given by the midwife or health visitor, ‘the listening visit’, will be
effective. For others, particularly those with more persistent states associated with
high levels of anxiety, brief cognitive therapy treatments and brief interpersonal
psychotherapy are as effective as antidepressants and may confer additional benefits
in terms of improving the mother–infant relationships and satisfaction. S imilar claims
have been made for infant massage and other therapies that focus the mother's
a ention on enjoying her baby. I t is particularly important during pregnancy to use
psychological treatments wherever possible and avoid the unnecessary prescription of
antidepressants.
Social support
Lack of social support, particularly when combined with adversity and life events, has
long been implicated in the aetiology of mild to moderate depressive illness in young
women. S ocial support not only includes practical assistance and advice but also
having an emotional confidante, female friends and people who improve self-esteem.
There is evidence that organizations that are underpinned by social support theory,
such as Home S tart and S ure S tart, can have a beneficial effect on maternal and infant
wellbeing and perhaps on mild postnatal depression (O akley et al 1996; Barlow et al
2007).
Pharmacological treatment
I n general, psychiatric illnesses occurring during the perinatal period respond to the
same treatments as at other times. There are no specific treatments for perinatal
psychiatric disorder. Moderate to severe depressive illnesses respond to
antidepressants, psychotic illnesses to antipsychotics and mood stabilizers may be
needed for those with bipolar illnesses. However, the possibility of adverse
consequences on the embryo and developing fetus and via breastmilk on the infant
makes the choice and dose of the drug important.
The evidence base for the safety or adverse consequences of psychotropic
medication is constantly changing both in the direction of increased concern and of
reassurance. A ny text detailing specific advice is in danger of being quickly out of date
and the reader is directed to the regularly updated information published by the
N ational Teratology I nformation S ervice (N TI S ) – via Toxbase website
www.toxbase.org/ – and to NICE (2007) Guidelines on A ntenatal and Postnatal Mental
Health or Drugs and Lactation Database (LactMed).
No matter what the changing evidence is, some general principles apply:
• The absence of evidence of harm is not the same as evidence of safety.
• It may take 20–30 years after the introduction of a drug for its adverse consequences
to be fully realized. An example of this is sodium valproate in pregnancy.
• In general there is more evidence on older than on newer drugs although this does
not necessarily mean they are safer.
• All psychotropic medication passes across the placenta and into the breastmilk.
• Both the architecture and function of the fetal central nervous system continues to
develop throughout pregnancy and in early infancy. Concern should not be confined
to the adverse effects in the first 3 months of pregnancy.
• The threshold for initiating medication in pregnancy and breastfeeding should be
high. If there is an alternative, non-pharmacological treatment, of equal efficacy then
that should be the treatment of choice.
• Serious mental illness requires robust treatment. In all cases of illness, occurring in a
pregnant or breastfeeding mother, the clinician must endeavour to balance the risk of
not treating the mother on both mother and baby against the risk to the fetus or
infant of treating the mother. The more serious the illness is, the more likely it is that
the risks of not treating outweigh the risks of treating.
• The risks to both mother and baby of a serious maternal mental illness are greater
than the risks of medication.
• The fetus and baby is no less likely to suffer from the side-effects of psychotropic
medication than an adult. Fetal and infant elimination of psychotropic medication is
slower and less than adults and their central nervous systems more sensitive to the
effects of these drugs.
• Adverse consequences of medication on the fetus and infant are dose-related. If
medication is used it should be used in the lowest effective dose and given in divided
dosage throughout the day.
• The exposure of the baby to psychotropic medication in breastmilk will depend on
the volume of milk, the frequency of feeding, weight and age. A totally breastfed
baby under 6 weeks old will receive relatively more psychotropic medication than an
older baby who is partially weaned.
Antidepressants
Tricyclic antidepressants
Pregnancy
Tricyclic antidepressants (e.g. imipramine, lofepramine, amitriptyline and dosulepin)
have been in use for 40 years. Tricyclic antidepressants are not associated with an
increased risk of fetal abnormality, early pregnancy loss or growth restriction when
used in later pregnancy. However clomipramine (A naframil) has been linked to
cardiac abnormalities. N ewborn babies of mothers who were receiving a therapeutic
dose of tricyclic antidepressants at the point of birth are at risk of suffering from
withdrawal effects (ji eriness, poor feeding and on occasion fits). Consideration
should therefore be given to a gradual tapering and reduction of the dose prior to
birth.
Breastfeeding
The excretion of tricyclic antidepressants in breastmilk is very low. However doxepin
should not be used because it has been reported to cause sedation in babies. A ny
adverse effects in the fully breastfed newborn baby can be minimized by dividing the
dose, e.g. 50 mg of imipramine t.d.s.
Selective serotonin reuptake inhibitors
Pregnancy
S elective serotonin reuptake inhibitors (S S RI s) (e.g. fluoxetine, paroxetine, citalopram)
have been in use for approximately 15 years and are now the antidepressants most
used in the treatment of depressive illness at other times.
There has been some concern about the possible adverse effects of certain S S RI s in
early pregnancy. The evidence continues to emerge and the risks are therefore difficult
to quantify. There may be an increased risk of miscarriage associated with the use of
all S S RI s. I t is likely that there is an increased risk of cardiac abnormalities related to
first trimester exposure to S S RI s, particularly ventricular septal defects (VS D ) with
paroxetine (S eroxat). This has led to both the manufacturer and the drug regulation
authorities in the USA and the UK advising against the use of paroxetine in pregnancy.
At the moment, this restriction does not apply to fluoxetine (Prozac) and sertraline
(Lustral) but it remains to be seen whether this adverse effect is related to all S S RI
medications. The N I CE (2007) guidelines recommend that either tricyclic
antidepressants or sertraline should be the treatment of choice if antidepressants are
required during pregnancy. They also recommend that antidepressants should not be
used for mild to moderate illness and that psychological treatments should be used
wherever possible. However, the withdrawal of S S RI antidepressants in early
pregnancy, particularly if the woman has been receiving them for some time, is often
associated with a withdrawal syndrome or the recurrence of her condition. I n such
circumstances, consideration should be given to changing the woman to a ‘safer’
alternative or reducing the dose and supervised withdrawal.
Continued use of S S RI medication during pregnancy has been associated with pre-
term birth, reduced crown–rump measurement and lower birth weight. Babies born to
mothers receiving S S RI medication at the point of birth are likely to experience
withdrawal effects, particularly those babies who are preterm. S S RI s, such as
citalopram and fluoxetine that have a long half-life, are also associated with a
serotonergic syndrome in the newborn (ji eriness, poor feeding, hypoglycaemia and
sleeplessness). Consideration should therefore be given to reducing and withdrawing
this medication before birth.
Breastfeeding
The excretion of S S RI s in breastmilk is higher than that of tricyclic antidepressants.
The fully breastfed newborn may be vulnerable to serotonergic side-effects. Those
S S RI s with a long half-life (fluoxetine and citalopram) should be avoided when
breastfeeding the newborn. Venlafaxine and paroxetine are not recommended for use
in breastfeeding mothers. However, in older and larger-weight infants, particularly
those who are partially weaned, other S S RI s, particularly sertraline, may be less
problematic.
Tricyclic antidepressants or sertraline should be the antidepressants of choice in
breastfeeding.
Antipsychotics
There are two groups of antipsychotic medications, the older ‘typical’ antipsychotics
(e.g. trifluoperazine, haloperidol, chlorpromazine) and the newer atypical antipsychotics
(e.g. risperidone, olanzapine, clozapine).
Typical antipsychotics
Pregnancy
Typical antipsychotics have been in use for 40 years. There is no evidence that their
use in early pregnancy is associated with an increased risk of fetal abnormality nor
that their continuing use in pregnancy is associated with growth restriction or pre-
term birth. However, antipsychotic medication freely passes to the developing fetus
and its brain and the dose should be reduced to that which is the minimum for clinical
effectiveness. Babies born to mothers receiving relatively high doses of typical
antipsychotics may experience a withdrawal syndrome and extrapyramidal symptoms
(muscle stiffness, rigidity, ji eriness and poor feeding). Consideration therefore
should be given to a reduction of the dose before birth and a possibility of induction at
term. Withdrawal of medication at any stage in pregnancy may be associated with a
risk of a relapse of the maternal condition.
Breastfeeding
Typical antipsychotics are present in breastmilk, although the amount to which the
infant is exposed is likely to be very small. The added benefits of breastfeeding to the
infant probably justify the continuation of breastfeeding providing that the dose
required is small and divided. D rugs such as procyclidine, given to prevent
extrapyramidal side-effects, are not recommended.
Atypical antipsychotics
The manufacturers advise against the use of atypical antipsychotics in pregnancy and
breastfeeding but this reflects lack of data rather than evidence of harm. The use of
olanzapine in pregnancy has been associated with an increased risk of gestational
diabetes. W omen who become pregnant while taking these newer antipsychotics
should be urgently reviewed. I n some cases, it may be possible to change their
medication to the older type of antipsychotic. I n others, because of the substantial risk
of relapse of their condition, it may be necessary to continue with their medication.
A gain this should be reduced to the lowest possible dose and consideration given to a
further reduction immediately prior to birth and, if necessary, a managed delivery.
Clozapine should not be used in pregnancy and breastfeeding because of the risk of
blood dyscrasias in the infant.
Mood stabilizers
This is a group of drugs used to treat the manic component of bipolar illness and, long
term, to prevent relapses of the condition. The drugs used as mood stabilizers are
lithium carbonate (Priadel) and various anti-epileptic drugs, commonly sodium
valproate and carbamazepine but also on occasion lamotrigine.
Pregnancy
Lithium carbonate in pregnancy is associated with a risk of developing a rare, serious
cardiac condition, Ebstein's anomaly. A lthough the relative risk is large, the absolute
risk is low, being 2 in 1000 exposed pregnancies. However, there is also an increased
risk of a range of cardiac abnormalities, including milder and less serious conditions.
The absolute risk of all types of cardiac abnormality is 10 per 100 exposed pregnancies.
Lithium in early pregnancy is not associated with an increased risk of neural tube
abnormalities.
The continued use of lithium throughout pregnancy is associated with an increased
risk of fetal hypothyroidism, diabetes insipidus, fetal macrosomia and the ‘floppy
baby’ syndrome (neonatal cyanosis and hypotonia). These risks are difficult to
quantify. A n additional problem is that the woman will require increasing doses of
lithium in later pregnancy to maintain a therapeutic serum level because of the
increased maternal clearance of lithium. However, the fetal clearance does not
increase. W omen receiving lithium in pregnancy therefore require frequent
estimations of their serum lithium and close monitoring of their condition. D uring
labour and immediately following birth, physiological diuresis can result in toxic
levels of maternal lithium. The woman therefore requires frequent estimations of her
serum lithium throughout labour and in the early postpartum days.
W omen who are taking lithium carbonate should be advised to carefully plan their
pregnancies and to seek medical advice. A brupt cessation of lithium is associated with
a substantial risk of a recurrence of their condition. These women will usually be
advised to either slowly withdraw their lithium prior to conception or consider
changing to another medication. However, there will be rare occasions when it is
necessary to continue lithium throughout pregnancy. S uch a pregnancy will need to be
managed by an obstetrician working closely with psychiatric services and a fully
compliant, well-informed woman.
Breastfeeding
Lithium should not be used in breastfeeding as it is present in substantial quantities
in breastmilk and can result in infant lithium toxicity, hypothyroidism and ‘floppy
baby’ syndrome.
Anticonvulsants
A nticonvulsants have been used as mood stabilizers for 30 years. Carbamazepine was
first used in this way, sodium valproate is now increasingly the mood stabilizer of
choice and recently the newer anticonvulsants such as lamotrigine and topiramate are
being used.
Pregnancy
A ll anticonvulsants are associated with a doubling of the base-line risk of fetal
abnormality if used in the first trimester of pregnancy. A total of 4 in 100 infants
exposed to carbamazepine will have a major congenital malformation. The risk of cleft
lip and palate is further increased with exposure to lamotrigine. The risks are highest
with sodium valproate: 8 per 100 exposed pregnancies. The use of folic acid reduces
but does not eliminate the risk of neural tube abnormalities. Continued use of
anticonvulsants throughout pregnancy is associated with an increased risk of
neurodevelopmental problems in the child. This is particularly high with sodium
valproate. For this reason, N I CE (2007)guidelines advise against the use of sodium
valproate in pregnancy. W omen receiving these medications should carefully plan
their pregnancies with expert advice. They should, wherever possible, either have a
supervised withdrawal of their medication or change to a ‘safer’ alternative. They
should also take folic acid. I f a woman becomes pregnant while still taking these
medications, she should be urgently referred for expert advice and for an early fetal
anomaly scan. A s all harm is dose-related, the woman should be advised wherever
possible to reduce her sodium valproate to below 1000 mg daily.
Breastfeeding
The advantages of breastfeeding probably outweigh the risks of taking carbamazepine
or sodium valproate during breastfeeding. However, the infant should be monitored
for excessive drowsiness and, in the case of sodium valproate, rashes. Lamotrigine
should not be used in breastfeeding because of the increased risk of severe skin
reactions in the infant.
Service provision
There are a number of national recommendations for the needs of women with
perinatal psychiatric disorders Box 25.7. The distinctive clinical features of the
conditions, their physical needs and the professional liaison with maternity services all
require specialist skills and knowledge (O ates 1996). The frequency of the serious
conditions at locality level makes it difficult for general adult psychiatric services to
manage the critical mass of patients required to develop and maintain their experience
and skills. I t is difficult for maternity services to relate to multiple psychiatric teams.
However, at supra-locality (regional) level, the frequency of serious perinatal
psychiatric disorder is sufficient to justify the joint commissioning and provision of
specialist services. Mothers, who require admission to a psychiatric hospital in the
early months postpartum should, unless it is positively contraindicated, be admi ed
to a mother and baby unit. This is not only humane but also in the best interests of the
infant and cost-effective as it shortens inpatient stay and prevents re-admission. There
should be specialist perinatal community outreach services available to every
maternity service, to deal with psychiatric problems that arise postpartum but also to
see women in pregnancy who are at high risk of developing a postnatal illness.
Box 25.7
P e rina t a l m e nt a l he a lt h: na t iona l docum e nt s
( re gula rly upda t e d)
Royal College of Psychiatrists CR88
SIGN Guidelines – postnatal and puerperal psychosis
CNST 2004
National Screening Committee
NICE guidelines on antenatal care: routine care for the healthy pregnant
woman
NICE guidelines on antenatal and postnatal mental health
NICE guidelines on postnatal care: routine postnatal care of women and
their babies
Department of Health Reports:
Children's, young person and maternity NSF. Maternity
Standard 11
Women's mental health into the mainstream
Responding to domestic abuse
CEMACH/CMACE ‘Why mothers die’ triennial reports
The majority of women suffering from postnatal mental illness will not require to be
seen by specialist psychiatric services. However, there is a need for integrated care
pathways to ensure that women are effectively identified and managed in primary care
and, if necessary, referred on to specialist services. There is a need to enhance the
skills and competencies of health visitors, midwives, obstetricians and GPs to deal
with the less severe illnesses themselves.
Prevention and prophylaxis
Prevention
T h e N ational S creening Commi ee (2001) and N I CE (2007) guidelines do not
recommend routine screening using the EPD S and other ‘paper and pen’ scales in the
antenatal period for those at risk of postnatal depression. They also find that there is a
lack of evidence to support antenatal interventions to reduce the risk of non-psychotic
postnatal illness. I n contrast, these and other bodies (D H 2004; N I CE 2008; CMACE
2011) all recommend that women should be screened at early pregnancy assessment
for a previous or family history of serious mental illness, particularly bipolar illness,
because they face at least a 50% risk of recurrence of that condition following birth.
Those who undertake early pregnancy assessment will need training to refresh their
knowledge of psychiatric disorder.
There is li le point in screening for women at high risk of developing severe
postnatal illness if systems for the pro-active peripartum management of these
conditions are not in place and if appropriate resources are not available. I t is
recommended that all women who are at high risk of developing a severe postpartum
illness by virtue of a previous history are seen by a specialist psychiatric team during
the pregnancy and a wri en management plan placed in the maternity records in late
pregnancy and shared with the woman, her partner, her GP, midwife, obstetrician and
psychiatrist.
Prophylaxis
I f a woman has a previous history of bipolar illness or puerperal psychosis,
consideration should be given to starting medication on day one postnatally. For
bipolar illness the use of lithium carbonate has been shown to reduce the risk of a
recurrence. I t is plausible that the use of antipsychotic medication may also reduce the
risk of recurrence. However, lithium is not compatible with breastfeeding. S ome
women will not wish to take medication when they perceive there is a 50% chance of
them remaining well. They may also place a priority on continuing to breastfeed.
Breastfeeding mothers at risk of developing a bipolar or mixed affective illness may
take carbamazepine or sodium valproate. The evidence that antidepressants taken
prophylactically may prevent the onset of a depressive psychosis is lacking.
A ntidepressants should be used with great caution in any woman who has bipolar
disorder in her personal or family history because of the propensity of antidepressants
to trigger a manic illness.
Hormones
There is no evidence that progesterone, natural or synthetic, prevents or treats
postnatal depression or puerperal psychosis. I ndeed there is evidence to suggest they
may cause depression. W hile there is some evidence that transdermal oestrogens are
effective in treating postnatal depression, the potential adverse physical effects
(D ennis et al 1999) and the known efficacy of antidepressants mean this should not be
the treatment of choice.
The most important aspect of preventative management and one that will promote
early identification and the avoidance of a life-threatening emergency is close
surveillance, contact and support in the early weeks, the period of maximum risk. A
specialist community perinatal psychiatric nurse together with the midwife should
visit on a daily basis for the first two weeks and remain in close contact for the first six.
The local mother and baby unit should be aware of the woman's expected date of birth
and systems put in place for direct admission if necessary.
The Confidential Enquiries into Maternal Deaths: psychiatric causes
of maternal death
Confidential Enquiries into Maternal D eaths (O ates 2001, 2004, 2007, 2011) have found
that suicide and other psychiatric causes of death are a leading cause (indirect) of
maternal death in the UK, between 1997 and 2008, contributing to over 15% of
maternal deaths.
Maternal suicide is more common than previously thought. O verall, the maternal
suicide rate appears to be equivalent to that of the general rate in the female
population. S uicide in pregnancy is less common. The majority of suicides took place
in the year following birth, most in the first 3 months. N ot only is the assumption of
the ‘protective effect of maternity’ called into question but also the relative risk of
suicide for seriously mentally ill women following childbirth is elevated. A n elevated
standardized mortality ratio (S MR) of 70 for women with serious mental illness in the
postpartum year has previously been reported (A ppleby et al 1998) and further
confirmed by evidence from the Enquiries with improved case ascertainment.
I n contrast to other causes of maternal death, suicide was not associated with
socioeconomic deprivation. The majority of suicides were older, married and relatively
socially advantaged and seriously ill. A worrying number were health professionals.
This underlines the error of merging issues of maternal mental health with those of
socioeconomic deprivation.
The majority of the suicides occurred violently by jumping from a height or by
hanging. This stands in contrast to the commonest method of suicide among women
in general (self-poisoning), and underlines the seriousness of the illness from which
the women died.
Half of the suicides had a previous history of admission to a psychiatric hospital. I n
few cases had this risk been identified at booking and in even fewer had any proactive
management been put into place. Had these women's illnesses been anticipated, a
substantial number of these deaths might have been avoided.
W omen also died from other consequences of psychiatric disorder. S ome of these
were due to accidental overdoses of illicit drugs. However, deaths also occurred from
physical illness that would not have occurred in the absence of a psychiatric disorder.
S ome of these were the physical consequences of alcohol or illicit drug misuse, others
from side-effects of psychotropic medication. However, a worrying number of deaths,
some of which took place in a psychiatric unit, were due to physical illness being
missed because of the psychiatric disorder or mistakenly a ributed to a psychiatric
disorder. These findings underline the importance of remembering that physical
illness can present as or complicate psychiatric disorder. S uicide is not the only risk
associated with perinatal psychiatric disorder. Box 25.8 identifies the four main
categories of psychiatric deaths emerging from ‘S aving Mothers’ Lives' (O ates and
Cantwell 2011).
Box 25.8
T he four m a in ca t e gorie s of psychia t ric de a t hs
e m e rging from ‘S a ving M ot he rs’ L ive s' ( O a t e s 2 0 0 7;
O a t e s a nd C a nt we ll 2 0 1 1)
• Suicide
• Overdose of drugs abuse
• Medical conditions caused by or mistaken for psychiatric disorder
• Violence and accidents related to psychiatric disorders
N ote: N ew themes are included, concerning child protection and
termination of pregnancy.
These findings have major implications for psychiatric and obstetric practice. I f
psychiatrists discussed with women plans for parenthood prior to conception; if
obstetricians and midwives detected those at risk of serious mental illness; if
psychiatric and maternity professionals communicated freely with each other and
worked together; if specialist perinatal mental health services were available for those
women who needed them; and if all had a greater understanding of perinatal mental
illness, then not only would a substantial number of maternal deaths be avoided but
also the care and outcome of other mentally ill women would be greatly improved.
Conclusion
The full range of psychiatric disorders can complicate pregnancy and the postpartum
year. The incidence of affective disorder, particularly at the most severe end of the
spectrum, increases following birth. The familiar signs and symptoms of psychiatric
disorder are all present in postpartum disorders as well, but the early maternity
context and the dominance of infant care and mother–infant relationships exert a
powerful effect on the content, if not the form, of the symptomatology. Early maternity
is a time when there is an expectation of joy, pleasure and fulfillment. The presence of
psychiatric disorder at this time, however mild, is disproportionately distressing. N o
ma er how ill the woman feels, there is still a baby and often other children to be
cared for. S he cannot rest and is reminded on a daily basis of her symptoms and
disability. Compassionate care and understanding and skilled care aimed at speedy
symptom relief and re-establishing maternal confidence are thus essential.
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Further reading
DiPietro JA. Maternal stress in pregnancy: considerations for fetal development.
Journal of Adolescent Health. 2012;51:S3–S8.
Considers a number of methodological issues in strengthening understanding of the
effects of stress/anxiety on fetal neuro-behaviour and possible consequences for the
developing nervous system..
National Institute for Health and Clinical Excellence. Pregnancy and complex social
factors (CG 110). NICE: London; 2010.
Addressing a variety of social complexities that may affect a woman's emotional
wellbeing such as poverty, homelessness, domestic abuse, communication difficulties,
refugee or asylum status, young teenage mother, substance misuse etc..
Shaw RL, Giles DC. Motherhood on ice? A media framing analysis of older
mothers in the UK news. Psychology and Health. 2009;24(2):221–236.
An interesting discourse about how older mothers are portrayed in the popular media..
Useful websites
Department of Health. www.dh.gov.uk.
Fathers Institute. www.fatherhoodinstitute.org/.
Midwifery 2020. www.midwifery2020.org.
Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries across
the UK. www.mbrrace.ox.ac.uk.
National Institute for Health and Care [formerly Clinical] Excellence.
www.nice.org.uk.
Perinatal Illness UK. www.chimat.org.uk [(from April 2013 this charity has
become part of Public Health England and the URL address is likely to change
in the near future).] .
Scottish Intercollegiate Guideline Network. www.sign.ac.uk.
C H AP T E R 2 6
Bereavement and loss in maternity care
Rosemary Mander
CHAPTER CONTENTS
Introduction 555
Grief and loss 556
Attachment 556
Grief 556
Significance 557
Culture 557
Forms of Loss 557
Perinatal loss 557
Infertility 558
Relinquishment for adoption 558
Termination of pregnancy (TOP) 558
The baby with a disability 558
Loss in healthy childbearing 559
The ‘inside baby’ 559
The mother's birth experience 559
The midwife's experience 559
Care 560
The baby 560
The mother 561
The family 563
The formal carers 563
Other aspects of care 564
The death of a mother 564
Conclusion 565
References 565
Further reading 566
Useful addresses and websites 567This chapter introduces the reader to
issues relating to bereavement and loss in the maternity area. The intention
is to facilitate better coping among staff and, thus, care for those affected.
Throughout the chapter, particular attention is paid to the knowledge on
which practice is based, such as research, evidence or personal experience.
The chapter aims to:
• consider the meaning of bereavement and loss in maternity and childbearing
• contemplate the significance of bereavement and loss in maternity and childbearing
• discuss forms of loss
• draw on research evidence and other knowledge to review the care of those affected
by loss.
Introduction
I n 21st-century Western society, bereavement is closely linked with loss through
death. I n this chapter, to increase the relevance of these concepts, the focus is
broadened to include other sources of grief that are likely to affect midwifery care. I n
widening the topic, the original meaning of ‘bereavement’ is reflected, which implies
plundering, robbing, snatching or otherwise removing traumatically and, crucially,
without consent. This meaning may conflict with the other part of the title – ‘loss’ –
which is also widely used in this context. But any inconsistency is fallacious because,
although bereavement involves ‘taking’ in various ways, the unspoken hopes and
expectations invested in that which is lost remain irretrievable.
I n many ways, loss in childbearing is unique, which is due to the awful contrast
between the sorrow of death and the mystical joy of a new life. A dditionally, the cruel
paradox of the ‘juxtaposition’ of birth and death aggravates responses (Howarth 2001:
435). We tend to assume that birth and death are separated by a lifetime; this means
that the experience becomes incomprehensible when they are unified (Bourne 1968).
A lthough any childbearing loss is unique, the uniqueness of both the individual's
experience and the phenomenon itself must be contrasted with the frequency with
which ‘lesser’ childbearing losses happen. S uch lesser losses include the reduction of
the parents' independence, the woman's loss of her special relationship with her fetus
at birth, or the family loss of the expected idealized baby when they recognize that the
actual baby is all too real (Atkinson 2006). Central to this chapter is the woman losing
a baby and her care by the midwife. The midwife draws on theory which, as in any
care, is grounded in firm knowledge, such as research evidence. S uch knowledge is
utilized in skilled care to facilitate adjustment to these greater and lesser losses. Thus,
as well as loss through death, other forms of childbearing-related loss are also
considered.
Grief and loss
Grief, like death and other fundamentally important ma ers, is a fact of life. A ll
human beings invariably face grief in some form, possibly when young. D espite its
universality, a woman in a higher income country experiencing childbearing loss may
be too young to have previously encountered the grief of death. This is a further
reason for the uniqueness of childbearing loss.
Attachment
Limited understanding of mother–baby a achment, or ‘bonding’, long prevented our
recognition of the significance of perinatal loss. The strength of the growing
relationship between the woman and her fetus emerged in a research project involving
bereaved mothers (Kennell et al 1970). This relationship develops with feeling
movement and experiencing pregnancy, including investigations such as ultrasound
scans. O rdinarily, a achment continues to develop beyond the birth (Bowlby 1997).
A achment during pregnancy means that, should the relationship not continue, it
must be ended as with any parting. Thus, the reality of the mother–baby relationship
needs to be recognized before the loss can be accepted. These processes are crucial for
the initiation of healthy grieving.
Grief
Through grieving we adjust to more serious, and lesser, losses throughout life.
Healthy grief means that we can move forward, although probably not directly, from
the initial distraught hopelessness. We eventually achieve some degree of resolution,
or perhaps integration, which permits ordinary functioning much of the time. Through
grief we learn something about both ourselves and our resources (Vera 2003).
Grief has been viewed historically as apathetic passivity, but it is really a time when
the bereaved person actively struggles with the emotional tasks facing her; the term
‘grief work’ summarizes this struggle ( Engel 1961). The stages of grief through which
the person works have been described in various ways, but Kübler-Ross's (1970)
account is memorable. These stages (Box 26.1) are not necessarily negotiated in
sequence; individual variations cause the person to move back and forth between
them before reaching a degree of resolution.
Box 26.1
S t a ge s of grie f
• Shock and denial
• Increasing awareness
– Emotions: sorrow – guilt – anger
– Searching
– Bargaining
• Realization
– Depression
– Apathy
– Bodily changes
• Resolution
– Equanimity
– Anniversary reactions.
The initial response to loss comprises a defence mechanism protecting the
individual from the full impact of the news or realization. This reaction comprises
shock or denial, which insulates the bereaved person from the unbearably unthinkable
reality. Facilitating coping with impending realization, this initial response allows
some ‘breathing space’, during which the person marshals their emotional resources.
D enial soon becomes ineffective and awareness of the reality of loss dawns.
A wareness brings powerful emotional reactions, together with physical
manifestations. S orrowful feelings emerge but, less acceptably, other emotions
simultaneously overwhelm the bereaved person. These include guilt and
dissatisfaction, as well as compulsive searching and, disconcertingly, anger.
Realization dawns in waves as the bereaved person tries coping strategies to ‘bargain’
with herself to delay accepting the grim reality.
W hen such fruitless strategies are exhausted, the despair of full realization
materializes, bringing apathy and poor concentration, together with bodily changes.
At this point, the bereaved person may show anxiety and physical symptoms, like
depression.
W hen the loss is eventually accepted, it starts to become integrated into the person's
life (Walter 1999). A s mentioned already, this is not straightforward and may involve
slow progress and many setbacks, with oscillation and hesitation. Although the person
may never ‘get over’ the loss, it should eventually be integrated. This ultimate degree
of ‘resolution’ is recognizable in the bereaved person's contemplation with equanimity
of the strengths, and weaknesses, of the lost person and relationship.
Significance
Healthy grieving ma ers because it contributes to balance or homeostasis in the
bereaved person's life. Grief helps people deal with the wounds inflicted by the greater
and lesser losses of life. The hazards of being unable to grieve healthily have long
been recognized in emotional terms, but there may be an association between
perinatal loss and physical illness (Boyce et al 2002). This research suggested the
woman's need for support regardless of the nature of the loss or the extent to which it
is recognized, or her grief sanctioned, by society.
Culture
A general picture of healthy grieving, and individual variation, common to people of
different ethnic backgrounds, has been described (Katbamna 2000). The
manifestations of grief, and accompanying mourning rituals, vary hugely. These
variations are influenced by many factors. Cecil (1996) shows the massive differences
between ethnic groups in a itudes towards childbearing loss. A midwife may
encounter difficulty understanding the different a itudes to loss in cultures other
than her own (Mander 2006). W hether the midwife is able to work through such
feelings, to support the woman with different a itudes, is uncertain. Closely bound up
with culture, and influencing mourning, are the grieving person's religious beliefs, or
lack thereof. These aspects, however, are difficult to separate from social class and
prevalent societal attitudes.
D espite huge variations in its manifestation, mourning has a universal underlying
purpose. I t establishes support for those closely affected, by strengthening links
between the people who remain. I n perinatal loss the midwife initially provides this
support. The midwife's role is to be with the woman when she begins to realize the
extent of her loss and to prevent interference in the woman's healthy initiation of
grieving.
Forms of loss
The terms ‘loss’ and ‘bereavement’ apply to a range of experiences, varying hugely in
severity and effects (D espelder and S trickland 2001). We must be careful, however, to
avoid assumptions about the meaning of loss to a particular person. I t is difficult, even
impossible, for anybody to understand the significance of a pregnancy or a baby to
someone else. This is because childbearing carries a vast range of profound feelings,
including unspoken hopes and expectations based on personal and cultural values. We
should accept that grief in childbearing, like pain, is what the person who is going
through it says it is (McCaffery 1979).
S ome situations in which we encounter grief are mentioned. S ome situations of
childbearing grief are not included here, while some situations listed here may not
engender grief.
Perinatal loss
W hen loss in childbearing is mentioned, loss in the perinatal period comes quickly to
mind, which includes the stillborn baby and the baby dying in the first week.
A empts have been made to compare the severity of grief of loss at different stages,
perhaps to demonstrate that certain women deserve more sympathy. A classic study
investigating severity, however, showed no significant differences in the grief response
between mothers losing a baby by miscarriage, stillbirth or neonatal death (Peppers
and Knapp 1980). This study emphasized the crucial role of the developing mother–
baby relationship – the understanding of which has facilitated changes in care.
Stillbirth
A retrospective S wedish study focused on the mother's long-term recovery from
stillbirth. Rådestad and colleagues (1996a) compared the recovery of 380 women who
had given birth to a stillborn baby with 379 women who birthed a healthy child. The
84% response rate shows the mothers' perception of the importance of this study.
These researchers found that the mother recovered be er if she could decide how long
to keep her baby with her after the birth and if she could keep birth mementoes. The
mother whose recovery was more difficult was the one where the birth of the baby was
delayed after realization of fetal demise. Clearly, these findings have important
implications for midwifery care (see section on The Mother, below). A dditionally, the
researchers discuss the ‘known’ stillbirth, when the mother knows before labour that
her baby has died, previously termed ‘intrauterine death’ or ‘I UD ’. A lternatively, the
loss is unexpected. W hile avoiding comparisons, it is understandable that the mother
aware of carrying a dead baby bears particular emotional burdens. These burdens,
compounded by the baby's changing appearance, may impede her grieving.
Early neonatal death
Grieving a liveborn baby who dies may be facilitated by three factors. First, the mother
has seen and held her real live baby; giving her genuine memories. S econd, United
Kingdom (UK) legislation requires the registration of both the birth and death of a
baby dying neonatally, providing wri en evidence of the baby's life. Third, staff
investment in the care of this dying baby increases the likelihood of effective parental
support (Singg 2003). Even for the mother whose preterm baby survives, though, there
may still be elements of grief (Shah et al 2011).
Accidental loss in early pregnancy: miscarriage
Early pregnancy loss may be due to various pathological processes, such as ectopic
pregnancy or spontaneous abortion. The word ‘abortion’ is be er avoided in this
context, because it carries connotations of deliberate interference, which are
unacceptable to a grieving mother. The term ‘miscarriage’ is preferable, to include all
accidental losses. The grief of miscarriage has long been ignored, because of its
frequency. This has been estimated to be about one-third of pregnancies, although the
figure may be higher (Oakley et al 1990).
Understanding the woman's experience of miscarriage has been sought through
qualitative research, which shows miscarriage to be far from an insignificant event,
with some mothers so ill that they fear for their lives. A lthough mothers find
reassurance in the conception of the pregnancy that was lost, some come to doubt
their fertility. A s in other forms of loss, the mother finds difficulty in locating support
and encounters comments denigrating her loss (S immons et al 2006). I t may be
necessary to seek the cause of a woman's miscarriage, especially if it happens
repeatedly (Hyer et al 2004). A lthough miscarriage has been linked with stressful life
events, N elson et al (2003) found no link between psychosocial stress and miscarriage.
Limited recognition of miscarriage is now being addressed, and women are
encouraged to create their own rituals to assist grieving. Brin (2004) showed the
helpful nature of a religious service, of photographs or of communicating sorrow
through writing a poem or letter.
Infertility
Grief associated with involuntary infertility is less focused than when grieving for a
particular person (Lau 2011). I n this situation the couple grieve for the hopes and
expectations integral to the conception of a baby. Realization of their infertility, and
the associated grief, is aggravated by the widespread assumption that conception is
easy, which is sufficiently prevalent for the emphasis, in society generally and
healthcare particularly, to be on preventing conception. Complex investigations and
prolonged infertility treatment result in a ‘roller-coaster’ of hope and despair.
A s with any grief, the couple in an infertile relationship grieve differently from each
other, engendering tensions. Being told the diagnosis or cause of their infertility
resolves some uncertainty, but raises other difficulties. These include one partner
being ‘labelled’ infertile and, hence, ‘blamed’ for the couple's difficulty. A complex
spiral of blame and recrimination may escalate to damage an already vulnerable
relationship (A llen 2009). Clearly, counselling an infertile couple differs markedly
from counselling those bereaved through death.
Relinquishment for adoption
A lthough long accepted that relinquishment is followed by grief (S orosky et al 1984),
the view persists that, because relinquishment is voluntary, grief is unlikely. Each
mother in the study conducted by Mander (1995) was clear that her relinquishment
was definitely involuntary and she had no alternative to relinquishment. These
mothers really were ‘bereaved’ in the original sense (see Introduction, above).
The grief of relinquishment differs crucially from grief following death. First, after
relinquishment grief is delayed. This is partly because of the woman's lifestyle and
partly because of the secrecy imposed on the woman who does not mother her baby as
is usual. S econdly, the grief of relinquishment is not resolved in the short or medium
term. This is because, ordinarily, acceptance of loss is crucial to resolving grief. A fter
relinquishment, such acceptance is impossible due to the likelihood that the one who
was relinquished will make contact when legally able. Being reunited with the
relinquished one was fundamentally important to the mothers interviewed. ‘Rosa’s’
words reflect many mothers' hopes: ‘I ’d be delighted if she would turn up on the
doorstep’ (Mander 1995).
Termination of pregnancy (TOP)
Grief associated with termination of an uncomplicated pregnancy is problematic and
for this reason it tends not to be included in the literature on grief. The experience of
grief following TO P for fetal abnormality and of guilt following TO P do, however, tend
to be recognized and accepted. I n view of the frequency of TO P and the grief
engendered, this deserves more attention.
TOP for fetal abnormality (TFA)
The package of investigations known as ‘prenatal diagnosis’ (see Chapter 11) may
ultimately lead to the decision to undergo TFA . A lthough it may be assumed that the
mother's reaction is solely one of relief at avoiding giving birth to a baby with a
disability, I les (1989) suggests reasons for a mother in this situation experiencing
conflicting emotions that impede grieving:
• the pregnancy was probably wanted;
• the TFA is a serious event in both physiological and social terms;
• the reason for TFA may arouse guilty feelings;
• the recurrence risk may constitute a future threat;
• the woman's biological clock is ticking away;
• her failure to achieve a ‘normal’ outcome may engender guilt.
I nterventions have been introduced to facilitate the grieving of the mother who has
undergone TFA , which involve counselling and the creation of memories, as in other
forms of child-bearing loss (see section on The Baby, below). A randomized controlled
trial to study the effectiveness of psychotherapeutic counselling in such mothers with
no other risk factors was undertaken by Lilford et al (1994). This study suggested that
bereavement counselling makes no difference to the difficulty or duration of grieving.
A dditionally, the researchers concluded that mothers a ending for counselling would
probably have resolved their grief more satisfactorily than the control group anyway.
TOP for other reasons
The non-recognition of grief associated with TO P may be because the mother whose
pregnancy is ended may be considered ‘undeserving’ of the luxury of grief. Further,
this may be aggravated by her being blamed for her situation. Research on the
psychological sequelae of TO P has focused on the guilt of having decided to end the
pregnancy, as opposed to grief reactions; it may be that this focus is associated with
the acrimonious abortion debate that continues in some countries. Thus, the grief and
depression, presenting as tearfulness, were thought normal after termination of
pregnancy (Wahlberg 2006). Perhaps these reactions could be prevented by
counselling before, as well as after, the TOP.
The baby with a disability
For various reasons a baby may be born with a disability, which may or may not be
anticipated. D isabilities vary hugely in severity and their implications for the baby.
The mother may have to adjust to the possibility of her baby dying, but many
conditions permit the continuation of a healthy life.
The mother's reaction to a baby with a disability will involve some grief. This is
particularly true if the condition was unexpected, as the mother must grieve for her
expected baby before relating to her real baby. The mother may be shocked to find
herself thinking that her baby might be be er off not surviving ( Lewis and Bourne
1989). A lthough the mother may be reassured that such thoughts are not unique, she
may still find it difficult to begin her grieving.
I f a baby is born with an unexpected disability, the problem of breaking the news
emerges. There are no easy answers to how this can be done to reduce the trauma, but
clear, effective and honest communication is crucial (Farrell et al 2001).
The midwife's experience
The emotional reaction that may sometimes be experienced by the midwife may come
as a surprise to her. Considering herself to be a professional person, she may be taken
aback by the strength and complexity of her feelings when caring for a bereaved
mother. This aspect has now begun to be addressed by research and to be opened up
to debate (Kenworthy and Kirkham 2011; see Box 26.2).
Box 26.2
That sad day
This is a summary of feelings and thoughts when I discovered an
intrauterine death at 41 weeks' gestation. The woman involved had been
admitted for induction of labour and neither of us was prepared for this.
My heart sank when on initial palpation her abdomen felt cold and then
the electronic fetal monitor did not detect the heart beat (I had just used
the machine earlier). I knew, although it would be difficult, that I had to try
and prepare her. I stayed later to try and give some continuity of care and
support for her and her husband. A fter the scan confirmed the death I
hugged her and her husband and cried with them. A fter this happened, I
had a day off work with a severe migraine caused by stress. I felt very
nervous and sick about going back to work, this was compounded when I
discovered that the woman had been admi ed to I ntensive Care and was
very ill. However, I did go back to work, visited the woman and sat holding
her hand. We talked about her sadness and she said she had been worried
about me leaving work late and wondered how I had coped ge ing home
and facing my two children. I couldn't believe that she was concerned about
me! S he remembered every word I had said to her and praised my honesty.
I had told her before the scan that I was sure that the baby had not
survived. Two weeks later I a ended the funeral in order to seek closure
and to demonstrate my sympathy and sadness for the parents.
I have been a midwife for over 12 years and this has N EVER happened to
me before. The whole event was very traumatic and upse ing for me. S ome
colleagues told me not to be upset, cry and/or get involved, but this was
ineffective advice. I was so determined that my experience should not be in
vain that I wrote this reflective piece. I n total I have experienced the loss of
over nine friends and relatives including my parents when I was fairly
young. However, nothing can prepare someone (even a professional) for
discovering that a baby has died and having to prepare the parents for this.
Without the love and support of my family, friends and colleagues I would
not have coped. A s healthcare professionals we should be empathic and
display understanding towards our colleagues in similar situations.
A s Rosemary Mander [2004b] writes in ‘W hen the professional gets
personal’:
for professional staff who provide effective care, there is likely to be a
personal cost. These are the ‘costs of caring’, which may be regarded as the
negative side of engaging with patients and clients and with one's work.
The whole experience will have a huge effect on my practice in various
ways. I will encourage midwives to be honest with the clients. This will
ensure that words are carefully chosen and also sensitively put, because
they will be clearly remembered in years to come. I will not try to smooth
over colleagues' feelings when they are involved in issues like this.
I am also going to liaise with the Local S upervising Authority to look at
guidance for other midwives in situations like this. The success of the ‘Birth
A fterthoughts S ervice’ within the Trust has led me to identify the need for
a service for midwives dealing with bereavement and perhaps morbidity as
well. Therefore, as a S upervisor of Midwives I aim to promote separate
sessions for midwives – even if the midwife says she is unaffected. This will
not be blame-based but will simply allow the members of staff to come to
terms with their emotions and feelings by helping them to move on in a
positive way.
To summarize, writing about this episode has been a catharsis for me
and hopefully my experience will have a positive outcome for other staff
who find themselves in the same sad and extremely difficult situation, and
therefore benefit the parents as well.
Source: Reproduced with the kind permission of The Practising Midwife
Loss in healthy childbearing
I t may be hard to understand that, even in uncomplicated, healthy childbearing, grief
may still present as a feature.
The ‘inside baby’
The woman's grief may be because, despite obstetric technology, the mother is unable
to view her baby before birth. I nevitably the real baby differs from the one whom she
came to love during pregnancy. These differences may be minor, such as the amount
of hair or crying behaviour. Lewis (1979) coined the term ‘inside baby’ to denote the
one whom she came to love during pregnancy and who was perfect. The ‘outside baby’
is the real one, for whom she will care and who may have some imperfections, such as
the wrong colour of hair. Clearly the mother may have moments of regret, during
which she grieves the loss of her fantasy ‘inside’ baby, before being able to begin her
relationship with her real baby.
The mother's birth experience
A further form of loss, over which the mother may need to grieve, is her loss of her
anticipated birth experience. I f she hoped for an uncomplicated birth, even some of
the more common interventions may leave her feeling like a failure (Green and Baston
2003). Thus, in the same way as the woman may need to grieve her ‘inside baby’, even
though all appears satisfactory, this disappointed mother has some grief work to
complete.
Care
I n considering the care that midwives provide in the event of loss, there are difficulties
in deciding where to begin. Thus, I have organized this section by focusing first on
those who are involved or affected and then on other crucial issues. From this material
will emerge the principles of midwifery care. W hile recognizing the artificiality of
distinguishing care for the individuals involved in this complex situation, this
approach helps us to consider the different needs among the people affected by the
loss.
The baby
I t is particularly hard to separate the care of the baby from the care of those who are
grieving, because much of our care comprises the creation of memories of the baby,
which will facilitate their grieving (Box 26.3). Midwives may think of the care of the
baby before the birth by considering the cot in the labour room (Mander 2006).
A lthough the cot's presence may cause the staff some discomfort, it reminds
everybody of the baby's reality. I f possible, that is if the baby's demise is known in
advance, the midwife discusses with the parents prior to the birth their contact with
the baby. This contact takes any of a number of forms, beginning with just a sight of
the wrapped baby. Contact with the baby has been said to resolve some of the
confusion surrounding the birth; but the benefits of such care have also been called
into question (Hughes et al 1999).
Box 26.3
C re a t ing m e m orie s
• Midwifery activities
– Information-giving
– Arranging for/taking photographs*
– Cutting a lock of hair*
– Taking a footprint*
– Giving a cot card and/or name-band
• Parental activities
– Naming baby
– Seeing baby
– Holding baby
– Caring for baby: bathing – dressing
– Taking photographs
• Other activities
Writing in a book of remembrance
Service/funeral/burial/cremation
Tree planting
Writing a letter and/or poem
*
Parents' informed consent will be needed.
The midwife faces the quandary of whether, and how much, she will encourage the
mother to make contact with her baby, drawing on her understanding of its beneficial
effect on grief (Mander 2006). This quandary is difficult, but midwives tend to be
overcautious in encouraging the mother to have contact. This was an important
finding from a study of 380 mothers who had experienced perinatal loss (Rådestad
et al 1996b). These researchers found that one-third of the mothers would have
appreciated more encouragement to have contact with their babies.
The mother may choose to have considerable contact with her baby, perhaps
keeping the baby with her for some time. D uring this time, the mother may wish to
have her baby baptized which, as well as its religious significance, emphasizes the
baby's reality. This simple act, possibly undertaken by the midwife, additionally
presents an opportunity to name the baby. The mother may also during this time have
other opportunities to create memories of her experience; these include doing some of
the things a mother ordinarily does for a baby, such as bathing and dressing him or
her.
I rrespective of whether the mother chooses to have contact with her baby
immediately, it is usual to collect certain mementoes at the time of the birth, such as a
lock of hair, a footprint or photographs. I f the mother chooses to have no contact at
the birth she may later ask for these mementoes. Taking photographs of a suitable
quality may present a challenge to the midwife who is not skilled in using a camera,
causing dissatisfaction (Rådestad et al 1996b) . Figure 26.1 shows the sensitive way in
which a photograph may be used to help create memories of the birth.
FIG. 26.1 Photograph showing a grieving mother cradling her baby, who has been named Baby
Shane.
I n the hope of preventing a future loss, the parents may be advised that the baby
should have a post mortem examination. This raises difficult issues for parents who
consider that their baby has already suffered enough. I n the UK there are guidelines
providing information for the parents prior to seeking their consent for the post
mortem. These guidelines aim to prevent certain abuses, which have previously
caused anguish to bereaved parents (D imond 2001; Royal College of Pathologists
[RCP] 2000).
The funeral serves a multiplicity of purposes, including a demonstration of general
support as well as establishing the reality of the loss. A young woman with no
experience of death may have difficulty imagining how such a ritual could ever be
beneficial. S he may be helped, though, by being reminded how cemetery and
crematorium staff are sensitive to the need to provide a suitable ceremony and a
congenial environment in which the child may subsequently be remembered. I n some
situations, such as early miscarriage, a funeral is inappropriate. The mother may find
that an impromptu service is helpful near the time of her loss or, later, she may create
her own memorial by writing a le er to her lost baby or planting a tree. The care of
this mother is particularly important if and when she decides to embark on another
pregnancy (Reid 2007; Armstrong et al 2009).
The mother
Much of the midwife's care of the grieving mother comprises helping her to make
sense of her mystifying experience. A s mentioned already, the mother needs help to
recognize that she has given birth, even though she no longer has her baby. I ntegral to
this is assisting her realization that she is a mother, through midwifery care.
The mother may start to make sense of her loss by talking about it. A lthough this
sounds simple enough, ‘opening up’ presents the mother with certain challenges. For
example, she may be inexperienced and uncomfortable in talking about profound
feelings. Further, she may have difficulty finding a suitable and willing listener
precisely when she feels ready. The problem of her finding a listener was identified in
a research project showing that senior hospital staff appear too busy, and other staff
insufficiently experienced, for her to unburden herself. Family members, who might
listen, have their own difficulties to face, making them less receptive to the mother's
needs (Rajan 1994).
I n a situation of loss, any of us may feel that our control over our lives is slipping
away. S uch feelings of losing control are exacerbated when the loss involves a
physiological process such as childbearing, which many people achieve successfully
and effortlessly. Midwives should be able to help the mother to retain some degree of
control. They can do this is by giving her accurate information about the choices open
to her and on which she is able to base decisions. I n this way, the midwife may be able
to empower the woman and the two may form a partnership together.
The reality of the grieving mother's control over her care was the subject of research
by Gohlish (1985). S he interviewed 15 mothers of stillborn babies and asked them to
identify the ‘nursing’ behaviours they considered most helpful. This study showed the
importance to the grieving mother of assuming control over her environment. W hile
the midwife may be keen to share many aspects of control in the form of decision-
making with the grieving mother, there are some decisions that midwives consider
unsuitable for the mother to make (Mander 1993). The suitable decisions include the
contact that the mother has with her baby; whereas the unsuitable decisions may
include the environment in which she is cared for during her hospital stay.
The support offered to the woman was the subject of a systematic review, which
found that there is li le evidence to indicate the effectiveness of psychological support
at this time (Flenady and Wilson 2008). A randomized controlled trial by Forrest et al
(1982) investigated the effects of support following perinatal loss. The experimental
group, comprising 25 bereaved mothers, received ideal supportive midwifery care
together with counselling; the control group comprised another 25 bereaved mothers
who received standard care. Unlike the more psychotherapeutically oriented study by
Lilford et al (1994), Forrest et al (1982) found that the well-supported and counselled
group recovered from their grief more quickly than the control group. Unfortunately,
both studies had difficulty retaining contact with the grieving mothers.
The mother may find helpful support in a number of people, who provide support
on a more or less formal basis (Forrest et al 1982). A lthough we may assume that
identifying support is easy, research by Rådestad et al (1996b) has shown that, like
finding a suitable listener, locating support may be problematic for the mother. These
researchers found that for just over one-quarter of bereaved mothers the support
lasted for under 1 month; while for just over another quarter the support was non-
existent.
Of particular significance to midwives is the contribution of the lay support and self-
help groups. Research by Mander (2006) showed that midwives are happy to
recommend that a mother may find a support group, such as the S tillbirth and
N eonatal D eath S ociety (S A N D S ), helpful. Unfortunately, li le is known about thei
effectiveness or the experiences of those who attend.
I f the loss occurs while the woman is in hospital, her transfer home is crucially
important, due to the likelihood of other agencies becoming involved. At this point
good inter-agency communication ensures that the woman's healthy grieving is not
jeopardized. I n her large study, Moulder (1998) identified the quality of the help
provided for the grieving mother by community agencies. S he found that women
experience very different standards of care from the various professionals, such as
health visitors, general practitioners, community midwives and counselling personnel.
S imilarly, the 6-week follow-up presents an opportunity, not only to check the
woman's physical recovery, but also to discuss important outstanding issues. These
include the couple's emotional recovery from their loss, the post mortem results (if
relevant), any questions arising or remaining, as well as plans for the future. The
research by Moulder (1998) found that this follow-up visit is often handled
appropriately sensitively, in a suitable environment, with appropriate personnel
present and adequate time to address ma ers of concern. Unfortunately, though,
some women's appointments were delayed and staff were condescending.
The family
The mother is clearly most intimately involved with, and affected by, a perinatal loss.
To a greater or lesser extent, those close by will share her grief. I n this context, the
chapter includes, as well as conventional family members, a range of non-blood and
non-marital relationships.
The father
The effect of the loss on the father may previously have been underestimated (Mander
2004a). This is partly because men tend to show their grief differently from women
and partly because they are socialized into supporting their womenfolk, possibly at
the cost of their own emotional well-being. Further, men are stereotypically unlikely to
avail themselves of the therapeutic effects of crying and articulating sorrow. Men's
coping mechanisms also involve less healthy grieving strategies, including returning
early to work and using potentially harmful substances such as nicotine or alcohol.
Possibly in association with their different pa erns of grieving (S amuelsson et al
2001), the parental relationship is likely to change following perinatal loss. W hether
the couple find their relationship strengthened or threatened is unpredictable.
Other family members
Perhaps because they are less closely involved, grandparents may be
disproportionately adversely affected by the loss, possibly due to their inability to
protect their children (the bereaved parents) from painful loss. I nevitably and
additionally they experience their own sense of loss at the threat to the continuity of
their family and what that means to them.
The effects of perinatal loss on a sibling may be problematic because of uncertainty
about the child's understanding of the event (Hayslip and Hansson 2003; Dyregrov
2008). This difficulty is compounded by the parents' difficulty in articulating their pain
in a suitable form. The parents may seek to ‘solve’ these problems by ‘protecting’ their
other child(ren) from the truth. They li le know that ‘protection’ creates a pa ern of
unhealthy grieving, leaving a family legacy of dysfunctional relationships (Dyregrov
2008).
W hilst midwives often assume that family are best at supporting a grieving mother
(Mander 1996), family responses may not always be healthy or helpful (Kissane and
Bloch 1994).
The formal carers
The difficulty that staff face in caring for a grieving mother has been linked with their
personal reactions to the loss of a baby (Bourne 1968). This may be the reason for the
historical neglect of such mothers in particular and this topic in general. Furthermore,
loss of a baby represents all too clearly the failure of the healthcare system, and those
who work in it, to ensure a successful outcome to the pregnancy. The fear of failure in
turn engenders a cycle of avoidance, which perpetuates neglect of the mother.
This vicious cycle has been interrupted so that as the care of the mother has been
changed, it is necessary to question whether the care of staff has kept pace (Clarke and
Mander 2006). The emotional costs of providing care are now being recognized
(Kenworthy and Kirkham 2011). The devaluation of the emotional component of care
is associated with increasing use of the medical model and contributes to the
increasing recognition of ‘burnout’. The need for extra support is particularly
important for less experienced staff when providing care for grieving families (Mander
2000). The education of staff for their counselling role is another solution, which is
enhanced by supervision for the counsellors. The role of the midwife manager in
creating a supportive environment for staff in stressful situations should not be
underestimated. The midwife may also be able to locate support in others alongside
whom she works, such as the hospital minister or chaplain or her named S upervisor of
Midwives. A dditionally, there are helpful agencies which may be located within or
outwith the healthcare system (see Useful Websites, below).
The involvement of staff in the mother's grief raises some difficult questions. First
there is the helpfulness or otherwise of the midwife sharing the bereaved mother's
tears. A lthough some midwives are prepared to cry alongside the mother, others feel
that crying is ‘unprofessional’ and would not be comfortable shedding even a few
tears. The midwives in Mander's (2006, 2009) research said that, generally, crying was
not a problem; but any loss of control that impeded their ability to provide care must
be avoided at all costs. A nother difficult decision is whether staff should a end the
baby's funeral. S ome of the midwives interviewed found this helpful and they had not
been uncomfortable attending. In some circumstances, however, this might not apply.
Other aspects of care
N ot least because of their effect on grieving, other aspects of care assume greater
importance.
Record-keeping and documentation
Record-keeping in this context becomes even more significant. This is because
communication is vital in ensuring consistent care, which will facilitate the mother's
grieving. A lthough not ideal, it may be difficult to avoid this care being provided by
different personnel. Thus, each midwife must be able to learn from the mother's
records about decisions and actions already taken (Horsfall 2001).
The cremation or burial
The documents required for the ‘disposal’ of the baby differ according to whether the
baby was born before or after 24 weeks' gestation (the current legal limit of viability in
the UK), according to whether the baby was born alive or not, and according to where
the baby was born. I f the baby was pre-viable, there is no legal requirement for the
baby to be buried or cremated. I t is, however, essential to ensure that the baby's
remains are removed according to the mother's wishes. I f she decides not to
participate in the removal of the baby's remains, they should still be removed
sensitively (Royal College of O bstetricians and Gynaecologists [RCO G] 2006 ). A book
of remembrance in the maternity unit is available to parents to record their names,
their baby's details and thoughts about the baby.
For a baby born after 24 weeks, burial or cremation may be arranged by the hospital,
with the parents' permission, or by the parents. Cemeteries and churchyards are
subject to individual regulation, but the local cemetery is likely to have a special plot
for babies to be buried individually and a religious or other service may be available.
There is also the possibility that the parents may erect a headstone, although the
design may be subject to approval.
The statutory documentation is specific to each of the countries of the UK. D etails of
the registration requirements in each of the four countries of the UK are provided on
the websites listed at the end of this chapter.
The mother's choices
I f she loses her baby, as well as her grief work, the mother has certain choices. I n
terms of how the baby's body should be buried or cremated, the mother decides
whether to arrange this privately or allow the hospital to organize it. The mother also
needs to decide the extent to which she would like to be involved in planning the
funeral, the blessing or the memorial ceremony. I n some hospitals, services of
remembrance are held on a regular basis, and bereaved parents choose whether to
a end. A s mentioned above, the mother needs appropriate information to decide
about the funeral and post mortem.
The death of a mother
A form of loss that happens even less frequently than the death of a baby is when the
mother dies; this is usually known as maternal death. I n the UK, the rate of maternal
death is approximately 1 in 10,000 births (Lewis 2011: 48). This means that in a
medium-sized maternity unit a mother is likely to die about once every 3 years.
A lthough the obstetric and epidemiological aspects of maternal death have been
well addressed (Maclean and N eilson 2002; Edwards 2004; Lewis 2011), the more
personal aspects tend to be avoided (Mander 2001a). There is, however, li le
understanding of the family's experience, or the life of the motherless child. Palliative
care principles may be appropriately applied to the care of the childbearing woman
with or dying from an incurable condition (Mander 2011). The care of this woman and
the implications for her baby and the other family members are likely to become
increasingly important as women choose to delay child-bearing into their mature
years. This childbearing woman's care has yet to be subjected to serious research
attention.
However, the experience of the midwife providing care around the time of the death
of a mother has begun to be addressed (Mander 2001b, 2004b). This research shows
the dire implications for the midwife of attending a mother who dies, to the extent that
the experience assumes the proportions of a disaster. The midwife's desperate need
for support may be met by midwifery colleagues who either shared her experience or
have been through a similar one. The midwife's family also plays a fundamentally
important role in supporting her (Mander 1999).
Conclusion
This chapter has shown that, for the midwife's care of the mother grieving a loss in
childbearing to be of a suitably high standard, there needs to be a suitably strong
knowledge base. A lthough obtaining such knowledge is not easy, it is only by
obtaining and using it that midwives are able to give this mother and family the high
standard of care which they deserve and need. I n this way, the midwife facilitates
healthy grieving in the mother, having avoided the impediments that interfere with or
complicate her grief and prevent its resolution. I n this most human of situations,
midwives must remember that ‘being nice’ is not enough; they need to ensure that
midwifery care is based on a firm knowledge base if the woman is to come to terms
with her loss. O ther, less widely recognized or discussed forms of loss in childbearing
have also been addressed.
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dying. Sage: Thousand Oaks, CA; 2003:838–846.
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PA; 1999.
Further Reading
Dickenson D, Johnson M, Samson Katz J. Death, dying and bereavement. 2nd edn.
Sage and The Open University: London; 2000.
An easily readable examination of a wide range of issues..
Field D, Hockey J, Small N. Death, gender and ethnicity. Routledge: London; 1997.
The politics of loss..
Jones A. Psychotherapy following childbirth. British Journal of Midwifery.
1996;4(5):239–243.
An in-depth exploration of relevant psychoanalytical issues..
Kenworthy D, Kirkham M. Midwives coping with loss and grief. Radcliffe: London;
2011.
A thought-provoking, yet accessible, analysis of the midwife's experience of caring for a
grieving woman..
Mander R. Loss and bereavement in childbearing. 2nd edn. Routledge: London; 2006.
A wide-ranging exploration of issues relating to childbearing loss, using research and
other knowledges..
Schott J, Henley A. Childbearing losses. British Journal of Midwifery.
1996;4(10):522–526.
The implications of cultural and religious variations in the context of childbearing loss..
Thompson N. Loss and grief: a guide for human services practitioners. Palgrave
Macmillan: Basingstoke; 2002.
Very relevant for midwives..
Walter T. On bereavement: the culture of grief. Open University Press: London;
1999.
A scientific examination of the social aspects of bereavement in general..
Wimpenny P, Costello J. Grief, loss and bereavement: evidence and practice for health
and social care practitioners. Routledge: London; 2012.
Some up-to-date ideas and recent developments..
Useful Websites
Registration and other statutory documentation of a stillborn baby
England & Wales. www.gro.gov.uk/gro/content/certificates/default.asp.
Scotland. www.gro-scotland.gov.uk/regscot/registering-a-stillbirth.html.
Northern Ireland. www.belfastcity.gov.uk/deaths/stillbirths.asp?
menuitem=registering-a-stilldeath.
Support groups
The Miscarriage Association. www.miscarriageassociation.org.uk/.
SANDS (Stillbirth and Neonatal Death Society). http://uk-sands.org/.
CRUSE Bereavement Care. www.crusebereavementcare.org.uk/.
BLISS – The Premature Baby Charity. www.bliss.org.uk/.
TCF – The Compassionate Friends (UK). www.tcf.org.uk/.
Support for bereaved parents and their families.
Born with Wings. www.bornwithwings.co.uk/.
Support for parents from parents.
EPT Ectopic Pregnancy Trust. www.ectopic.org.uk/.
NORCAP. www.norcap.org.uk/.
Support for adults affected by adoption.
Infertility Network UK. www.infertilitynetworkuk.com/.
Advice, support and understanding.
SOFT UK. www.soft.org.uk/.
Support organization for trisomy 13/18 and related disorders.
ARC Antenatal Results & Choices. www.arc-uk.org/.
Incorporating SATFA (Support Around Termination for Abnormality).
Support for the Midwife
AIMS – Association for Improvements in Maternity Services. www.aims.org.uk/.
Midwifery Supervisor and Local Supervising Authority.
RCM – Royal College of Midwives. www.rcm.org.uk/.
The Local Steward or Regional Officer can be contacted via the website..
C H AP T E R 2 7
Contraception and sexual health in a
global society
Karen Jackson
CHAPTER CONTENTS
The role of the midwife 570
Hormonal contraceptive methods 570
The combined hormonal contraceptive pill 570
The combined hormone injectable (Lunelle) 574
The combined hormone patch 574
The combined hormone vaginal ring 574
The progestogen-only pills 574
Long acting reversible contraception (LARC) 575
Progestogen injections 575
Subdermal contraceptive implants 576
Intrauterine contraceptive device (IUCD) 577
Progestogen-releasing intrauterine system (IUS) 578
Barrier methods of contraception (male and female methods) 578
Male condom 578
Female condom 578
Diaphragm 578
Cervical and vault caps 581
Spermicidal products 581
Emergency contraception 581
Coitus interruptus 582
Fertility awareness (Natural Family Planning) 582
Fertility awareness methods 583
Symptothermal methods 584
Fertility monitoring device 584
Lactational amenorrhoea method (LAM) 584
Male and female sterilization 585
Female sterilization 585
Male sterilization (vasectomy) 586
The future of contraception and sexual health services 586
Ongoing developments 586
References 587
Further reading 588
Useful websites/contacts 588
Contraception and sexual health are important considerations for women of
childbearing age. There are numerous ways in which women can control
their fertility, but the choice of contraception will depend on a multitude of
factors, including: method of infant feeding, age, culture, religion, access to
contraception and previous experience. Women with additional challenges
such as physical, sensory or cognitive needs, or those who do not speak or
read English, may need extra support and information to enable them to
make informed decisions about postpartum contraception.
The chapter aims to:
• provide up-to-date knowledge of all forms of contraception
• emphasize the role of the midwife in providing contraceptive information and advice for
women in their care.
The role of the midwife
The midwife has a unique and pivotal role in discussing contraception and sexual
health. The N ursing and Midwifery Council (N MC) in the United Kingdom (UK) state
that one of the activities of a midwife is to provide sound family planning information
and advice (NMC 2012). Midwives are encouraged to take on a wider public health role
and are in a key position to create and use opportunities to enable women to express
their needs in respect of choice of contraception.
The most appropriate time to discuss sexual health, resumption of sexual activity
and contraception will, in some respect, be dependent on the individual woman. S ome
midwives may feel that any encounter with postnatal women, even soon after giving
birth, will capitalize on contraceptive and sexual health education opportunities. The
N ational I nstitute for Health and Clinical Excellence (N I CE) (2006)recommends that
contraception advice should be imparted within a week of the birth. I ssues such as
loss of libido, adjustment to motherhood, breastfeeding, discomfort of the perineum,
vaginal dryness and body image may also influence choice and use of a particular
method of contraception (Faculty of S exual and Reproductive Healthcare Clinical
Effectiveness Unit [FS RH] 2009a ). The use of a leaflet from the Family Planning
A ssociation (FPA) can be helpful as such leaflets are clear to understand in both text
and illustration, and are in a variety of languages. The midwife should be familiar with
the contraception and sexual health services available in the area in which she
practises and know the system of referral to these specialist services.
For contraceptive methods discussed in this chapter, the efficacy rate is given as a
percentage. This rate does not reflect the fact that fertility decreases with age and may
be suppressed during lactation, or that the success of a method is partially dependent
on motivation, experience of using the method and the teaching received on its use. I t
is recognized that if 100 sexually active women do not use any contraception, 80–90 of
them will become pregnant within a year (FPA 2012). S exual intercourse following
childbirth is a hitherto seldom discussed issue. McD onald and Brown (2013) found in
their study of 1507 primigravidae that almost 60% of the women had not resumed
intercourse six weeks following the birth. D iscussions need to take place well before
this time to ensure no unintended pregnancies occur. S ome women may even
appreciate information on contraception in the antenatal period, to give them plenty
of time to decide which contraceptive method would be right for them. Partnership
working between the new mother and midwife is essential and conversations
regarding contraception should take place in a quiet, relaxed se ing, with the midwife
having up-to-date knowledge on all methods available.
I n the UK, all contraception is available free of charge from the N ational Health
S ervice (N HS ). This is different in other parts of the world, with a range of charges for
certain methods of contraception.
Hormonal contraceptive methods
The combined hormonal contraceptive pill
The combined oral contraceptive pill (CO C or‘the pill’) (Fig. 27.1) came as a
breakthrough, in 1960, in terms of women being in a be er position to control their
fertility. This method has subsequently proven to be both effective and safe. The
overall use varies greatly between countries but it is estimated to be used by
approximately 1% of J apanese women who are married or in a union, 53% in Germany,
28% in the UK and 50% of women in Western Europe (G uillebaud and MacGregor
2013). I n the UK, approximately 95% of women under the age of 30 have used oral
contraceptives at some time. A round 100 million women rely on the pill worldwide
(Guillebaud and MacGregor 2013).
FIG. 27.1 The combined hormonal contraceptive choices.
The combined pill contains the synthetic steroid hormones oestrogen and progestogen.
A ll CO Cs available in the UK contain ethinyl oestradiol
, with the exception of N orinyl-
l, which contains mestranol and Q laira which contains estradiol valerate. There are a
variety of CO Cs available containing different progestogens. This accounts for subtle
differences in their biological effects and provides women with a wide choice. The
most commonly used pills in the UK are monophasic pills, which deliver a constant
dose of steroids throughout the packet. ‘Everyday’ pills contain 28 pills in each packet,
21 of which are active monophasic pills while the seven remaining pills contain no
hormones (FPA 2012).
A lso available are biphasic and triphasic pills, in which the dose of steroids
administered varies in two or three phases throughout the packet to mimic the natural
fluctuations of the hormones during the menstrual cycle. These pills are less
commonly used in the UK. A relatively new pill, called Q laira, is licensed in the UK; it
is a complex quadraphasic pill designed to give optimal cycle control. I t is taken every
day but has two placebo tablets.
The first generation CO C pills contained large doses of oestrogen and were
associated with a high risk of deep vein thrombosis. They were replaced in the late
1960s with pills that had lower doses of oestrogen and progestogen. They were equally
as effective as the earlier pills, being much safer and be er tolerated. The
progestogens in these second generation pills were norethisterone and levonorgestrel.
The third generation pills, which came along in the mid-1980s, contained a variety of
new synthetic progestogens, that appeared to have be er effects on serum lipid
profiles. A mong these were desogestrel and norgestimate, which were also less
androgenic; gestodene, which was the most potent, achieving the best cycle control;
and cyproterone acetate, which was anti-androgenic but licensed only as a treatment
for acne. D rospirenone has been available from the late 1990s, with mild
antimineralocorticoid activity to counteract oestrogen-induced water retention. I t is
also anti-androgenic.
Mode of action
Combined oral contraceptives work primarily by preventing ovulation. The first seven
active pills in a packet inhibit ovulation and the remaining pills maintain anovulation
(FSRH 2011a).
O estrogen and progestogen suppress follicle stimulating hormone (FS H) and
luteinizing hormone (LH) production causing the ovaries to go into a resting state; the
ovarian follicles do not mature and ovulation does not normally take place.
Progestogen also causes the cervical mucus to thicken, making penetration by
spermatozoa difficult. The pill renders the endometrium unreceptive to implantation
by the blastocyst. These actions provide additional contraception in the event of
breakthrough ovulation occurring.
Efficacy
Provided that the pill is taken correctly and consistently, and that it is absorbed
normally and interaction with other medication does not affect its metabolism, its
reliability with consistent perfect use is almost 100% (Guillebaud and MacGregor 2013).
Important considerations
The combined oral contraceptive pill is a reliable contraceptive, which is independent
of sexual intercourse and has many advantages. Healthcare providers should manage
consultations for contraceptive pills with due regard for the woman's personal context
and contraception experience.
A dditional benefits of taking the CO C pill, in the short term, are regular, lighter,
less painful periods, possible reduction in premenstrual symptoms, reduction in acne,
protection against pelvic inflammatory disease (PI D ) (because of the thickened
cervical mucus), decreased incidence of ectopic pregnancy and reduced risk of benign
breast disease. Taken long term, CO C pills offer protection against ovarian and
endometrial cancers and reduction in the incidence of ovarian cysts and benign
ovarian tumours (FSRH 2011a).
Use of the CO C pill may lead to side-effects such as irregular bleeding, headaches,
nausea and breast tenderness; there is li le evidence to support the association of
weight increase, depression and CO C use (F S RH 2011a). These effects often diminish
with continued use or may improve with a change of pill. A basic knowledge of the
side-effects a ributable to the components of the CO C pill is helpful when making
decisions about changing pills.
O estrogen dominance in a pill may cause water retention, resulting in breast
tenderness, mild headaches, elevated blood pressure and cyclical weight gain. I t may
also be responsible for nausea and vomiting, excessive vaginal secretion (leucorrhoea)
and skin pigmentation similar to chloasma. The progestogens may lower mood and
libido, provoke acne and seborrhoea and cause mastalgia.
The vast majority of women experience no adverse effects. Every woman is unique in
their biological response and also in their perception and tolerance of side-effects. The
metabolic effects of the CO C pill can occasionally result in major side-effects. The
risks of venous thromboembolism (VTE) with the CO C pill, in absolute terms, show a
rarity of VTE in women of reproductive age (seeTable 27.1). The risk of VTE is higher
in women with a Body Mass I ndex (BMI ) over 30, heavy smokers, those with a previous
history of deep vein thrombosis or a family history of venous thrombosis and those
who are immobile.
Table 27.1
Risks of venous thromboembolism
Risk of VTE per 10 000 woman years
Not using COC 4–5
COC users (risk depends on type of COC) 9–10
In pregnancy 29
Immediate postpartum 300–400
Adapted from FSRH 2011a
Allan and Koppula (2012) concluded that the risks of VTE when comparing all CO Cs
appear to be unclear, but if there are differences they are likely to be very small and
similar, therefore, any of the CO Cs may be considered for prescription if this method
has been chosen for contraception.
S ome women may develop a significantly high blood pressure, which could increase
the potential for haemorrhagic stroke and myocardial infarction. Hypertension with a
blood pressure (BP) between 141/91 mmHg and 159/94 mmHg is considered to be at a
level of risk that outweighs the benefits of using the CO C. Hypertension with BP of
160/95 mmHg or higher poses an unacceptable health risk with COC use (FSRH 2011a).
Cigare e smoking is known to potentiate most of the risks associated with CO C pill
use such as ischaemic and haemorrhagic stroke and myocardial infarction (FSRH
2011a).
The research surrounding the risk of developing breast cancer for CO C users is
largely contradictory, but it is widely acknowledged that there is a small increase in
this risk (FPA 2012). A ny excess risk of breast cancer associated with CO C use declines
in the first ten years after discontinuing the pill.
S tudies show a small increase in the relative risk of cervical cancer, which is
associated with a long duration of use (Guillebaud and MacGregor 2013). However, the
effects of confounding factors such as sexually transmi ed infections (S TI ), non-use of
barrier methods and a high number of sexual partners may distort an accurate
understanding of the influence of the COC pill.
Contraindications to CO C pill use are pregnancy, undiagnosed abnormal vaginal
bleeding, history of arterial or venous thrombosis (or predisposing factors such as
immobility), hypertension, focal migraines, current liver disease, trophoblastic disease
(until serum human chorionic gonadotrophin [hCG] is no longer detectable), smoking
(if the woman's age is over 35 years) and a BMI over 39. This is not an exhaustive list.
A s the pill is not suitable for everyone, women wishing to consider using this form of
contraception should have a full history recorded and be fully informed and
counselled regarding possible side-effects.
Using the COC pill
W hen initially commencing the pill, the very first pill is usually taken on the first day
of the menstrual period (for postpartum use, see later). S tarting on any day up to the
fifth day is just as effective, provided the first seven pills are taken correctly. I f a 21-
day pill has been prescribed, the contraceptive effect is immediate, provided that the
remainder of pills in the packet are taken correctly. I f the pill is initially commenced
on any day beyond the fifth day of the cycle, additional contraception (such as a
condom) should be used in conjunction with the pill for the first seven days. I t is
recommended that Q laira is taken on the first day of the menstrual cycle, and if taken
on any other day, additional contraception should be used for nine days. O ne pill is
taken every day for 21 days, then no pills for the next seven days. Vaginal bleeding
usually occurs within the seven day break, before the next packet of pills is
commenced (FPA 2012).
W hen commencing the ‘Everyday’ (ED ) CO C pill, the active pills are taken first. O ne
pill is taken daily, with care to take the pills in the correct order. Vaginal bleeding will
usually occur when the inactive pills are taken, which are usually denoted by a
different coloured section on the pill packet. I f two or more pills have been missed, or
the next pack of pills is two or more days late, the advice given in Fig. 27.2 should be
followed. I f a pill is forgo en from the beginning or end of a packet, the pill-free
interval is lengthened and ovulation may be more likely to occur (FS RH 2011a). I f a
woman is concerned about a missed or late pill, she can contact the local contraception
clinic or General Practitioner (GP) for reassurance or advice, as emergency
contraception may be indicated (see later).
FIG. 27.2 Missed pill rule (FSRH 2011b).
O ther factors that may render the pill less effective include interaction with other
medication, vomiting within 2 hours of taking a pill and severe diarrhoea. Medications
that may hinder the effectiveness of the pill include liver-enzyme-inducing drugs such
as rifampicin, some anticonvulsants and some herbal remedies, for example S t J ohn's
wort. A fter absorption, synthetic oestrogen and progestogen are transported to the
liver via the portal vein. Liver-enzyme-inducing drugs reduce the efficacy of the pill by
increasing the metabolism, and subsequent elimination of oestrogen and progestogen
in the bile. S ome newer antiepileptics are not enzyme inducers but the CO C pill may
reduce seizure control with lamotrigine.
Please note that additional precautions are no longer required when taking
antibiotics (non-enzyme inducing) (FSRH 2011a).
The advice to be given in cases of an illness with severe vomiting and diarrhoea is to
follow the missed pill rules. I t is important that women are made aware of possible
drug interactions and inform their medical practitioner/GP that the CO C pill is being
taken whenever other medications are prescribed.
Preconception considerations
I t is useful to wait for one natural period after discontinuing the pill before trying to
conceive as dating the pregnancy can be more accurate and pre-pregnancy care can
begin.
Postpartum considerations
The combined oral contraceptive pill reduces milk supply, particularly if lactation is
not well established, and is therefore not recommended for use in the early months in
lactating women. I f the mother is bo le-feeding her baby, the CO C pill may be
commenced 21 days postpartum. This allows the high oestrogen levels of pregnancy to
decrease before introducing the pill (Guillebaud and MacGregor 2013), thus reducing
the risk of thromboembolism, but allowing the contraceptive effect to be initiated
before ovulation resumes. W omen who have experienced pregnancy-induced
hypertension should be assessed on an individual basis with regard to recommencing
COC use (Guillebaud and MacGregor 2013).
The CO C pill can be commenced immediately following spontaneous miscarriage or
therapeutic termination of pregnancy. D ue to the risk of thromboembolism, the CO C
pill should be discontinued 4 weeks before major surgery and a progestogen-only
method of contraception used. I f this is not possible, then thromboprophylaxis and
compression hosiery are advised. W omen who have minor surgery do not need to
discontinue taking the pill.
Further postpartum considerations for discussion with the mother may include
whether remembering to take the pill will fit into her current lifestyle and if she can
easily access a clinic or doctor's surgery. A ppropriate follow-up, including blood
pressure assessments, should be conducted. Following the first prescription, follow-up
is usually at 3 months postpartum and thereafter it may be annually.
The combined hormone injectable (Lunelle)
Lunelle contains 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. I t
is not yet licensed in the UK due to its poor uptake and subsequent withdrawal from
the market in the United S tates of A merica (US A), but it is popular in S outh A merica
and A sia (Guillebaud and MacGregor 2013). Lunelle is commenced on the first day or
within five days of a menstrual period, and given every 28–33 days. I t is both effective
and reversible. S ide-effects include breakthrough bleeding and weight gain. The
efficacy is comparable with perfect use of the CO C pill. Cyclofem and Mesigyna are
similar monthly injections also available to women in many countries outside of the
USA, mainly in South America and Asia.
The combined hormone patch
The combined hormone patch (EVRA) was licensed in the UK in 2003. O ne patch is
used weekly for three weeks followed by one week patch-free. I t is particularly suitable
for women who are unable to tolerate oral medications and those with malabsorption
syndrome. I t releases 20 mg of ethinyl oestradiol and 150 mg of norelgestromin every
24 hours. Compliance and cycle control may be improved. The efficacy of the
combined hormone patch is comparable with the CO C pill. The patch may be worn on
most places on the body except the breasts. I t is extremely sticky and should stay on
during showering or swimming.
T h e FPA (2011a) suggest it may be used from day 21 in the postnatal period.
However, if the mother is breastfeeding her baby, the patch should not be
recommended as it will reduce breast milk production.
The combined hormone vaginal ring
The combined hormone vaginal ring (NuvaRing) is inserted into the vagina on the first
day of the menstrual cycle. I f inserted at any other time additional contraception such
as condoms should be used for seven days. I t is then used continuously for three
weeks followed by one week free of its use. I t releases 15 mg of ethinyl oestradiol and
120 µg of etonogestrel per 24 hours. The N uvaRing appears to be acceptable to many
women and well tolerated, with studies finding that compliance and cycle control are
also remarkably good (Roumen et al 2006; Brucker et al 2008). The efficacy of the
NuvaRing is comparable with the COC pill.
The progestogen-only pills
Progestogen-only pills (PO P) were introduced partly to avoid the side-effects of
oestrogen in the combined pill, as discussed earlier. They also offer increased choice
for women. Currently available in the UK are the older preparations, which contain
norethisterone (N oriday, Micronor), etynodiol diacetate (Femulen) and levonorgestrel
(N orgeston) and the new anovulant progestogen-only pills containing desogestrel
(Cerazette). All have lower doses of progestogen compared with the COC pill.
Mode of action
The POP exerts its contraceptive effects at different levels. The cervical mucus is viscid,
making it impenetrable to spermatozoa and the endometrium is modified to prevent
implantation. The older PO Ps have been shown to suppress ovulation in up to 60% of
women. The new PO P Ceraze e is anovulant and also suppresses FS H and LH
consistently such that it is effective in about 97% of women (FSRH 2008a).
Limitations to PO P use include menstrual disturbances, encompassing
unpredictable and quite often prolonged bleeding, oligomenorrhoea or amenorrhoea.
Li le is understood about the mechanism of erratic uterine bleeding, which most
women experience to some degree. The menstrual disruption is the most common
reason for discontinuation of progestogen-only methods. This indicates the need for
careful explanation of the limitations to potential users.
A n increased prevalence of functional ovarian cysts has been demonstrated in
women using progestogen-only pills. These may se le with continuation of use and
will resolve if the POP is discontinued.
Contraindications to the use of progestogen-only-pills are pregnancy, undiagnosed
abnormal vaginal bleeding, severe arterial disease and hydatidiform mole (until serum
hCG is no longer detectable). The rate of ectopic pregnancy in women using the
progestogen-only pill is no higher than in women using no contraception; however,
the PO P prevents uterine pregnancy more effectively than tubal pregnancy. This is not
a problem with the anovulant POP Cerazette.
A ntibiotics do not adversely affect progestogen-only methods of contraception but
women should be advised to consult the doctor/GP regarding possible interactions if
any other medications (especially enzyme inducers such as rifampicin) are prescribed.
Preconception considerations
There is no evidence of a teratogenic effect with the POP.
Postpartum considerations
Progestogen-only-pills may be commenced 21 days postpartum for contraception.
These pills have no adverse effect on lactation. Secretion of the hormone in breast milk
and absorption by the neonate is minimal and does not affect the short-term growth
and development of infants. The PO P can be used immediately following spontaneous
miscarriage or therapeutic termination of pregnancy.
Using the POP
The PO P is taken every day as there are no pill-free days and thus tablets are taken
throughout the menstrual period. I f the first tablet is taken on the first to fifth day of
the menstrual cycle, the contraceptive effect is immediate. I f the PO P is started on any
other day of the cycle then additional contraception, such as a condom, should be used
for the first two days (FSRH 2008a).
I f a pill is forgotten, the woman has only 3 hours in which to remember to take it. I f
the woman is over 3 hours late in taking a pill, she should continue taking her pills
and use additional contraception for the next two days. However, with the anovulant
PO P Ceraze e, the woman has up to 12 hours in which to remember to take the
forgotten pill.
Following vomiting or severe diarrhoea, additional contraception should be used
until two days after the illness ceases. W omen concerned about missed or late pills
should be advised to contact their contraception and sexual health clinic or GP, as
emergency contraception may be indicated (see later). The effects of broad-spectrum
antibiotics on the gut flora do not affect the action of the POP.
Efficacy
The effectiveness of the older PO P is dependent upon meticulous compliance. With
perfect use, the POP is more than 99% effective (FSRH 2008a).
Long acting reversible contraception (LARC)
Contraceptives that are used daily or weekly sometimes fail because of non-adherence
or incorrect use. A LA RC is defined byN I CE (2005) as contraceptive methods that
require administration less than once per menstrual cycle or month. These guidelines
recommend giving women wider access to long acting reversible contraceptive (LA RC)
methods, as a feasible way to reduce unintended pregnancy (N I CE 2005). Long acting
reversible contraceptive methods are considered to be more reliable and cost-effective
than other methods.
Long acting reversible contraceptive methods include injectable progestogen
contraceptives, intrauterine contraceptive devices (I UCD ), intrauterine hormonal
systems and subdermal contraceptive implants. These are all available in the UK but
usage remains low due to inadequate awareness of their availability and access as
most GPs and practice nurses do not fit implants and intrauterine methods of
contraception.
For a long acting method to be initiated, informed choice is crucial because only
women who have realistic expectations may tolerate protracted side-effects. The
implants and intrauterine systems are expensive, therefore a reasonable continuation
rate is pertinent.
Progestogen injections
The two contraceptive progestogen injections currently available in the UK are D epo-
Provera, or depot medroxyprogesterone acetate (D MPA), and N oristerat
(norethisterone enanthate). Both methods are given by deep intramuscular injection.
D MPA is the method of choice for many women, not simply those for whom other
methods are contraindicated. O ver 6 million women use this method in 130 countries
worldwide, and in some countries, for example S outh A frica, it is the most commonly
used reversible method. I n the UK, less than 2% of women a ending contraception
clinics use injectables. The progestogen injections prevent ovulation, thicken cervical
mucus and cause atrophy of the endometrium.
Depot medroxyprogesterone acetate
This is the most commonly used injectable and is given in a 150 mg dose at 12 week
intervals. I t is released slowly from the injection site into the circulation. D MPA is
more than 99% effective. Prolonged spo ing, however, is a common side-effect in the
first year but amenorrhoea often prevails in long-term use. S ome D MPA users
experience other side-effects such as breast discomfort, nausea, vomiting, weight gain,
seborrhoea, acne and mood swings. I t is now recognized that amenorrhoea for more
than two years with D MPA is associated with chronic low serum oestrogen and
reduced bone density. A ll women choosing D MPA should be aware of this
information. Teenagers, who will not have a ained peak bone mass, should be advised
to use other methods. The peak bone mass is a ained around the age of 30 years.
W omen who have been amenorrhoeic for more than three years receiving D MPA
should have their bone density assessed with dual X-ray absorptiometry (D EXA) scan.
I t may be reassuring to learn that reduced bone mineral density (BMD ) when using
D MPA does not progress indefinitely but usually stabilizes after about five years. The
BMD returns to normal after discontinuation (Scholes et al 2005).
D epot medroxyprogesterone acetate can offer additional health benefits for women
with homozygous sickle cell haemoglobinopathy by reducing haemolytic and bone
pain crises (Guillebaud and MacGregor 2013).
A fter discontinuation of D MPA , there may be a delay in the return of fertility for up
to 18 months.
Norethisterone enanthate (NET-EN)
Marketed as N oristerat, this injectable contraceptive is given intramuscularly in a
200 mg dose at 8 week intervals. I t is used more commonly in Germany and many
developing countries. N oristerat is more than 99% effective and its side-effects are
similar to DMPA.
Using injectable progestogens
I f the initial injection is given within the first five days of the menstrual period
(preferably days 1 to 3), the contraceptive effect is immediate. I f given at any other
time, the practitioner must ensure that there is no likelihood of pregnancy already and
advise that additional contraceptive cover is required for the next seven days
(Guillebaud and MacGregor 2013).
Specific considerations
This method is irreversible from the time of action, therefore any side-effects may be
present until the injection wears off. The efficacy of DMPA and NET-EN is not affected
by concurrent use of liver enzyme-inducing medications.
Preconception considerations
I njectable progestogen is not recommended as contraception for women who plan to
conceive soon.
Postpartum considerations
I njectable progestogen contraceptives can be given prior to the 21st day postpartum,
thus preventing the earliest ovulation; however, the woman must be warned about the
increased risk of bleeding. I t can be used by women who are breastfeeding their baby
but delaying commencement until 6 weeks postpartum is often advised to ensure
lactation is well established and reduce bleeding problems.
Subdermal contraceptive implants
Contraceptive implants have been used internationally for several years. N orplant was
used in the UK from 1993 and replaced by I mplanon from 1999. N explanon, however,
replaced I mplanon in 2010. The differences in the more recent implant are that the rod
is radio-opaque, containing barium in order to locate it on X-ray if necessary, and it has
a pre-loaded applicator which has been designed to reduce insertion errors.
Using implants
I mplants are capsules containing progestogen, which are inserted under local
anaesthetic into the inner aspect of the non-dominant upper arm (Fig. 27.3). The
steroid is released into the circulation, producing a change in the cervical mucus which
prevents spermatozoa penetration, disturbance of the maturation of the endometrium
and suppression of ovulation.
FIG. 27.3 Subdermal implant.
N orplant, which had six capsules containing levonorgestrel, has been replaced by
N orplant 2 (also marketed as J adelle), which has two capsules. J adelle is effective for 5
years and still available in many developing countries. N explanon and I mplanon are
single contraceptive rods containing 68 mg of etonogestrel. These single contraceptive
rod devices should be inserted during the first five days of the menstrual cycle and no
additional contraceptive cover is required. O vulation is suppressed within 24 hours.
They are effective for 3 years but can be removed at any time if the woman wishes.
A fter removal, the serum is cleared of etonogestrel within 1 week and fertility is
promptly regained.
Efficacy
N orplant is more than 99% effective. N explanon and I mplanon have practically zero
failure rates if instructions are carefully followed (Guillebaud and MacGregor 2013).
Reported implant failures are often due to interaction with enzyme-inducing
medications used concurrently, failing to recognize that the implant has been
incorrectly inserted and failing to recognize the woman is pregnant before the fitting.
Specific considerations
I rregular bleeding is the most common problem for women using subdermal
contraceptive implants. O nly 20–30% of users become amenorrhoeic, however
headache, seborrhoea, acne and mood swings have also been reported as side-effects.
I nsertion and removal require a minor surgical procedure, with accompanying risks of
bleeding and infection. These aspects should be discussed prior to the woman making
her decision. Counselling before fi ing and during use appears to be the only way to
reduce premature discontinuation due to the side-effects.
Preconception considerations
The action of the implant is quickly reversible and ovulation can return within 21 days
of removal in 94% of women (FS RH 2008b). This makes it suitable also for women
wishing to ‘space’ pregnancies.
Postpartum considerations
I f the implant is inserted up to or at 21 days postpartum it is effective immediately;
however, if it is inserted after the 21st day postpartum, additional contraception, such
as a condom, should be used. The implant is safe for women who are breastfeeding
their babies. The implant can also be inserted immediately after miscarriages or
induced terminations of pregnancy. N o extra contraceptive precautions need to be
taken.
Intrauterine contraceptive device (IUCD)
These devices are inserted into the uterus, as illustrated in Fig. 27.4. They contain
copper, which increases contraceptive efficacy. There seems to be an aversion for the
use of I UCD s and progestogen-releasing intrauterine systems (I US ) in the UK, wher
only 6% of women use them (Guillebaud and MacGregor 2013). The I UCD is the most
popular method in some countries and 150 million women worldwide use I UCD s, of
which 60 million are in China.
FIG. 27.4 Intrauterine contraceptive devices (IUDs). After insertion through the cervix, the
framed devices assume the shape shown; the threads attached to it protrude into the vagina. (A)
Copper-carrying device. (B) Frameless copper device. (C) Levonorgestrel-releasing system.
Mode of action
The I UCD creates an inflammatory response in the endometrium. Leucocytes are
capable of destroying spermatozoa and ova. Gamete viability is also impaired by
alteration of uterine and tubal fluids. Copper affects endometrial enzymes, glycogen
metabolism and oestrogen uptake, thus rendering the endometrium hostile to
implantation, consequently IUCDs are more than 99% effective (see Fig. 27.4A).
Using the IUCD
A copper I UCD can be inserted any time during the menstrual cycle if it is certain that
the woman is not pregnant, or up to 5 days following the earliest estimated date of
ovulation: that is, day 19 in a 28-day cycle, when it will be effective immediately. The
woman may experience some discomfort during the procedure, which should be
performed using aseptic techniques. D epending upon the type of I UCD used, it may
be left in place from 5–10 years and longer in some instances; e.g. if a woman aged 40
years or over has an I UCD fi ed, it may remain in place until one year after the
menopause, if this occurs after the age of 50. O nce in situ, the device requires no action
of the user and it does not interfere with sexual intercourse. W omen are usually taught
to feel the threads a ached to the I UCD on a regular basis as reassurance that it
remains in place. A follow-up appointment in 3–6 weeks following insertion is
recommended to assess for any infection, translocation or expulsion. S ubsequently the
woman requires further follow-up appointments only if she has any concerns. The
traditional routine annual review is no longer recommended (NICE 2005).
S ide-effects of using the I UCD include menorrhagia, dysmenorrhoea, bacterial
vaginosis and colonization by Actinomycetes-like organisms. W hen the la er is
reported in a routine cervical smear, the woman should be counselled about the
options of either changing the I UCD or retaining it and being reviewed periodically to
ensure there is no pelvic infection. Removal of the I UCD whenever desired is easy and
painless, and fertility is promptly restored.
The suggestion that I UCD s promote pelvic inflammatory disease (PI D ) has been
refuted. Clinical risk assessment for sexually transmi ed infection (S TI ) is
recommended (Guillebaud and MacGregor 2013). Routine or selective screening for
chlamydia and gonorrhoea may be appropriate in some cases, where prompt
treatment and contact tracing will be offered. I ntrauterine contraceptive devices are
associated with a decreased risk of ectopic pregnancies because of their effectiveness.
However, in the unlikely event that a pregnancy should occur, the ratio of ectopic to
intrauterine pregnancies is greater among women using I UCD s, as in general the
device prevents more intrauterine pregnancies than ectopic pregnancies. Thus a
woman who has an I UCD fi ed should be advised to seek early medical advice, should
she suspect that she is pregnant.
I f uterine pregnancy occurs, there is an increased risk of spontaneous miscarriage,
therefore gentle removal of the device is preferred, to prevent infection and premature
labour. I f removal is not possible, it is reassuring to know there is no evidence of
teratogenicity in the fetus.
A newer frameless device, GyneFix, as shown inFig. 27.4(B), comprising six copper
sleeves crimped onto a polypropylene monofilament thread, is fi ed with one end
embedded into the fundal myometrium of the uterus. This device is associated with
lower expulsion rates and less dysmenorrhoea.
Progestogen-releasing intrauterine system (IUS)
The intrauterine system was developed to overcome some of the problems associated
with conventional I UCD s and heavy menstrual bleeding. The progestogen-releasing
intrauterine system in current use consists of a small plastic T-shaped frame carrying a
S ilastic sleeve loaded with 52 mg of levonorgestrel (see Fig. 27.4C). I t is inserted into
the uterus and the steroid hormone is released steadily at 20 µg/day. The hormone
prevents endometrial proliferation, thickens the cervical mucus and may suppress
ovulation in some cycles. The frame, by inducing a sterile inflammatory reaction, may
also contribute to the contraceptive effect. The system is fi ed within the first seven
days of the menstrual period, when the contraceptive effect is immediate. I t is licensed
for 5 years of use and is more than 99% effective. A new frameless device containing
progestogen has already been developed (Fibroplant-LN G) and has been trialled in
several countries, including Belgium. I n addition, a lower dose T-frame I US called
Femilis (Femilis S lim for nulliparae) have been developed with trials also being
undertaken in Belgium regarding its use and efficacy. I t is not known, however, if
these products will be introduced into the UK market in the near future.
Specific considerations
I rregular vaginal bleeding is common initially with the I US , and then it gradually
ceases. The uterine bleeding associated with the I US is lighter than the menstrual
period experienced when using a copper I UCD , with possible amenorrhoea in the long
term. The failure rates of both intrauterine methods compare favourably with female
sterilization.
Postpartum considerations
The I US and copper I UCD have no adverse effect on lactation. They can be inserted
weeks after vaginal birth or Caesarean section (FSRH 2009b). Following miscarriage or
induced termination of pregnancy, immediate insertion is safe.
Barrier methods of contraception (male and female
methods)
Barrier methods of contraception prevent the sperm coming into contact with the
oocyte. These methods include male and female condoms, caps and diaphragms which
can be used in conjunction with spermicidal preparations to further increase their
efficacy.
S ome of the advantages of using condoms are that they are easily available at many
outlets in the UK and using them does not require medical intervention. They offer
some protection against S TI s (F PA 2011b) and cervical cancer and can be used with
another method of contraception. This is often called ‘double Dutch method’. O ne of the
main disadvantages of using barrier methods of contraception is the possible
interruption to sexual intercourse, which may be off-putting for some couples.
I t is good practice to ensure that anyone choosing a barrier method is also aware of
emergency contraception and how to access it, should it be required.
Male condom
S ome 4.4 billion couples worldwide use the male condom (Fig. 27.5) for contraception,
with 6 billion couples using it for Human I mmunodeficiency Virus (HI V) prevention.
However, there are striking geographical differences. J apan accounts for more than
one-quarter of all condom users in the world, being used by 75% of the contraception-
using population. By contrast, and despite the substantial problem of HI V, the use of
this method of contraception remains remarkably low in A frica, the Middle East and
Latin America (Guillebaud and MacGregor 2013).
FIG. 27.5 Male condom. Photograph K Jackson.
Guillebaud and MacGregor (2013)state that recent studies show approximately 25%
of all couples in the UK use condoms but this may be occasional use or in addition to
other methods. There are many varieties of condoms on the market, including latex,
hypoallergenic and polyurethane. Polyurethane condoms are less sensitive to heat and
humidity and not affected by oil-based lubricants (FPA 2011b).
Correct use of condoms is essential. O nly condoms with a CE (European standard)
mark should be used and the expiry date should be checked on the condom's package.
Condoms should be stored away from extremes of heat, light and damp and care
should be taken when handling the condom to prevent it from tearing. The condom is
rolled on to the erect penis before any genital contact is made, as it is possible for some
sperm to be present in the pre-ejaculate (Guillebaud and MacGregor 2013). A bout
1 cm of air-free space must be left at the tip of the condom for the ejaculate, otherwise
the condom may burst. S ome condoms are designed with a teat end for this purpose.
The penis should be withdrawn very soon after ejaculation before it reduces in size
and the condom becomes loose. The condom should be held in place during
withdrawal of the erect penis so that it does not slip off. The condom should only be
used once, and then disposed of in a waste bin: it should not be flushed down the
toilet.
O il-based lubricants can damage rubber condoms but not polyurethane types.
Water-based lubricants are not known to cause damage and are therefore
recommended.
The efficacy of the condom if used correctly is 98% but is dependent on experience
and age of the user.
Female condom
The female condom consists of a polyurethane sheath that is inserted into the vagina
(Fig. 27.6). The closed inner end is anchored in place by a polyurethane ring, while the
outer edge lies flat against the vulva. I t is available free from contraception clinics and
may be purchased from selected chemists. Great care has to be taken to ensure that
the penis is inserted inside the polyurethane sheath and not incorrectly positioned
between the condom and the vaginal wall.
FIG. 27.6 Female condom. Image reproduced courtesy of Sciencephoto, with permission.
The efficacy depends on age and experience of the user, as with the male condom;
however, the FPA (2011b) states that if it is used correctly it is 95% effective.
Diaphragm
A diaphragm consists of a thin rubber dome with a metal circumference to help
maintain its shape (Fig. 27.7). A range of types and sizes are available and, in the UK,
diaphragms are individually fitted at contraception clinics and some GP practices. Less
than 1% of women use this method of contraception in the UK (Guillebaud and
MacGregor 2013). I t is not used widely in developing countries and Guillebaud and
MacGregor (2013) believe this may be due to the fact that the device requires medical
fitting.
FIG. 27.7 The diaphragm. Image reproduced courtesy of Sciencephoto, with permission.
W hen in place, the rim of the diaphragm should lie closely against the vaginal walls
and rest between the posterior fornix and the symphysis pubis. Before insertion, a
spermicide should be applied. A fter insertion, the woman has to check that her cervix
is covered by the diaphragm (see Fig. 27.8). I n order to preserve spontaneity during
sexual intercourse, the diaphragm can be inserted every evening as a matter of routine.
FIG. 27.8 The diaphragm in place.
I f sexual intercourse occurs more than 3 hours after insertion of the diaphragm,
then additional spermicide is required. The diaphragm must be left in place for at
least 6 hours after the last intercourse, to ensure any sperm cannot reach the cervix.
O nce removed, the diaphragm should be washed with a mild soap, dried and
inspected for any damage. A new diaphragm should be fi ed annually or following a
loss or gain in weight of more than 3 kg.
Efficacy depends on the age and experience of the user and the FPA (2010a) quote
that it is between 92% and 96% effective if used according to their guidance.
Cultural beliefs may affect use of this method, for example in J udaism, where it is
viewed as unacceptable to use any method of contraception that prevents the sperm
from reaching its intended goal (Jogee 2004).
Postnatal considerations
The size of diaphragm should be reassessed at the 6th week postpartum, when the
vagina and pelvic floor muscles will have regained some of their tone and any tissue
injury sustained from the birth will have healed.
Cervical and vault caps
Cervical and vault caps cover only the cervix, adhering to it by suction. They are made
of rubber and look smaller in diameter than the diaphragm (Fig. 27.9). They require
fi ing at a contraception clinic. O nly one cervical cap, the FemCap, is now available in
the UK (Guillebaud and MacGregor 2013).
FIG. 27.9 The cervical/vault cap. Image reproduced courtesy of Sciencephoto, with permission.
Spermicidal products
S permicidal agents have not been shown to increase efficacy of condoms and because
they can cause irritation to genitalia, may in fact increase the risk of HI V transmission.
Use of N onoxinol-9 lubricated condoms is no longer generally recommended.
However, current advice is still to use this spermicide with the female barrier methods
– diaphragms and caps – as this has been shown to be beneficial (Guillebaud and
MacGregor 2013). Up until recently, a range of spermicidal products were available for
use in the UK. However, the only product now available is Gygel, a clear gel containing
N onoxinol-9. S permicidal pessaries are no longer available in the UK. Foams and
aerosols are yet to be introduced into the UK market, but may well be available in
other countries (Guillebaud and MacGregor 2013).
Efficacy
General teaching in the UK is that spermicidal products are not effective when used
alone.
Emergency contraception
Emergency contraception is required when contraception has not been used before, or
during sexual intercourse, used incorrectly or when there is perceived to have been a
failure in the contraception used, e.g. a condom mishap such as breaking, tearing or
coming off. There are three types of emergency contraception:
• emergency hormonal contraception (EHC)
• selective progesterone receptor modulator (SPRM)
• copper intra-uterine contraceptive device (IUCD).
Emergency hormonal contraception (EHC)
EHC is a progestogen preparation with the brand name Levonelle which consists of
one pill containing 1.5 mg of levonorgestrel and is available in many countries
throughout the world. I n the UK it is free from sexual health clinics, walk-in centres,
some accident and emergency departments and GP practices. Many health centres and
clinics provide EHC free of charge through selected pharmacies in an effort to reduce
unwanted pregnancies. It can also be purchased over the counter from pharmacies.
This method works by delaying ovulation or preventing implantation of the
fertilized oocyte, depending on the stage of ovulation. This method may be
contraindicated if there has been more than one episode of unprotected sexual
intercourse (UPS I ) during the cycle, as the earlier sexual intercourse may already have
resulted in a pregnancy. Very careful questioning by the practitioner needs to take
place prior to supplying EHC to prevent an unfavourable outcome.
N ausea is uncommon with the progestogen-based pill but an additional pill may be
required if the woman vomits within 2 hours of taking the medication. The next
menstrual period may begin earlier or later than expected and it should be stressed
that contraception must be used until the next period commences. I f the woman
receives the EHC in a contraception clinic in the UK, she is always given an
appointment to return to the clinic if menstruation does not commence on time, or is
shorter or lighter than usual. If menstruation is more than 7 days late, a pregnancy test
will be offered. A ny unusual lower abdominal pain must be investigated as this could
be a sign of an ectopic pregnancy.
The efficacy of EHC depends on how quickly the emergency contraception is
commenced. I f taken within 24 hours of unprotected sexual intercourse, it will prevent
95% of pregnancies. This gradually decreases to 58% by 72 hours (FPA 2011c). There
are very few contraindications to using this method but those health professionals
administering Levonelle need to know about any other medication being used by the
woman. Emergency hormonal contraception can be used more than once in each
menstrual cycle, but it may disrupt the menstrual period pattern.
Selective progesterone receptor modulator (SPRM)
Ulipristal acetate with the brand name ellaO ne is an emergency contraception that has
been in use since 2009. I n the UK ellaO ne is free from sexual health clinics, walk-in
centres, some accident and emergency departments and GP practices. I t is given as a
30 mg oral dose which should be taken as soon as possible after UPS I or failed
contraception. The action of S PRM is thought to be due to inhibition or delay in
ovulation and alteration of the endometrium (Brache et al 2010). EllaO ne is licensed
for up to 120 hours following an exposure of risk to pregnancy. O nly one dose of
ellaO ne can be taken per menstrual cycle. A s with EHC, careful questioning within a
consultation is required to ensure that there has been no previous risk of pregnancy
either within a previous or the current menstrual cycle.
Randomized controlled trials (RCTs) have shown that ellaO ne is at least as effective
at preventing pregnancy as Levonelle, and pooled data demonstrate that ellaO ne is
more effective than EHC up to 120 hours following UPS I or failed contraceptionFSRH(
2011b).
S ide-effects include abdominal pain, menstrual disorders such as irregular vaginal
bleeding, disruption to the menstrual cycle with most women reporting lengthening of
their cycle by 3 days; however, some women report a shortening of their cycle. D rug
interactions can occur with liver enzyme-inducers such as carbemazepine and drugs
that increase gastric pH, such as antacids. Ulipristal binds to progesterone receptors
and therefore may reduce the efficacy of progesterone-containing contraceptives
(FSRH 2011b).
W omen may be asked to return to the clinic in 3-4 weeks to have a pregnancy test, or
if menstruation is more that 7 days late.
The copper intrauterine device (IUCD)
The I UCD is the most effective method of emergency contraception, with a failure rate
of less than 1%. I mplantation of the fertilized oocyte is avoided if the I UCD is inserted
within 5 days of UPS I or earliest estimated date of ovulation. This provides the
clinician a much longer time range in which to offer emergency contraception. For
example, in a regular 28-day cycle, the I UCD can be fi ed up to day 19 of the cycle. I t
can then be left in place for use as a regular method of contraception, or removed
during the next menstrual period.
Coitus interruptus
Technically coitus interruptus should not be considered a form of contraception as it
potentially has a high failure rate. I t involves withdrawal of the penis from the vagina
prior to ejaculation, and couples should be made aware of emergency contraception.
Many euphemisms are used when referring to this, such as ‘being careful’ or the
‘withdrawal method’ . A ndrews (2005) gives a rate of 90% effectiveness as a
contraceptive. Failure is due to the small amount of semen that may leak from the
penis prior to ejaculation with the potential of penetrating the ovum. The success of
this method depends on the man exercising a great amount of self-control and is
based on trust and honesty. This method is used widely throughout the world by
different cultures and is the oldest form of contraception, being referred to in the O ld
Testament of the Bible.
Fertility awareness (natural family planning)
The study of fertility awareness, previously (and sometimes still) referred to as natural
family planning, is a fascinating observation of the way in which the female body works
to produce the optimum conditions for conception.
A ccording to UK Medical Eligibility Criteria for Contraceptive UseFS ( RH 2009b),
N atural Family Planning includes all the methods of contraception based on the
identification of the fertile time in the menstrual cycle. The effectiveness of these
methods depends on accurately identifying the fertile time and modifying sexual
behaviour. To avoid pregnancy, the couple can either abstain from sexual intercourse
or use a barrier method of contraception during the fertile time. N atural methods are
a ractive to couples who do not wish to use hormonal or mechanical methods of
contraception. The midwife can provide the appropriate FPA leaflet, signpost the
couple to the local contraception clinic or find local information on fertility awareness
teachers and available education from the website: www.fertilityuk.com.
The method can also be used as a guide to women wishing to become pregnant, by
concentrating sexual intercourse on the days they are most fertile. The fertile time
lasts around 8–9 days of each menstrual cycle. The oocyte survives for up to 24 hours,
however the FPA (2010b) suggest that a second oocyte could, occasionally, be released
within 24 hours of the first. I n addition, the FPA (2010b) state that as a sperm can live
inside a female body for up to 7 days, this means that should sexual intercourse occur
7 days before ovulation, a pregnancy could result.
Fertility awareness methods
Physiological signs of fertility are:
• cervical secretions (Billings or ovulation method)
• basal body (waking) temperature
• cervical palpation
• calendar calculation.
Cervical secretions
Following menstruation the vagina will become dry. A s oestrogen levels rise, the fluid
and nutrient content of the secretions increases to facilitate sperm motility,
consequently a sticky white, creamy or opaque secretion is noticed. A s ovulation
approaches the secretions become we er, more transparent and slippery with the
appearance of raw egg white that are capable of considerable stretching between the
finger and thumb. The last day of the transparent slippery secretions is called the peak
day, which coincides closely with ovulation. Following ovulation, the hormone
progesterone causes the secretions to thicken forming a plug of mucus in the cervical
canal, acting as a barrier to sperm. The secretions will then appear sticky and dry until
the next menstrual period.
W hen practising this method of contraception, the cervical secretions are observed
daily. The fertile time starts when secretions are first noticed following menstruation
and ends on the third morning after the peak day. I f the secretions are used as a single
indicator of fertility, the presence of seminal fluid can make observation difficult.
Changes in secretions will be affected by seminal fluid, menstrual blood, spermicidal
products, vaginal infections and some medications (Guillebaud and MacGregor 2013).
Postpartum considerations
I n the first 6 months following childbirth, the majority of women who are fully
breastfeeding will be able to rely on the lactational amenorrhoea method (LA M) for
contraception. W omen who wish to continue using natural methods of contraception
should begin observing cervical secretions for the last two weeks before the LA M
criteria will no longer apply (i.e. 5 months and 2 weeks postpartum), in order to
establish their basic infertile pattern.
Basal body temperature
A woman can calculate her ovulation by recording her temperature immediately on
waking each day. S hould the woman have arisen during the night, she must take at
least 3 hours rest before recording her temperature. A fter ovulation, the hormone
progesterone produced by the corpus luteum causes the temperature to rise by about
0.2 °C. The temperature remains at this higher level until the next menstrual period.
The infertile phase of the menstrual cycle will begin on the third day after the
temperature rise has been observed. A ndrews (2005) points out that the temperature
can be affected by infection, therefore care needs to be taken when interpreting
temperature charts.
Postpartum considerations
A mother with the demands of a new baby may find difficulty in recording her
temperature at the same time every day. Consequently many women prefer to rely on
examining cervical secretions, or combine noting secretions with cervical changes at
this time.
Cervical palpation
Changes in the cervix throughout the menstrual cycle can be detected by daily
palpation of the cervix by the woman or her partner. A fter menstruation the cervix is
low, easy to reach, feels firm and dry and the os is closed. As ovulation approaches, the
cervix shortens, softens, sits higher in the vagina and the os dilates slightly under the
influence of oestrogen.
Postpartum considerations
Hormonal changes in pregnancy take around 12 weeks to se le postpartum. The cervix
will not revert completely to its pre-pregnant state as the os will remain slightly
dilated even in the infertile time.
Calendar calculation
The calendar method (see Fig. 27.10) is based on observation of the woman's past
menstrual cycles. W hen commencing to use this method, the specialist practitioner
and the woman should examine the previous six menstrual cycles (Andrews 2005). The
shortest and longest cycles over the previous six months are used to identify the likely
fertile time. The first fertile day is calculated by subtracting 21 days from the end of the
shortest menstrual cycle. I n a 28-day cycle, this would be day 7. The last fertile day is
calculated by subtracting 11 days from the end of the longest menstrual cycle. I n a 28-
day cycle, this would be day 17. Cycle length is constantly reassessed and appropriate
calculations made. Guillebaud and MacGregor (2013) indicate that the calendar
method is not sufficiently reliable to be recommended as a single indicator of fertility,
but is useful when combined with other indicators of fertility. O vulation usually takes
place 14 days before the first day of the next menstrual period. Therefore a woman
who has a 28-day cycle would ovulate on approximately day 14 of her cycle and a
woman who has a 30-day cycle would ovulate on approximately day 16 of her cycle.
FIG. 27.10 Natural family planning: The fertility awareness (rhythm) method. Diagram to
illustrate rhythm method of contraception in a 28-day menstrual cycle.
Postpartum considerations
Calendar calculations must be recalculated once normal menstruation has
recommenced.
Symptothermal method
This is a combination of temperature charting, observing cervical secretions and
calendar calculation, with the option of observing cervical palpation in order to
identify the most fertile time. A ndrews (2005) also includes in this method the
observation of ovulation pain or ‘mittelschmerz’ and cyclic changes such as breast
tenderness. Use of more than one indicator increases the accuracy in identification of
the fertile time. W hen combining indicators, a couple should avoid sexual intercourse
from the first fertile day by calculation, or the first change in the cervix until the third
day of elevated temperature, provided all elevated temperatures occur after the peak
day.
Fertility monitoring device
These hand-held computerized devices monitor luteinizing hormone (LH) and
oestrone-3-gluronide (a metabolite of oestradiol) through testing the urine. The most
well known in the UK is the ‘Persona’ monitoring device which is about 94% effective
and will detect from the urine test when a woman is fertile, indicating this through a
series of lights. A green light indicates the infertile phase and a red light indicates the
fertile phase, therefore barrier methods must be used should sexual intercourse be
contemplated. A yellow light indicates that the database requires more information
and a further urine test is required.
Postnatal considerations
The fertility monitor is not recommended as a method of contraception during
lactation. The manufacturers of the Persona recommend that a woman has had two
normal menstruations with cycle lengths from 23 to 35 days before using the monitor
at the beginning of the third period (Guillebaud and MacGregor 2013).
Lactational amenorrhoea method (LAM)
I t is thought that the action of the infant suckling at the breast causes neural inputs to
the hypothalamus. This results in the inhibition of gonadotrophin release from the
anterior pituitary gland, leading to suppression of ovarian activity. The delay in return
of postnatal fertility in lactating mothers varies greatly as it depends on pa erns of
breastfeeding, which are influenced by local culture and socioeconomic status. The
time taken for the return of ovulation is directly related to sucking frequency and
duration. The maintenance of night-feeds and the introduction of supplementary
feeds also affects the return of ovulation.
The lactational amenorrhoea method (LA M) is a very effective method of
contraception when used according to the Bellagio consensus statement (Guillebaud
and MacGregor 2013). Research data concludes that there is over 98% protection
against pregnancy during the first 6 months following birth if a woman is still
amenorrhoeic and fully or almost fully breastfeeding her baby (FPA 2010b). I n order
to confirm that LA M remains effective as a contraceptive method, the woman should
be asked if three questions (as indicated in Fig. 27.11) still apply. Mothers who work
outside the home can still be considered to be nearly fully breastfeeding, provided
they stimulate their breasts by expressing breastmilk several times a day.
FIG. 27.11 Natural contraception: lactational amenorrhoea method (LAM).
The LA M is not recommended for use after 6 months following birth, because of the
increased likelihood of ovulation. S tudies throughout the world have been conducted
on the effectiveness of LA M as a contraceptive,confirming a rate of over 98%
protection against pregnancy (Labbok 2012), suggesting it is a viable option for some
postnatal breastfeeding women.
Male and female sterilization
This is the choice of contraception for many couples once they have decided their
family is complete. S terilization should be viewed as permanent, although in a few
cases reversal of the operation is requested. Couples requesting sterilization need
thorough counselling to ensure that they have considered all eventualities, including
possible changes in family circumstances. A lthough consent of a partner is not
necessary, joint counselling of both partners is desirable. The procedure is available
on the N HS for both sexes but waiting times can vary. There are no alterations to
hormone production following sterilization in males or females and some couples find
the freedom from fear of pregnancy very liberating.
Female sterilization
A n estimated 600 million women worldwide have undergone female sterilization
(Guillebaud and MacGregor 2013). D uring the procedure (Fig. 27.12), the uterine tube
is occluded using division and ligation, application of clips or rings, diathermy or laser
treatment.
FIG. 27.12 Female sterilization.
The operation is performed under local or general anaesthetic. The procedure can be
performed via a laparotomy, minilaparotomy or laparoscopy. I t can also be performed
vaginally using a hysteroscope. The procedure usually requires a day in hospital.
W omen are advised to continue to use contraception for four weeks following the
procedure, or in the case of hysteroscopic sterilization (Essure) contraception should
continue for 3 months, after which successful tubal blockage is confirmed by
hysterosalpingography (FPA 2010c). The couple should be advised to seek medical
help urgently if they suspect pregnancy following sterilization because of the
increased risk of ectopic pregnancy if the procedure is unsuccessful.
Postpartum considerations
S hould sterilization occur around the time of birth, it is vital that the woman receives
thorough counselling prior to the procedure to avoid any regret later on. W omen are
often advised to wait 6 weeks after the birth before undergoing the procedure. The
FRSH (2009a) suggest that if sterilization is going to be undertaken at the same time as
an elective caesarean operation, then one week or more should be provided for
counselling and decision-making before the procedure finally takes place.
Guillebaud and MacGregor (2013) suggest that a waiting period of 12 weeks is
desirable to ensure that the couple will have no regrets over the sterilization.
The failure rate for female sterilization is 1 in 200 (FPA 2010c). Reversal of the
sterilization is not usually available though the NHS in the UK and can be difficult and
expensive to obtain privately. W omen considering sterilization should be made aware
of the availability of LARC methods, which are highly effective but reversible.
Male sterilization (vasectomy)
The procedure of male sterilization involves excision or removal of part of the vas
deferens, which is the tube that carries sperm from the testes to the penis (Fig. 27.13).
A small cut or puncture to the skin of the scrotum is made to gain easier access to the
vas deferens. The tubes are cut and the ends closed by tying them or sealing them with
diathermy. The wound on the scrotum will be very small and stitches are not usually
required. I n the UK the operation is carried out in an outpatients department or clinic
se ing. I t is usually completed under local anaesthetic and takes around 10–15
minutes. Men are advised to refrain from excessive physical activity for about one
week and to avoid heavy lifting following the procedure (Andrews 2005).
FIG. 27.13 Male sterilization (vasectomy).
I t may take some time for sperm to be cleared from the vas deferens; it can take
approximately 12 weeks after the operation for this to occur. Consequently, the semen
must be tested to confirm that it no longer contains sperm and sometimes further
tests are necessary to confirm the absence of sperm. S exual intercourse can take place
during this period but contraception must be used until a negative sperm result is
confirmed.
The failure rate of male sterilization is 1 in 2000 (FPA 2010c). Careful counselling
needs to take place before the procedure is carried out. Reversal of vasectomy is not
usually available through the N HS andA ndrews (2005) quotes around a 50% success
rate in achieving a pregnancy following successful reversal within 10 years of the
procedure being undertaken.
The future of contraception and sexual health services
I n the UK the government remains commi ed to developing confidential, non-
judgemental, integrated sexual health services, including S TI screening and treatment,
contraception, termination of pregnancy, health promotion and prevention (HM
Government 2010). A recent D epartment of Health (D H) publication, ‘A framework
for sexual health improvement in England’ (D H 2013), sets out a clear strategy for
tackling sexual health issues such as S TI s and teenage pregnancy. However, current
financial challenges mean that the FS RH (2012)are concerned that budget cuts and
changes to commissioning processes may compromise access to and quality of
contraceptive and sexual health services for the forseeable future.
I n response to the S ocial Exclusion Unit Report D( H 1999), many N HS Trusts now
provide clinics and projects for young people, and improved access to contraceptive
and sexual health services has led to a decrease in the conception rate of the under-18s.
O ne of the specific targets of this report was to reduce the teenage pregnancy rate by
50% by 2010. The actual statistics showed a 13.3% decline in conceptions to the under-
18s and 25% reduction in births in this same age group. Plans to decrease teenage
conceptions further continue (DH 2010). With strict adherence to the Fraser guidelines
(Guillebaud and MacGregor 2013), teenagers under the age of 16 can receive advice
and treatment from a contraceptive and sexual health practitioner.
T h e N I CE guidelines (2005) have emphasized the need to promote long acting
reversible contraception (LA RC). This recommendation will encourage more women
to use a form of contraception that does not have to be remembered on a daily basis.
There is a trend in the UK for many women to have their children later in life and to
have much smaller families. Throughout the world, couples will seek to find new ways
to limit their family size as the need to reduce population growth continues
(Guillebaud and MacGregor 2013).
Ongoing developments
A n extended regimen of combined contraceptive pills for 84 days, e.g. S easonale, has
been confirmed to be safe. S easonale is a CO C pill that has the equivalent of
Microgynon 30 but is packaged in four packets to be taken consecutively followed by a
pre-determined pill-free interval (Guillebaud and MacGregor 2013). I t is currently
licensed in many countries, including the US A , and may be available in the UK soon.
O ther similar products include S easonique. A lternative delivery systems reducing the
need for daily pill-taking are being explored. S ubcutaneous injections (depo-subQ )
and chewable tablets are being developed for progestogens. Research into
biodegradable implants (which would be particularly useful in low income countries)
and the use of transdermal spray for the delivery of a potent progestogen is ongoing.
The Population Council is considering research into proteomics and an immunological
approach to contraception. Effective methods for men are still problematic and the
long-awaited male pill is still not imminent (Guillebaud and MacGregor 2013). Gene
blockers (reducing sperm mobility), the male patch and heat-based methods are
amongst those being developed. Long acting testosterone injections with implanted
progestogens or semen blocking methods may be available in the future (D orman and
Bishai 2012).
References
Allan M, Koppula S. Risk of venous thromboembolism with various hormonal
contraceptives. Canadian Family Physician. 2012;58(10):1097.
Andrews G. Women's sexual health. 3rd edn. Elsevier: Edinburgh; 2005.
Brache V, Cochon L, Jesam C, et al. Immediate pre-ovulatory administration of
30 mg ulipristal acetate significantly delays follicular rupture. Human
Reproduction. 2010;25:2256–2263.
Brucker C, Karck U, Merkle E. Cycle control, tolerability, efficacy and
acceptability of the vaginal contraceptive ring, NuvaRing: results of clinical
experience in Germany. European Journal of Contraception and Reproductive
Health Care. 2008;13(1):31–38.
DH (Department of Health). Teenage pregnancy. Report by the Social Exclusion Unit.
TSO: London; 1999.
DH (Department of Health). Teenage pregnancy strategy beyond 2010. DH: London;
2010.
DH (Department of Health). A framework for sexual health improvement in
England. DH: London; 2013.
Dorman E, Bishai D. Demand for male contraception. Expert Reviews in
Pharmacoeconomics and Outcomes Research. 2012;12(5):605–613.
FPA (Family Planning Association). Leaflet: Your guide to diaphragms and caps.
FPA: London; 2010.
FPA (Family Planning Association). Leaflet: Your guide to natural family planning.
FPA: London; 2010.
FPA (Family Planning Association). Leaflet: Your guide to male and female
sterilization. FPA: London; 2010.
FPA (Family Planning Association). Leaflet: Your guide to the contraceptive patch.
FPA: London; 2011.
FPA (Family Planning Association). Leaflet: Your guide to male and female condoms.
FPA: London; 2011.
FPA (Family Planning Association). Leaflet: Your guide to emergency contraception.
FPA: London; 2011.
FPA (Family Planning Association). Leaflet: Your guide to the combined pill. FPA:
London; 2012.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. Progestogen-only pills. [(updated 2009)] RCOG: London; 2008.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. Progestogen-only implants. [(updated 2009)] RCOG: London; 2008.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. Postnatal sexual and reproductive health. RCOG: London; 2009.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. UK medical eligibility criteria for contraceptive use. RCOG: London; 2009.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. Combined hormonal contraception. [(updated 2012)] RCOG: London; 2011.
FSRH (Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness
Unit. Emergency contraception. [(updated 2012)] RCOG: London; 2011.
FSRH (Faculty of Sexual and Reproductive Healthcare). FSRH response to the
APPG SRH inquiry into restrictions in access to contraceptive services. RCOG:
London; 2012.
Guillebaud J, MacGregor A. Contraception: your questions answered. 6th edn.
Churchill Livingstone: Edinburgh; 2013.
HM Government. Healthy lives healthy people: our strategy for public health in
England. TSO: London; 2010.
Jogee M. Religions and cultures. 6th edn. R & C Publications: Edinburgh; 2004.
Labbok M. The lactational amenorrhoea method (LAM) for postnatal contraception.
Australian Breastfeeding Association: Malvern East, VIC; 2012.
McDonald E, Brown S. Does method of birth make a difference to when women
resume sex after childbirth? BJOG: An International Journal of Obstetrics and
Gynaecology. 2013;120(7):823–830.
NICE (National Institute for Health and Clinical Excellence). Long acting
reversible contraception. [(modified 2013)] Department of Health: London; 2005.
NICE (National Institute for Health and Clinical Excellence). Routine postnatal
care for women and their babies. Department of Health: London; 2006.
NMC (Nursing and Midwifery Council). Midwives rules and standards. NMC:
London; 2012.
Roumen F, op ten Berg M, Hoomans E. The combined contraceptive vaginal ring
(NuvaRing): first experience in daily clinical practice in The Netherlands.
European Journal of Contraception and Reproductive Health Care. 2006;11:14–22.
Scholes D, LaCroix AZ, Ichikawa LE, et al. Change in bone mineral density
among adolescent women using and discontinuing depot
medroxyprogesterone acetate contraception. Archives of Paediatric and
Adolescent Medicine. 2005;159:139–144.
Further reading
Gebbie A, O’Connell White K. Fast facts contraception. Health Press: Abingdon;
2009.
This textbook covers the wide spectrum of contraception, in an easy to read and accessible
format..
Guillebaud J, MacGregor A. Contraception: your questions answered. 6th edn.
Churchill Livingstone: Edinburgh; 2013.
The latest edition of this book is extremely comprehensive and up-to-date, covering all
available contraceptive methods not just available in the UK but worldwide. It is in a
question and answer style regarding each particular contraceptive method and
provides the best available evidence to guide and support clinical practice..
National Institute for Health and Clinical Excellence. Long acting reversible
contraception. [(modified 2013)] Department of Health: London; 2005.
This document has been recently modified to reflect the replacement of Implanon with
Nexplanon, and also includes guidance on the management of unscheduled bleeding
in women with implants in situ. It is therefore still applicable to current
contraceptive services, as it recognizes the value of encouraging the use of long acting
reversible contraception in reducing unwanted pregnancies..
Useful websites/contacts
[Brook] www.brook.org.uk [UK tel: 0808 802 1234] .
Free and confidential information for under 25s.
Faculty of Sexual and Reproductive Healthcare. www.fsrh.org.uk.
Family Planning Association UK. www.fpa.org.uk [Northern Ireland: tel: 0845
122 8687. England tel: 0845 122 8690] .
Fertility UK. www.fertilityuk.org.
S E CT I ON 6
The neonate
OU T LIN E
Chapter 28 Recognizing the healthy baby at term through examination of the
newborn screening
Chapter 29 Resuscitation of the healthy baby at birth
Chapter 30 The healthy low birth weight baby
Chapter 31 Trauma during birth, haemorrhages and convulsions
Chapter 32 Congenital malformations
Chapter 33 Significant problems in the newborn baby
Chapter 34 Infant feeding
C H AP T E R 2 8
Recognizing the healthy baby at term
through examination of the newborn
screening
Carole England
CHAPTER CONTENTS
The first examination after birth 592
Assessment of the neonatal skin 592
The head 593
The face 594
The neck 595
The chest and abdomen 596
The anus 596
The genitalia 596
Limbs, hands and feet 597
The spine 598
Communication and documentation 598
The daily examination screen 598
Breathing 598
Thermoregulation-the importance of keeping warm 598
Skin care 599
Cardiovascular system and blood physiology 600
Renal system 600
Gastrointestinal system 600
Immunity 601
Reproductive system: genitalia and breasts 601
Skeleto-muscular system 601
The Neonatal and Infant Physical Examination (NIPE) 601
Examination of the heart 602
Examination of the eye 605
Examination of the hips 606
Examination of the genitalia 607
Neurological examination 607
References 608
Further reading 609
Useful websites 609
This chapter will focus upon the characteristics of the healthy term baby.
The midwife performs a systematic screening assessment of a baby's health
and wellbeing on a regular basis. These include the first examination after
birth, the ongoing daily examination and for those who have received
specialist education and training, the Newborn and Infant Physical
Examination (NIPE), performed within three days (72 hours) of birth. Each
examination assesses the whole baby and builds on previous findings
related to the pregnancy, birth and neonatal assessments. The midwife's
role is not to diagnose but to examine and distinguish the healthy baby
from the one that requires referral to a medical practitioner. To do this
effectively the midwife must have a sound knowledge of abnormality to be
able to make appropriate and timely referral, especially if the condition is
immediately life-threatening.
The chapter aims to:
• highlight the features of a healthy baby and know which baby needs referral to a
medical practitioner
• emphasize the importance of reading the woman's records before any physical
assessment of her baby is attempted
• recognize the vital importance of appropriate communication with the parents,
especially when obtaining consent, listening to the mother on her opinion of her baby's
health and in reporting the findings of the examination
• provide the details of a top-to-toe examination of the newborn performed in the first 24
hours of life
• explore the assessment provided in the daily examination of the baby
• critically discuss the NIPE assessment
• discuss how each screening examination is an opportunity for health
education/promotion and psychological empowerment of both parents in how to
recognize health and wellbeing in their baby
• stress the importance of writing (and drawing if indicated) a clear detailed record of
findings and communications that have taken place.
The first examination after birth
The aim of the first examination performed within 24 hours of birth is to detect any
observable congenital malformations and to assess initial adaptation to extrauterine
life that could compromise health and wellbeing (Resuscitation Council 2011). The
examination should be performed in the presence of the mother and partner (as
appropriate). The ideal time is after the baby has had skin-to-skin contact and had its
first feed, during which it maintained a body temperature within normal parameters.
The midwife present at the birth often performs this examination and should ensure
that the environment is warm and draught-free, with equipment ready for use.
D iligent hand-washing is essential. The baby should be at rest on a flat surface. The
skills of observation, palpation and auscultation should be utilized. S ee Box 28.1 for
screening principles that should be communicated when screening is undertaken.
Box 28.1
T he principle s of scre e ning
The midwife should:
• inform the mother exactly why the examination is being conducted
• obtain informed consent from the mother to perform the examination on
her baby
• ensure the baby is wearing identification bracelets that correspond with
the mother's identity and documentation
• perform a thorough examination of the baby
• provide full details of the findings of the examination
• offer an action plan of care as required
• document detailed findings and evidence of communication that arose
between the midwife and mother/parents before, during and after the
examination
Source: UK National Screening Committee (2008)
Assessment of the neonatal skin
According to Baston and Durward (2010), the colour of the skin is generally considered
a reflection of good health, but is most difficult to assess accurately in the first few
hours of extrauterine life and the midwife needs to distinguish between different
types and degrees of blue skin to know if the baby is well or whether to refer to the
neonatal registrar.
A blue skin as a result of central cyanosis
To assess blueness due to accumulation of carbon dioxide and deprivation of oxygen is
a difficult task in white ethnic groups and even more so in babies from black ethnic
groups who have a pigmented skin. The baby's oral mucus membranes and tongue are
not pigmented and will provide the midwife with reliable evidence of central cyanosis.
A dull blue skin may indicate poor perfusion and can be assessed by measuring
capillary refill time (CRT) by blanching the baby's chest skin with a finger and, on
release, seeing how long it takes for the capillaries to refill. A ny time over 2 seconds
indicates poor peripheral perfusion. Pallor of the skin is a result of peripheral
shutdown and is always a serious sign as this could also indicate acute blood loss,
anaemia, the processes involved in cooling or/and the presence of infection. J aundice
that develops from birth in the first 24 hours is considered pathological, is usually as a
result of haemolysis (excessive breakdown of red blood cells) and should also be
reported immediately (England 2010b) (see Chapter 33).
A blue skin as a result of other factors
Most babies will have peripheral shutdown (acrocyanosis) in hands and feet as blood
is diverted to major organs. O ccasionally babies will present with a blue face as a
result of petechiae, which are pinpoint haemorrhagic spots on the skin, usually as a
result of a tightening cord around the neck which constricts the jugular veins during
fetal descent in the second stage of labour. The venous blood is trapped in the sinuses
of the brain and will find an exit point into the skin, thus the facial tissues become
bruised. The use of a pulse oximeter will indicate the amount of haemoglobin
saturated with oxygen in the baby's blood and should be about 95% or above in the
first 24 hours of life.
Common skin lesions found at birth
S kin lesions, as they are discovered either by the parents or midwife, need addressing
immediately. There is no room for guesswork and the prudent midwife will ask for a
second opinion should there be any doubt.
Cuts, abrasions and bruises
These are carefully assessed as they may serve as portals of entry for infection. Create
a line drawing in documentation to illustrate size and complexity to avoid disputes
regarding origin (iatrogenic lesions caused by treatment, e.g. use of forceps or
ventouse; see Chapter 31, Figs 31.1, 31.2) or as a result of non-accidental injury.
Extensive bruising may lead to clinical jaundice.
Vascular birth marks found at birth
Vascular proliferations (increase in growth) in the skin will resolve and involute in time:
• Salmon patch haemangioma or ‘stork marks’: occur in 50% of babies, are superficial
capillaries that blanche on pressure, resolve spontaneously, commonly found on the
nape of the neck, eyelids and glabella.
• Strawberry haemangioma: not always present at birth; occurs in 10% of babies by the
age of one year; bright red in colour. Benign but can develop over orifices, e.g. anus,
to cause obstruction and can leave scar tissue. Laser treatment is available but
natural resolution offers a better cosmetic outcome.
• Cavernous haemangioma: similar to the strawberry haemangioma but invades
deeper into the vascular tissues; leaves a blue discoloration to the skin and grows
with the child.
Vasculature malformations that do not involute are permanent and always present at
birth:
• Port wine stain: red, purple markings present in 0.3 % of neonates (Gordon and
Lomax 2011) can be an isolated mark or associated with syndromes. Some lesions
(Sturge–Weber syndrome) follow the trigeminal nerve (fifth cranial nerve); have a
midline cut off and can infiltrate into the meninges and cerebral cortex on the
affected side resulting in seizures and eye abnormalities. This condition can
devastate parents and the midwife needs to provide empathic informed support.
Pigmented birthmarks
• Mongolian blue spots are produced by clusters of melanocytes in the dermis, are
benign and have no clinical significance. Present in 90% African, 81% Asian and 9.6%
white caucasian babies, they have a slate-grey to blue-black discoloration usually
found over the buttocks, back and legs and fade by 7 years of age. They resemble
bruising so a line drawing is useful to distinguish from future non-accidental injury
(Griffith 2009).
• Pigmented naevi affect 3% of babies, present at birth as a dark brown patch on the
lower back or buttocks with speckles around the edge of the lesion, usually as a
solitary patch (Fig. 28.1). Major concern is the development of malignancy over time
and must be monitored closely for changes in size and shape (Gordon and Lomax
2011).
FIG. 28.1 Large pigmented naevus. With thanks to Carl Kuschel 2007.
• Milia are small white follicular cysts commonly known as milk spots (Fig. 28.2). They
normally appear on the cheeks forehead and nose and are thought to be retention of
keratin and sebaceous secretions. They clear within 4 weeks of birth.
FIG. 28.2 Milia.
The head
According to Noonan et al (2011), the shape, size and symmetry of the head in relation
to the face and rest of the body should be assessed. The head circumference
measurement of the occipitofrontal diameter should be in the range of 32–36 cm for a
term baby. Lumsden (2010) asserts that macrocephaly (greater than the 97th centile) or
microcephaly (below the 2nd centile) can be plo ed on a head circumference growth
chart in the Child Health Record. A head that is disproportionate to body size may
indicate asymmetrical intrauterine growth restriction where the head has been spared
disruption to its growth (see Chapter 30). Be aware that a stand-alone head
measurement may appear perfectly normal but its relationship with the body may
render it large. A large head is also associated with hydrocephaly and congenital
syndromes. A small head is associated with poor brain development. Fetal alcohol
spectrum disorders (FA S D ) and transplacental infections will deleteriously affect fetal
brain growth. O bservation and palpation of the scalp will indicate the presence and
degree of caput succedaneum which will resolve in 2–3 days. The direction and degree
of moulding can indicate the engaging diameter of the fetal skull involved in the
process of labour. The bones, sutures and fontanelles can then be examined. The
anterior fontanelle (bregma) closes at 18 months of age and if tense or bulging can
indicate congenital hydrocephaly, intercranial haemorrhage or meningitis. A sunken
bregma is associated with dehydration because as an extracellular fluid, cerebrospinal
fluid is derived from venous blood. The posterior fontanelle (lambda) closes around 6
weeks. More than one lambda along the lamboidal suture lines often alongside a flat
occiput can indicate trisomy 21, as can abnormal pa erns of hair growth (low hair line,
extra crowns) which are featured in a variety of syndromes (see Chapter 32).
The face
The midwife should endeavour to see both parents before expressing concern on an
unusual-looking face, however an assumption should not be made that the male
partner is the biological father of the baby. The face should be analysed as a whole.
I ndividual features in isolation do not necessarily indicate a syndrome but in
combination with other features they make a syndrome more likely. The baby's facial
expression could indicate an underlying condition, e.g. pain, irritability, distress and is
worthy of note. The symmetry of the face should be observed as this could indicate
birth trauma in the form of facial paralysis where one side of the face appears to
droop, especially around the eye and mouth on one side, when the baby is crying (Fig.
28.3). This is a result of damage to the seventh cranial nerve (facial), known as Bell's
palsy, during the application of forceps or from head compression against the sacral
promontory during birth. A ny degree of recovery will depend upon the amount of
damage to the myelin sheath that covers and feeds the nerve.
FIG. 28.3 Right-sided facial palsy. Note that the eye is open on the paralysed side and the
mouth is drawn over to the non-paralysed side. Reproduced from Thomas R, Harvey D 1997 Colour guide:
neonatology, 2nd edn, Churchill Livingstone, Edinburgh, with permission of Elsevier.
The ear position should be similar on both sides. The upper margin of the ear pinna
should be on the level of the eyes. However, a finding of low set ears alone may be a
normal variation. Malformed and/or low set ears are associated with chromosomal
abnormalities or urogenital malformations and warrant referral. Roth et al (2008)
argue that peri-auricular skin tags can indicate hearing impairment. The incidence of
significant permanent congenital hearing impairment (PCHI ) is 1 : 1000 births in
developed countries. The N HS N ewborn Hearing S creening ProgrammeUK ( N ational
S creening Commi ee 2012) offers hearing screening in the first week of life and aims
to provide high-quality detection care and support for babies and their families. A pre-
auricular sinus may be blind-ending or connected to the inner ear. The la er condition
will need referral to the Ear Nose and Throat (ENT) surgeon.
The nose shape will vary, but the two nares should be centrally placed and be
patent. Most babies are obligatory nose-breathers and patency can be observed when
the baby is breathing normally at rest. N asal flaring may be indicative of respiratory
distress. Choanal atresia is a condition in which one or both posterior nasal passages
are blocked by either bone or soft tissue. I n the bilateral condition the baby will be
centrally cyanosed at rest but will become better perfused when crying. Urgent referral
to an ENT surgeon will be required.
W hen a cleft lip is detected by antenatal screening, automatic referral is made to the
local cleft lip and palate team (plastic surgeon, EN T surgeon, audiologist, orthodontic
surgeon and speech therapist) before the baby is born. For those babies who have
their condition detected after birth, the midwife should refer to the registrar who will
make referral to the cleft lip and palate team. Cleft lip can be either unilateral or
bilateral and can extend into the hard and soft palate. A cleft palate is not always
obvious and requires thorough assessment in order to confirm its presence. A gloved
finger should be inserted into the mouth, eliciting a suck reflex. By palpating the hard
palate it should be possible to feel if a cleft is present. D etection of clefts in the soft
palate should involve visual inspection using a pen torch and tongue depressor. The
palate should be high arched, intact with a central uvula. Cleft lip and/or palate may
be familial or may be as a result of maternal medication (e.g. phenytoin) or
chromosomal abnormality (e.g. D own and Patau's syndrome). Lumsden (2010) reports
that clefting of the lip and palate affects 1 : 700 babies in the United Kingdom (UK),
with 50% lip and palate together, 25% lip alone and 25% palate alone, so is a relatively
common condition. A small jaw (micrognathia) may be familial or part of a syndrome
like Pierre Robin, which comprises a midline cleft palate and protruding tongue
(glossoptosis). The midwife must be aware that the main problem is of the tongue
falling back and obstructing the oropharynx. The baby may also experience problems
with feeding. Referral to the EN T and orthodontic surgeons will be made alongside
the speech therapist.
Epstein's pearls are a cluster of several white spots in the mouth at the junction of
the soft and hard palate in the midline. They are the same as milia, are of no
significance and disappear spontaneously. N atal teeth are lower incisors that have
small crowns with no roots and pose the risk of tongue ulceration and, if they become
loose, inhalation into the trachea. Referral to the orthodontic team for elective removal
is required. The tongue should also be examined for cysts and dimples. A tight
frenulum that is a ached too far forward to the floor of the mouth restricts mobility of
the tongue to different degrees and will give the appearance of tongue-tie
(ankyloglossia). Treatment for severe tongue-tie is frenulotomy (surgical division of
the frenulum), especially when breastfeeding is being adversely affected.
The eyes should be symmetrically positioned on the face in relation to the other
facial features such as eyelids, eyebrows and the slant of the palpebral fissures (see
Fig. 28.4). The outer canthal distance can be divided equally into thirds, with one eye
width fi ing into the inner canthal space. Extremely wide (hypertelorism) or narrowly
spaced eyes are abnormal and may indicate a syndrome, as may epicanthic folds,
however the la er finding is a normal feature in some ethnic groups, so some caution
is warranted. The sclera is normally white in colour; a yellow discoloration occurs with
jaundice. Conjunctival haemorrhages may occur as a result of the birth, are
insignificant and will take a few days to resolve but are, according to Griffith (2009),
associated with non-accidental injury, so documentation of their appearance and size
is vital. The iris of a baby is navy blue with fibres radiating from the centre. I t should
be perfectly circular with a round pupil in the centre. W hite specks on the iris called
Bushfield spots are associated with Down syndrome. Opacity of the lens could indicate
congenital cataract. Clouding of the cornea could be a sign of congenital glaucoma.
S mall eyes occur as a result of transplacental infection, e.g. rubella, cytomegalovirus.
A ny profuse or purulent discharge from the eyes (Fig. 28.5) should be swabbed and
sent for culture and sensitivity. Eye drops/ointments to treat gonococcal infection,
staphylococci and chlamydial conjunctivitis should be started while awaiting the
results. A bsence of one or both eyes may have an environmental or chromosomal
cause and such a finding requires referral to the ophthalmologist.
FIG. 28.4 Features of the baby's eyes in relation to the face.
FIG. 28.5 Ophthalmia neonatorum. Reproduced from Mitchell H 2004 Sexually transmitted infections in
pregnancy. In: Adler M W, Cowen F, French P et al (eds) ABC of sexually transmitted infections, 5th edn, p 35, with
permission from Blackwell Publishing.
The neck
This may be shortened or webbed with extra skin and is a sign of Turner's syndrome.
The clavicles should be examined for fractures, especially if there is any history of
shoulder dystocia or any suggestions of Erb's palsy (see Chapter 31 and Fig. 31.5).
The chest and abdomen
Bedford and Lomax (2011) assert that the heart rate will vary in range from 100 to 160
beats per minute (bpm). The respiratory rate will be 30–40 breaths per minute (bpm),
but not exceed 60 bpm and will vary in rhythm with small periods of apnoea (absence
of breathing for 20 seconds or more). There should be no sternal or costal recession.
The nipples should be lateral to the mid-clavicular line and should be normal in shape
and form. The presence of abnormal or supernumerary (extra) nipples should be
recorded as a line drawing on a body map with referral to the registrar.
O bservation of respiratory movement should reveal that chest and abdominal
movements are synchronous as the diaphragm is the major muscle of respiration.
A symmetrical chest movement may be caused by either unilateral pneumothorax or
phrenic nerve damage on the side that isn't moving. A lso consider the presence of a
diaphragmatic hernia noted when the chest looks relatively big in comparison to a
scaphoid (sunken) abdomen. Auscultation of ectopic bowel sounds in the chest may
support this supposition (see Chapter 33).
The abdomen should look and feel soft and rounded. The cord should be checked
for bleeding. The cord vessels should have two arteries and one vein. A single
umbilical artery increases the chances of congenital abnormalities but further
investigations are not justified on this finding alone. Exomphalos is where the bowel,
covered by a transparent sac composed of amnion and peritoneum, protrudes through
the umbilical cord and is associated with Beckwith–Wiedemann syndrome
(exomphalos, large for gestational age, abnormal glucose metabolism, characteristic
skin creases to the ears). By comparison, gastroschisis is caused by a defect in the
abdominal wall, which allows bowel to protrude through it. N o sack covers the loops
of bowel, so before birth the bowel has been in contact with the irritant properties of
amniotic fluid, but there are no associations with other congenital abnormalities. Both
conditions may be found on antenatal screening and at birth the protruding bowel is
covered with film wrap to prevent fluid and heat loss in readiness for surgical repair.
The anus
I nspection for the presence and appearance of the anus is vital. The presence of
meconium does not always exclude imperforate anus (anal atresia). I n a perforate anus, the
rectum and anal sphincter connect so that substantial amounts of meconium can be
passed at any one time. I f there is an underlying defect referred to as a high
imperforate obstruction, there could be a rectal–vaginal fistula or a rectal–urethral
fistula that may allow passage of small amounts of meconuim. A ‘low’ anomaly may
merely consist of a membrane covering the anal sphincter, which, while in place, will
impede the passage of all meconium. England (2010a) contends that anal
abnormalities can indicate that other gastrointestinal malformations may be present,
so caution with feeding is recommended. The passage of a nasogastric tube and
withdrawal of hydrochloric acid can exclude oesophageal atresia but does not
necessarily rule out tracheo-oesophageal fistula.
The genitalia
Male genitalia
The penis should be about 3 cm in length, straight, with no chordee (a bend in the
shaft). A ccording to Fox et al (2010), an apparently short penis is more common,
usually buried in supra-pubic fat, but remains a finding that can cause real
consternation to parents. True micro-penis is rare and associated with hypopituitarism
and referral to the paediatric endocrinologist may occasionally be warranted. The
midwife should never attempt to withdraw the foreskin.
O bserving the baby pass urine may help to detect a hypospadius where the urethral
meatus opens on the ventral (under) side of the penis and an epispadius where the
urethral meatus opens on the dorsal (upper) side. Parents should be advised not to
have their baby circumcised for religious or cultural reasons, as the foreskin will be
used to surgically repair the defect.
A ccording to Gordon (2011), the scrotum should be examined to ensure symmetry
on both sides as asymmetry may indicate a persistent connection between the
abdominal cavity and scrotum, so that fluid (hydrocele) or loops of bowel (inguinal
hernia) can escape and occupy the scrotal sac on the affected side. A dark
discoloration of the scrotum, with or without swelling, is abnormal and may indicate
testicular torsion. The testicle twists on itself, limits its own blood supply and the
testicle dies from ischaemia. Torsion can occur at any age and requires immediate
surgical review. The testicles should descend into the scrotal sac by term. Each testicle
is 1–1.5 cm in size, palpable along the route from the posterior abdomen to the scrotal
sac, often found in the groin. Undescended testicles (cryptorchidism) occurs in 2–4%
of term babies. I f not descended by one year, orchidopexy is performed to surgically
place the testicle in the scrotal sac to prevent infertility and malignancy in later life.
Female genitalia
The examination will confirm that the general anatomy appears appropriate, with the
labia majora covering the labia minora.
Disorders of sex development (ambiguous genitalia)
The midwife's communication skills will be of utmost importance as the parents ask
‘W hat have we got and is it alright?’ The stark but not recommended answer to these
questions is, ‘I don’t know and no’. Honesty is the only way to effectively manage this
situation, however, and the midwife's choice of words should be tactful but truthful,
with an immediate response to the parents' queries. Recent practice of placing the
newborn onto the mother's abdomen has enabled the parents to examine their baby
and make their own discoveries, often before the midwife has had chance to see for
her/himself. I t is helpful to suggest to the parents that they initially give their baby a
cross-gender name like S am or J o so that pronouns like he and she are avoided. This
may also help as a temporary measure when informing family members of the birth
and the baby's name.
A ccording to Wassner and S pack (2012), there are many different causes of
ambiguous genitalia: the most common is congenital adrenal hyperplasia, with an
incidence of 1 : 15 000 babies. A n XX female baby has an enlarged clitoris that appears
like a penis and labia that may look more like a scrotum. This is an autosomal
recessive condition where lack of an enzyme called 21 hydroxylase interferes with the
cholesterol pathway in the production of progesterone (from which cortisol and
aldosterone are formed), testosterone and oestradiol. I n the absence of serum cortisol
and aldosterone, the anterior pituitary hormone adrencorticotrophin (A CTH)
stimulates the pathway but only testosterone is produced, which results in
masculinized genitalia and life-threatening imbalances in sodium and cortisol levels.
Referral to an endocrinologist and a paediatric surgeon will follow (see Chapters 32
and 33). The genitalia of male XY babies look within normal limits but these babies
may present later with failure to thrive, vomiting and dehydration related to abnormal
aldosterone and steroid physiology. The midwife should warn the parents of the
likelihood that their baby may be transferred to the neonatal intensive care unit
(NICU) for extra monitoring.
Limbs, hands and feet
The term baby will lie in a flexed position with the head in the midline or turned
slightly to one side. The hands are flexed, with the thumb lying beneath the fingers in
a fist. In addition to noting length and movement of the limbs and joints, it is essential
that the digits are counted and separated to ensure that webbing (syndactyly) is not
present on hands and feet. The hands should be opened fully as any extra digits
(polydactyly) may be concealed in the clenched fist. X-ray assessment will determine
whether the defect needs referral to either the plastic surgeon (skin only) or
orthopaedic surgeon (bone and skin). A single palmar (S imian) crease is associated
with D own syndrome, however 10% of the normal population have a single palmar
crease on one hand and 5% have one on both hands.
D avis (2011) uses the word structural clubfoot to refer to the most common foot
deformity (1 : 1000 births in the UK), known as congenital talipes equinovarus. The
word talipes means ankle and foot. I n this condition the foot is plantar-flexed (turned
downwards like a horse's foot and inwards towards the midline of the baby). The ratio
of boys to girls is 3 : 1 and in 50 % of cases, both feet are affected. The cause is
unknown but is associated with D own syndrome and spina bifida. Referral to an
orthopaedic surgeon is required. First line treatment is the Porseti method of gentle
manipulation and serial casting in plaster of Paris at weekly intervals, which allows the
foot to be gradually corrected over a period of 6 weeks.
Positional conditions of the foot are caused by intrauterine overcrowding. These are:
• positional clubfoot/talipes equinovarus, which when gently manipulated will easily
correct. Davis (2011) argues that a normal baby's foot can be turned outwards by 50–
70° and upwards by 20°. If this can be achieved, a physiotherapist can advise the
parents on gentle massage. Davis further argues that it is not uncommon for a child
to have a structural clubfoot on one side and a positional one on the other, with no clear
view if they are of the same entity. This notion does call for the midwife to check each
foot individually and not automatically assume that both feet are affected in the same
way.
• talipes calcaneo-valgus, which is characterized by dorsiflexion where the foot is
turned upwards and outwards and associated with the breech position and
developmental dysplasia of the hip (DDH). Referral to an orthopaedic surgeon is
required. Often gentle manipulation conducted by parents will bring about correct
alignment, with occasional need for a plaster cast.
The spine
The best way to examine the spine is by holding the baby per chest/abdomen on one
hand, and running the fingers of the other hand down the spinal processes. A ny
curvature of the spine can be noted. S pina bifida occulta (characterized by a missing
vertebral process) may lie beneath a fat pad, swelling, dimple, tuft of hair or
birthmark. For spina bifida cystica (mylomeningocele and meningocele), see Chapter
32. A sacral dimple should be carefully examined to make sure it is skin-lined with no
sinus to the CS F pathway. I f CS F is leaking it represents a portal for infection, so
referral to both the plastic surgeon and neurosurgical teams will be made. I n the
interim, X-ray of the lumbosacral spine and an ultrasound scan of the lower spinal
cord, kidneys and bladder will be arranged.
Communication and documentation
A s soon as the examination is completed, the baby should be handed back to the
mother and skin-to-skin contact re-established. This first examination after birth is
extremely important and needs to be done thoroughly. A ccording to England and Morgan
(2012), parents are often taken aback by the course of events that unfolds if a
malformation or problem is identified. This is often because they are not correctly
prepared for the screening intervention. The words used to obtain consent from the
mother set the scene on how she will perceive the importance of the examination. For
example, if the midwife says ‘I need to take a quick look over your baby to see if
everything is alright’, this could imply that the examination is being done quickly
because it is not really necessary but is routine and has to be done. I f the midwife says
‘Will you please allow me to examine your baby in detail, so that if I find anything that
I think will affect your baby’s health, I can tell you about it and then, with your
permission, ask for a second opinion?’, this question offers a detailed explanation of
the midwife's intention in gaining consent. W hat the midwife says should be
documented alongside details of examination findings, parental reaction, referral
details and support provided. The midwife should not be influenced by the limited
space provided in the record being completed (England and Morgan 2012).
The daily examination screen
This examination is usually performed daily while the baby remains in hospital and
continues on a more intermi ent basis once the baby is in community until discharge
to the care of the health visitor. Health education stems from how the baby is
behaving and its general appearance. A healthy term baby weighs approximately
3.5 kg, has a clear skin, good muscle tone, cries lustily, feeds well, keeps warm and
sleeps. The midwife will continue the health screening process by always asking the
mother how her baby is. Carefully listening to her answer is a crucial part of the
examination and her response will often dictate in what order the midwife performs
the examination, starting with any areas of concern. Recording what the mother has
said (and how she said it) is helpful for other health care practitioners who will see the
baby at a future time (England 2010c).
Breathing
The midwife should observe the baby's respiratory rate that involves the diaphragm,
chest and abdomen rising and falling synchronously. I t should be explained to the
parents that babies have a periodic breathing pa ern that is erratic, with respirations
being shallow and irregular, interspersed with brief 10–15 second periods of apnoea.
Given that babies are either obligatory (required) or preferential nose-breathers, it is
important to check that their nostrils are clear of dried secretions. Tickling the edge of
the nostrils with co on wool can induce sneezing, which aids some clearance. A n
irritable baby with excessive snuffles and sneezing could indicate opiate withdrawal.
I n an assessment of health, the midwife must consider that respiratory difficulties can
occur because of neurological, metabolic, circulatory or thermoregulatory dysfunction
as well as infection, airway obstruction or abnormalities of the respiratory tract itself.
Thermoregulation – the importance of keeping warm
O ne of the midwife's priorities is to make sure the baby is maintaining a body
temperature within normal parameters. A ccording to Brown and Landers (2011), a
neutral thermal environment is one that is neither too hot nor too cold and enables the baby to
use the minimal amount of energy to stay warm. Babies are individuals, with each one
having their own metabolic rate, so the clinical acceptable temperature range of 36.5–
37.5 °C is wide. I n the first week of life core temperature can be unstable as the heat-
regulating centre in the hypothalamus and medulla oblongata is a empting to adapt
from a hot water intrauterine environment to an cooler extrauterine air environment
with concurrent threats of heat loss via radiation, conduction, evaporation and
convection (Fig. 28.6). Cooling babies are unable to shiver and instead a empt to
maintain body heat by a means of non-shivering thermogenesis whereby they utilize
brown fat and simultaneously increase their metabolic rate by increasing glucose and
oxygen consumption to make more energy, carbon dioxide and heat. For this process
o f aerobic glycolysis to function effectively, the baby needs available oxygen and
glucose. A s oxygen is consumed, energy can be made in the absence of, or with
minimal amounts of oxygen, which is referred to as anaerobic glycolysis, however the
amounts of glucose to maintain this form of energy production is more than 20 times
greater to make the same amount of energy as in aerobic glycolysis. Hence the baby
becomes hypoxic and may begin to show signs of respiratory distress. England (2010a)
argues that a transient expiratory grunt may be one of the first respiratory signs of
cooling. N asal flaring, tachypnoea, sternal or subcostal recession, are all signs of
respiratory distress that may follow. Hence the importance of listening to how the
mother or father describes the baby. The baby will not grunt like a pig; one father
described how his son made ‘a strange noise on each breathe’. S ubtle colour changes
may accompany these fleeting episodes.
FIG. 28.6 Modes of heat loss in the neonate.
The first step is to observe the baby overall and feel the head and chest to gather a
general sense of how warm the baby is. Follow this by the use of a thermometer via the
axilla, tympanic membrane (ear), or in the groin. A clothed term baby should maintain
its body temperature satisfactorily provided the environmental temperature is
draught-free, sustained between 18 °C and 21 °C, nutrition is adequate and movements
are not restricted by tight swaddling. I nadequate clothing or/and being inadvertently
left exposed is a common cause of heat loss. I f the baby is cooling, skin-to-skin contact
with the mother should be initiated immediately. The baby's temperature and general
condition should be reviewed after 30 minutes.
Blackburn (2007) argues that pyrexia (37.7 °C and above) in a term baby may indicate
infection; however, hyperthermia can occur if the baby is exposed to an inappropriate
heat source (placed in a sunny window) or dressed inappropriately for the ambient
temperature. Feet-to-foot placing of the baby in the cot in the supine position has
contributed to the reduction in overheating and associated sudden infant death
syndrome (Foundation for S udden I nfant D eath 2013). O ver-heating increases
metabolic rate and can draw upon supplies of glucose and oxygen to maintain the
required energy level. Respiratory distress may follow unless the baby is allowed to
cool slowly.
Skin care
A lthough sterile at birth, the skin, when exposed to air is quickly colonized by
microorganisms, which produce a pH of 4.9, creating an acid mantle that protects the
skin from infection. Vernix caseosa should be allowed to absorb into the skin because
it is a highly sophisticated mixture of proteins and fa y acids that produce an
antibacterial and antifungal skin barrier. Gordon and Lomax (2011) assert that the
midwife should not be tempted to apply anything to a post-term skin that is dry and
cracked, because within a few days of peeling, perfect skin will be revealed beneath.
S kin-to-skin contact just after birth and during subsequent feeding (to include
formula-fed babies too) is an excellent way to colonize the baby's skin with friendly
bacteria. Great care must be provided to maintain the integrity of the lipids (fats) that
seal each skin cell. Chemicals used in manufactured baby skin products can
irrevocably damage epidermal lipids and lead to trans-epidermal water loss. I t is
recommended by Tro er (2010) that for the first month of life it is safer to bath all
babies in plain water once or twice a week only. Co on wool balls should be used for
baby cleansing (top and tail).
A ccording to Gordon and Lomax (2011), the midwife should inspect the skin for
rashes, septic spots, excoriation or abrasions. S eborrhoeic dermatitis (cradle cap) is
commonly seen on the scalp of the newborn, but can occur in the axillae, groins and
nappy area. I t presents with scaly lesions that are greasy to the touch and thought to
be as a response to irritants. S kin rashes such as erythema toxicum that occur within
72 hours of birth as a red blotchy rash, usually over the face and trunk, may be a sign
of over-heating. Removing some of the baby's clothing/bedding will usually resolve it.
This is in comparison to septic spots that will need swabbing for culture and
sensitivity followed by topical or systemic antibiotic therapy as necessary. S imilarly,
paronychia, which is infection of the nail cuticle caused by ragged nails, will be treated
in the same way. Parents should be advised to file their baby's nails and not use scissors
or bite them off to keep them short. The umbilical stump is rapidly colonized, necroses
and separates by a process of dry gangrene, which usually takes between 7 and 15
days. The cord represents a portal of entry for infection (especially Escherichia coli as a
result of contamination from stools) and must be observed for any signs of redness in
the surrounding abdominal skin, referred to as an umbilical flare. I f the flare begins to
spread and extend up the abdomen, this must be reported immediately as antibiotic
therapy will be required.
Cardiovascular system and blood physiology
T he Resuscitation Council (2011) recommends that the umbilical cord is not clamped
for at least the first minute after birth, to allow oxygenated blood to be transferred
from the placenta to the baby. A s a result, the total circulating blood volume at birth
may exceed 80–90 ml/kg and ward off neonatal iron-deficiency anaemia. The
haemoglobin level may also be in excess of 18–22 g/l. The red cell count (5–7 ×1012/l)
may contribute to the development of physiological jaundice (see Chapter 33).
Blackburn (2007) believes that conversion from fetal to adult haemoglobin, which
commences at 36 weeks gestation, is completed in the first 1–2 years of life. The white
cell count is high initially (18.0 ×109/l) but decreases rapidly.
A ccording to Lwaleed and Kazmi (2009), the blood clo ing system is immature
because there is no transplacental passage of coagulation proteins from the mother, so
all levels of blood clo ing reflect fetal synthesis which is completed before the 30th
gestational week. Vitamin K is poorly transferred across the placenta, and due to the
low amount in breast milk the incidence of classic haemorrhagic disease of the
newborn (HD N ) occurring within the first week of life is enhanced in babies who are
exclusively breastfed, until the bowel becomes colonized by E. coli and the Vitamin K-
dependent clo ing factors I I (prothrombin), VI I , I X and X can be synthesized in the
presence of bile salts. Vitamin K (intramuscular or oral suspension) is available to all
babies in the UK as a prophylactic precaution against HD N . Early onset HD N (within
first 24 hours) is exclusively caused by transplacental passage of anticoagulant
medicines that inhibit Vitamin K activity. I n this situation the baby will be prescribed
a therapeutic dose of Vitamin K via intramuscular injection (Lwaleed and Kazmi 2009).
Renal system
A bout 20% of babies will pass urine in the birthing room and this should be noted.
N inety per cent will void by 24 hours of age and 99% by 48 hours. The rate of urine
formation varies from 0.05 to 5.0 ml/kg/hour at all gestational ages with a range of 25–
300 ml/kg/day. The commonest cause of initial delay or decreased urine production is
inadequate perfusion of the kidney. A dded to this, the kidneys are immature and the
glomerular filtration rate is low, but mature within the first month of life. Tubular
reabsorption capabilities are also limited, which renders the baby unable neither to
concentrate or dilute urine adequately, nor to compensate for high or low levels of
sodium, potassium and chloride in the blood. This results in a narrow margin between
under- and over-hydration and, as Blackburn (2007) argues, the ability to excrete
medicines is also restricted. The urine is dilute, straw-coloured and odourless. Urate
crystals may cause red brick staining in the nappy, which is usually a sign of under-
hydration but is largely insignificant. I t is the midwife's responsibility to assess
whether the urine output falls within acceptable parameters by asking the mother
about the character of the baby's wet nappies given that delay in urine
production/passage may be due to physiological stress, intrinsic renal abnormalities or
obstruction of the urinary tract. The midwife should check the records for antenatal
scan findings that may identify abnormality such as the presence of oligohydramnios,
which may indicate problems with passing urine as a fetus. Many syndromes involve
kidney function, especially those babies with low set ears, abnormal genitalia, anal
atresia and lower spine anomalies. Fox et al (2010) argue that the baby should be
assessed for signs of dehydration, infection and a palpable abdominal bladder with
referral to the registrar for further investigations as necessary.
Gastrointestinal system
The gastrointestinal (GI ) tract of the neonate is structurally complete, although
functionally immature in comparison with that of the adult (Blackburn 2007). The
mucous membrane of the mouth is pink and moist. The teeth are buried in the gums
and ptyalin secretion is low. S ucking and swallowing reflexes are coordinated. The
tongue may be coated with milk plaques, which should be distinguished from the
fungus Candida albicans, which will need treatment. The stomach has a small capacity
(15–30 ml), which increases rapidly in the first weeks of life. The cardiac sphincter is
weak, predisposing to regurgitation of milk or posseting. Gastric acidity, equal to that
of the adult within a few hours after birth, diminishes rapidly within the first few days
and by the 10th day the baby is virtually achlorhydric (without acid), which increases
the risk of infection from the mouth. Gastric emptying time is normally 2–3 hours.
Enzymes are present, although there is a deficiency of amylase and lipase, which
diminishes the baby's ability to digest compound carbohydrates and fat, therefore no
sandwiches are allowed! W hen milk enters the stomach, a gastrocolic reflex results in
the opening of the ileocaecal valve. The contents of the ileum pass into the large
intestine and rapid peristalsis means that feeding is often accompanied by reflex emptying
of the bowel.
Bowel sounds can be heard on auscultation within one hour of birth. S terile
meconium present in the large intestine from 16 weeks' gestation, is passed within the
first 24 hours of life and should be totally excreted within 48–72 hours. A s a result of
air entering the gastrointestinal (GI ) tract, E. coli colonizes the bowel and the stools
become brownish-yellow in colour and odorous. O nce feeding is established the faeces
become yellow. The consistency and frequency of stools reflect the type of feeding.
D igested breast milk produces loose, bright yellow and inoffensive acid stools. The
baby may pass 8–10 stools a day. The stools of the formula-fed baby are paler in
colour, semi-formed, less acidic and have a more offensive odour. A melaena stool
contains digested blood from high in the GI tract, has a tar-like appearance and may
be caused by blood swallowed at birth, bleeding maternal nipples or damage to the
baby's GI tract itself. Low GI bleeding may result in frank blood, which is blood that
can be seen in the stools with the naked eye and may be related to HD N (L waleed and
Kazmi 2009).
Glycogen stores are rapidly depleted so early feeding is required to maintain normal
blood glucose levels (2.6–4.4 mmol/l). Weight loss is normal in the first few days but
more than 10% body weight loss is abnormal and requires investigation. Most babies
regain their birth weight in 7–10 days, thereafter gaining weight at a rate of 150–200 g
per week.
Immunity
A ccording to Paterson (2010), neonates demonstrate a marked susceptibility to
infections, particularly those gaining entry through the mucosa of the respiratory and
gastrointestinal systems. Localization of infection is poor, with minor infections
having the potential to become generalized very easily. The baby has some
immunoglobulins at birth but the sheltered intrauterine existence limits the need for
learned immune responses to specific antigens. There are three main
immunoglobulins: IgG, IgA and IgM.
I mmunoglobulin G is small enough to cross the placental barrier. I t affords
immunity to specific viral infections and at birth the baby's level of I gG is equal to or
slightly higher than those of the mother. This provides passive immunity during the
first few months of life and by 2 months the baby is able to produce a good response
to protein vaccines hence the timing for the commencement of routine childhood
immunization programmes (Paterson 2010).
I mmunoglobulin M (I gM) and A (I gA) can be manufactured by the fetus and raised
blood levels of I gM at birth are suggestive of intrauterine infection. This relatively low
level of I gM is thought to render the baby more susceptible to gastroenteritis. Levels
of I gA are also low and increase slowly. S ecretory salivary levels a ain adult values
within 2 months and protect against infection of the respiratory tract, gastrointestinal
tract and eyes. Colostrum and breastmilk provide the baby with passive immunity in
the form of Lactobacillus bifidus, lactoferrin, lysozyme and secretory IgA.
Reproductive system: genitalia and breasts
I n both sexes, withdrawal of maternal oestrogens results in transient breast
engorgement, sometimes accompanied by a milky secretion around the 5th day. Girls
may develop pseudo-menstruation, a blood-stained discharge in the nappy, for the
same reason. Both findings are insignificant but can be concerning for parents and an
appropriate explanation should dispel any anxieties.
Skeleto-muscular system
The muscles are complete, subsequent growth occurring by hypertrophy rather than
by hyperplasia. Palpation around the sternomastoid muscle can identify a developing
haematoma that feels hard to the touch and is referred to as a tumour (congenital
torticollis). The head may be held to one side and is the result of traction and tearing
of the muscle. Physiotherapy referral will be made once diagnosed. The long bones are
incompletely ossified to facilitate growth at the epiphyses.
The neonatal and infant physical examination (NIPE)
Performed within the first 72 hours of birth, this examination specifically screens for
congenital heart disease (CHD ), congenital cataract, developmental dysplasia of the
hip (D D H) and undescended testes, usually in that order. This is not a top-to-toe
examination but more of an opportunistic approach when the baby is quiet enough to
support auscultation of the chest and awake sufficiently to open its eyes.
Examination of the heart
The incidence of CHD is 8/1000 live births and is the most common group of structural
anomalies, accounting for 30% of all congenital malformations (Horrox 2002) . Sinha
et al (2012) argue that the best time for the heart examination to be conducted is when
the baby's major physiological adaptations are complete, so 48 hours post birth is
ideal. Half of the known cases of congenital heart disease are detected by antenatal
ultrasound scan so the postnatal physical examination is the only other means of early
detection. Less than 50% of heart defects are actually detected because many heart
conditions are asymptomatic and trivial. Blake (2008) recommends that reading the
case notes for details of the present pregnancy, perinatal events and neonatal
examinations already performed, is a necessary prerequisite.
Park (2008) reports that maternal congenital heart disease offers 15% prevalence to
the woman's children compared to 1% in the general population. W hen one child is
affected the sibling recurrence risk is 3%, especially for a high prevalence condition
like Ventricular S eptal D efect (VS D ), which is the most common variety of CHD and
accounts for one-third of all cases. Fox et al (2010) assert that maternal rubella
infection in the first trimester commonly results in patent ductus arteriosus (PD A)
and pulmonary artery stenosis. O ther viral infections in late pregnancy may cause
myocarditis. Maternal medications such as anticonvulsants (phenytoin) and
amphetamines are highly suspected teratogens. Excessive maternal alcohol intake may
cause fetal alcohol syndrome in which VS D , PD A and the tetralogy of Fallot are
commonly seen. Maternal diabetes increases the prevalence of transposition of the
great arteries (TGA), VS D , PD A and cardiomyopathy. S inha et al (2012) report that
heart defects are common in chromosomal disorders, to include trisomy 13,18, 21 and
Turner's syndrome (XO).
The cardiovascular examination
Gill and O 'Brien (2007)recommend that the heart itself should technically be left until
last with auscultation as the final step, however auscultation is ineffectual if the baby
starts to cry, so many examiners listen to the heart earlier in the examination. The
mother's view is invaluable and is treated as significant unless proven otherwise.
Using words to describe her baby as happy, cranky, responsive, sleepy, floppy can
provide useful information on the baby's neurological and homeostatic state,
especially how her baby responds physically to taking a feed.
Inspection
England (2010c) believes that inspection is the most important skill because it yields
more information about the baby's cardiovascular behaviour and therefore should not
be rushed. The examiner should look at the sleeping/resting baby's general
appearance and compare gestational age with weight and size, as smallness could
indicate growth disruption at the time when major organs were evolving. The
examiner should question whether the baby has any dysmorphic features indicative of
chromosomal abnormalities that are associated with heart defects. O nce the baby's
chest is undressed, breathing can be assessed. The rate should be counted for over a
minute as breathing tends to be irregular. Central cyanosis needs urgent management.
Pallor may precede respiratory distress, but again is difficult to assess, and as Bedford
(2011) argues, an oxygen saturation of haemoglobin <95% is abnormal and merits
cardiologist assessment. It is wise to always check saturation levels pre and post ductal
so if the baby has a PD A , proximal (hand) saturations may be within normal limits
and post-ductal levels (foot) will be much lower. England (2010a) believes that
respiratory distress may be a sign of cardiac compensation so it is important to inspect
for asymmetrical chest wall movements, a tachypnoea > 60 breaths per minute, nasal
flaring, sternal or costal recession, the use of respiratory accessory muscles, head
bobbing and the presence of an expiratory grunt. Capillary refill greater than 2
seconds is abnormal but oxygen therapy should always be considered cautiously as it
may close a PD A , which could be is acting as a life-saving conduit in certain heart
conditions (Horrox 2002; Bedford 2011).
Palpation
Palpation of the peripheral pulses for rhythm, strength, volume and character then
follows. The easiest pulse to feel is the brachial at the antecubital fossa. The rate
should be counted over a period of 10 seconds. Palpation of the femoral pulses is a
difficult task. Many examiners apply too much pressure to the artery and in effect they
eradicate the pulse wave. S trong arm pulses and weak leg pulses suggests coarctation
of the aorta (CO A). I f the right brachial artery pulse is stronger than the left brachial
artery pulse, this could suggest a CO A where the constriction is proximal to the left
subclavian artery. Equal but bounding brachial pulses are found in PD A with a wide
but diminishing pulse pressure in the lower limbs. A weak thready pulse is found in
congestive heart failure (CHF) and in circulatory shock.
Rhythms originating in the sino-atrial node are called sinus rhythms. I n a regular
sinus rhythm, the rhythm and rate of the heartbeat are normal for the age of the baby.
I n sinus tachycardia, with beats above 160 per minute, first consider pyrexia. Gill and
O 'Brien (2007) contend that the pulse rate will accelerate approximately 10 beats per
minute for every 1°C rise in temperature. Hypoxia, circulatory shock, CHF and
thyrotoxicosis are other possible causes. S inus bradycardia is defined as beats below
80 per minute. Hypothermia, hypoxia, increased intercranial pressure and
hypothyroidism may be causative factors.
The midwife can place their open hand onto the precordium, which is the area over
the sternum and ribs to the left side of the chest. A palpable precordium murmur is
referred to as a thrill, which can sometimes be seen with the naked eye, is
characteristic of heart disease with a high volume overload such as a left-to-right shunt
through the ductus arteriosus and is always of diagnostic value. Right ventricular
enlargement is best sought with one's fingertips placed between the 2nd, 3rd and 4th
ribs along the left sternal edge. The apex beat is found in the 4th intercostal space
along the mid-clavicular or nipple line. A diffuse, forceful and displaced apex beat,
usually caused by hypertrophied heart muscle is relatively rare and described as a
heave. Palpation of the upper abdomen that reveals an enlarged liver (greater than 1 cm
below the costal margin) may indicate heart failure as the liver acts as a reservoir of
blood because the heart cannot cope with the required workload. A n enlarged spleen,
palpable in the left upper quadrant of the abdomen, complements this clinical picture.
Auscultation
By the time inspection and palpation have been performed much of the information
the baby can supply has been obtained and auscultation is the last step. I t is
recommended that a paediatric stethoscope should be used and its diaphragm (the
flat side) utilized at all auscultation sites to hear the high-pitched sounds of a systolic
murmur.
The sternum, clavicles and ribs, to include the costal and intercostal spaces, are
important landmarks as well as the heart structures. There are two upper landmarks
each side of the upper sternum. The right sternal, 2nd intercostal space is the aortic
area. This is referred to as the upper right sternal border (URS B). The left sternal 2nd
intercostal space is the pulmonary area and is known as the upper left sternal border
(ULS B). A further two landmarks are both located to the left of the lower sternum. The
left sternal 5th intercostal space is the tricuspid area and may be called the lower left
sternal border (LLS B) and the apex is found below the nipple on the mid-clavicular
line, in the 4th or 5th intercostal spaces. This is the mitral area. The baby should then
be turned onto its right side and the heart should be examined for murmurs along the
route of the aorta on the left side of the spine from the scapular area to below the ribs.
The examiner is listening for turbulence of blood in the newly developed collateral
circulation caused by COA.
Each cardiac cycle has two heart sounds that can be heard through a stethoscope
when applied to the chest wall. The first heart sound (S 1) is known as ‘lub’ and is
described as long and booming and occurs when the atriventricular (AV) valves, the
tricuspid and bicuspid (mitral) valves are closing at the beginning of ventricular
contraction (systole). The second heart sound is ‘dub’; it is short and sharp, and
reflects closure of the semi lunar valves of the aorta and pulmonary artery, at the
beginning of ventricular relaxation (diastole). The best place to hear the first heart
sound (S 1) is at the apex or the LLS B. S pli ing of the heart sound where the tricuspid
and mitral valves close slightly out of synchrony, is not usually heard in a normal
baby.
The second heart sound (S 2) is heard in the ULS B. S pli ing of closure of the aortic
and pulmonary artery valves is easily heard with the stethoscope and the degree of
spli ing normally varies with respiration, increasing on inspiration and decreasing or
becoming a single sound on expiration. The third and fourth heart sounds are not
normally heard but can be best auscultated at the apex or LLS B. The third heart sound
(S 3) represents ventricular filling that starts as soon as the mitral and tricuspid valves
open, and the fourth heart sound represents ventricular filling that occurs in response
to contraction of the atria. The fourth heart sound (S 4) if heard at the apex is
pathological and is seen in conditions with decreased ventricular compliance
(flexibility) or CHF. W here there is a combination of a loud S 3 or S 4 with a tachycardia,
common in CHF, this is referred to as a gallop rhythm. This information can only
complement a clinical picture of a deteriorating neonate that has a respiratory distress
and is not feeding.
A heart murmur is an additional noise heard during the cardiac cycle. Absence of a
murmur does not exclude congenital heart disease. The location, timing in the cycle, grade,
duration or rhythm, quality and radiation of the murmur should be assessed. I t is
usual to listen to the chest wall in four specific areas. A systolic murmur occurs
between S 1 and S 2 and is classified as one of two types, either an ejection or
regurgitant murmur. The examiner should pay particular a ention to the timing of the
onset of the murmur because the onset in relation to S 1 is far more important than the
duration of the murmur. I n ejection systolic murmurs there is always an interval
between S 1 and the onset of the murmur. They are referred to as crescendo–
decrescendo murmurs as the murmur is at its maximum, half-way between S 1 and S 2.
A murmur may be short or long in duration and can be caused either by a large
volume of blood passing through the semi-lunar valves or a normal flow of blood
passing through stenosed or deformed semi-lunar valves.
By comparison, regurgitant systolic murmurs begin with S 1 and usually last through
systole (and even into diastole) and are referred to as pansystolic, meaning from start
to finish. Park (2008) argues that these murmurs are always pathological and are
associated with VS D and feature regurgitation of the mitral and tricuspid valves.
Bedford (2011) believes that examiners should only be concerned with systolic
murmurs in the neonate as the heart is beating too fast to pick up a diastolic murmur,
which occurs when the heart is at rest between S2 and S1.
The intensity of the murmur is customarily graded from 1 to 6. I nnocent murmurs
are no louder than 2. Grade 3 murmurs are moderately loud. Palpable murmurs (thrill)
are graded as 4, are loud and regarded as pathological. Grades 5 murmurs are very
loud and audible with the stethoscope barely on the chest wall, whilst grade 6 is
audible when standing at the end of the baby's cot.
Q uality refers to how the examiner describes the sounds heard, e.g. systolic
murmurs of VS D have a uniform high-pitched quality often described as blowing
whereas an ejection systolic murmur where stenosis is featured, has a harsh grating
quality. I f a murmur radiates from one area to another it is usually pathological (Park
2008). The things that ma er most are the presence of central cyanosis, poor perfusion,
tachycardia, an abnormal precordium, a heart murmur with a gallop rhythm and
hepatosplenomegaly. Thorough documentation should reflect inspection, palpation
and auscultation findings. A cardiac murmur if present should include details of
location, timing in the cycle, grade, character and be illustrated. I f the baby looks and
feels healthy but the midwife can hear extra heart sounds that warrant a second
opinion, referral should be made to the registrar, with the parent's informed consent.
A s a result of the registrar's opinion, the parents should be informed that at this
moment in time their baby's heart appears healthy or, alternatively, needs further
investigation (see Box 28.2).
Box 28.2
C a se vigne e
Baby Joe
This vigne e is to illustrate that significant cardiovascular disease may not
be clinically apparent at the time of the N I PE and that consent information
should highlight this fact to the parents.
Consider the case of baby J oe, born at term in good condition with no
history of scan anomalies. His 36-hour N I PE reports him as a healthy baby
in all aspects. At 52 hours of age he deteriorates quickly and presents with
central cyanosis, poor perfusion and respiratory distress. His tone is poor.
The precordium and pulses are normal. O n auscultation there are no heart
murmurs or extra sounds. Joe is extremely sick.
The care provided:
• emergency referral and admission to the NICU
• prostaglandin E prescribed to open the ductus arteriosus
• transposition of the great arteries diagnosed on echocardiograph
• transfer to cardiac surgical unit arranged.
The care provided to Joe's parents:
A N I PE midwife may be called upon to provide/contribute to information
given to the parents about their sick baby. The parents will usually be
upset, fearful, possibly angry and, as a result, not able to listen effectively
(England and Morgan 2012). In this situation the most asked questions are:
• why didn't the anomaly scan and NIPE examination reveal the condition?
• what is the condition?
• what is happening to Joe now?
• will Joe die … when can we see him?
Using language that will have to be personalized for both parents to
understand, the following information may be given. S hort explanations
that answer parents' direct questions are required. Line drawings that are
created alongside the verbal explanations may be helpful:
‘Joe has a rare condition called transposition of the great arteries. This is
where the aorta which transports blood to the body and the pulmonary artery
which takes it to the lungs are in the wrong position. On a 20-week anomaly
scan the four chambers of the heart can be seen but it is not always possible
to see which major blood vessel arises from which ventricle. In Joe’s case
his pulmonary artery was coming from his left ventricle, blood was going to
his lungs and then returning to the left side of his heart creating a mini
circulation. On the right side, blood was returning to his heart but instead of
going to his lungs, the blood was directed into the misplaced aorta, which
took the blood back to his body. From birth, Joe appeared well because an
extra vessel called the ductus arteriosus was open and able to shunt oxygen
to Joe’s body tissues, but as this vessel started to close (which is a normal
occurrence), Joe started to deteriorate. This is why the midwife examiner
emphasized to you at the end of Joe’s examination “at this point in time … on
this occasion, Joe appears well”, because at that time, he did appear well.'
England (2010c) believes there is an accepted given that thorough
examiners will send home a baby that will be readmi ed with a serious
heart defect. This emphasizes the importance of ensuring that parents
really understand that the assessment can only reflect the status of the baby
at the time of the examination.
Examination of the eye
The neonatal eye is 75% of the adult size but the visual system is immature and neural
connections from eye to brain are incomplete. Babies have no depth perception
because this relies on both eyes working together and neonatal eyes resemble those of
chameleons where one eye appears to be functioning independently from the other.
D uring the first three months of life there is a need for both eyes to function well
because reduced light stimulation to the eye causes the condition amblyopia where
the brain fails to pay enough a ention to the messages coming from each eye and as a
result, the neural connections for each eye are not created. By 6 months of age, the
eyes and brain become ‘locked on’ to each other and this then sets the stage for the
baby's future visual acuity. A mblyopia can occur in one or both eyes and is usually
caused by disruption of the light pathways to the retina when there is corneal clouding
or scarring, congenital cataract or clouding of the vitreous humour. I t is vital to screen for
these media opacities within 72 hours of birth and later at 6 weeks of age.
The skills of examination start with inspection. O edema of the eyelids is common
and bruising may be present. The examiner should confirm that any trauma and
bruising is commensurate with the birth history and ensure the bruising is not a birth
mark. The ocular landmarks are the structures that surround the eye and how they
appear as part of the face as a whole. With the ophthalmoscope ready for use, the
examiner should be prepared to inspect the eyes should the baby open them. Prising
eyelids open may add to any oedema and a ptosis (drooping of the eyelid) may go
unnoticed. Reducing the room lighting, si ing the baby up or asking the mother to
hold the baby over her shoulder with the examiner approaching from behind the
mother, works well for some.
The red reflex should be elicited first. The retina is the nervous tissue of the eye,
which is stimulated by light. A nteriorly, it is in contact with the vitreous humour and
is avascular. Posteriorly it is supported by a vascular and lymphatic supply from the
underlying choroid. W hen a light is shone into the eyes, the vascular retina shines back
and is known on photographs as ‘red eye’. I f the red reflex can be seen, this should indicate
to the examiner that there are no media opacities present. However the redness of the red
reflex may be affected by the pigmentation of the baby's skin, and particularly in
A sian, A fro-Caribbean, Chinese and J apanese babies they offer different hues of
redness from brown to grey to purple, which is a reflection of their pigmented choroid
and is a normal finding.
The ophthalmoscope dial should be turned to 0 and with the right hand the scope
should be held to the examiner's right eye (or vice versa if left handed). Holding the
scope close to the examiner's eye is important if one uses the analogy of a hole in a
fence. To look through a hole in a fence, one needs to get up close to the hole to see
through to the other side. Each eye of the baby is initially examined separately. Thus
the examiner should shine a white light from the ophthalmoscope at the baby's eye
from a distance of 5–10 cm and focus on the pupil margin. A red glow from the pupil
will be silhoue ed against the edge of the iris. To examine both eyes together, the
examiner now holds the ophthalmoscope at a distance of 20 cm from the baby's eyes to
simultaneously elicit the red reflex from each eye. I f there is any asymmetry
(inequality) of the colour and intensity of the red reflex, or a white papillary reflex
(leucocuria) is seen, the possibility of a media opacity in one or both eyes should be
considered and documented. A congenital cataract (2–3 per 10 000 births) is, according
to Noonan et al (2011), the commonest cause of blindness and should be uppermost in
the examiner's differential diagnosis, but retinoblastoma, a malignant tumour (44 per
million births in Europe), represents the most common intraocular tumour of
childhood. Congenital infection from toxoplasmosis and retinopathy of prematurity
are less common causes.
The ophthalmoscope should then be set to +9 dioptres to conduct a detailed
examination of the front of the eye to detect any abnormalities that are not available to
the naked eye. The conjunctiva and sclera should be white. S ub-conjunctival
haemorrhages are of no clinical significance (but their presence and size should be
documented, as non-accidental injury cannot be ruled out). A blue sclera is worthy of
note as it is indicative of collagen disease. The sclera looks blue because it is thin and
not supported by collagen and is associated with the collagen disease osteogenesis
imperfecta (brittle bone disease), which warrants referral.
The cornea should be clear and any lacerations or scarring should be noted.
Clouding and/or bulging of the cornea could indicate congenital glaucoma, which
needs urgent referral. Both pupils should equally respond to light. A coloboma is
where the iris does not form a complete circle and may be associated with
abnormalities that extend to include the ciliary body and choroid. Complete absence
of the iris known as aniridia will also need referral. D ifferent-coloured irises at this
stage in life is also suspicious (Gill and O'Brien 2007).
A ssessing whether the eye is infected should be no casual task and the examiner
should always consider the gravity of ophthalmia neonatorum. A ccording to Noonan
et al (2011), a sticky eye demands microbiological investigation to rule out gonococcal
and/or chlamydial infection, which if untreated can rapidly lead to corneal ulceration
and blindness. Gonococcal conjunctivitis can present from 1 to 3 days with a profuse
purulent discharge with swelling of the conjunctiva and lids. A swab must be taken for
microscopy and culture followed by saline irrigation, topical and systemic antibiotics,
usually penicillin. The mother and sexual contact(s) need referral to the genitourinary
clinic. Likewise chlamydial conjunctivitis presents later, at 5–14 days, but is associated
with neonatal pneumonia if the initial systemic antibiotic treatment has been
inadequate. Fox et al (2010) assert that specific chlamydial swabs should be used with
erythromycin the choice of antibiotic. N oonan et al (2011) further contend that herpes
virus type II and bacterial infections such as Staphylococcus aureus, Streptococci and E. coli
need immediate treatment. Full documentation of what has been found should be
detailed for each eye and the parents informed that on this occasion, the eyes appear
healthy (or otherwise).
Examination of the hips
D evelopmental dysplasia of the hip (D D H) represents a spectrum of defects where the
femoral head is not totally in the acetabulum, but possibly on its border and can only
be diagnosed on ultrasound scan (Kasser 2012). D islocation is when the femoral head
is outside of the acetabulum. The femoral head continues to grow but if the femoral
head is not in the acetabulum, the acetabulum fails to grow. S econdary adaptive changes
occur so that ligaments and muscles shorten and tighten and the acetabulum fills with
scar-like tissue. The incidence is 1 in 400 live births and there are two factors that
relate to the natural history of D D H which makes screening difficult. J ones (1998)
asserts that as many as 20 babies in every 1000 births have unstable hips but 90% of
these will stabilize spontaneously. I t is not possible to predict which 10% of these hips
will remain unstable. Stable hips at birth may later develop D D H. The hip is at its most
unstable at the time of term birth. I n early gestation there is nearly total spherical
enclosure of the femoral head by the acetabulum, but by term when the tightness of
the uterus and the lack of leg and hip freedom is at its peak the femur is shallow, then
deepens again in the postnatal period. The low incidence of D D H in preterm babies
supports this notion. Paton (2011) argues that predominantly it is a disease of girls,
with a 6 : 1 ratio with boys, and is more common on the left side (2 : 1). The ideal time
for screening the newborn hip is 7 days. The N I PE screen is technically too early, is a
compromise but should be followed by an examination at 4–8 weeks by the general
practitioner or the health visitor.
The baby must be warm and comfortable, be on a firm flat surface and one of the
parents must be present. The midwife must have enough room to gain access to the
baby and be physically able and comfortable to perform the manoeuvres (J ones 1998).
A general inspection followed by a detailed skeletal examination of the baby may
reveal additional risk factors (see Box 28.3) that the history has not elicited.
O ligohydramnios, postural foot deformities, plagiocephaly, scoliosis and a prominent
sacral dimple are all associated with hip abnormalities. Babies that show the effects of
intrauterine growth restriction (I UGR) and those with dysmorphic features are
particularly at risk.
Box 28.3
P re disposing fa ct ors t o de ve lopm e nt a l dyspla sia of
t he hip ( D D H )
1. Squashed hips in utero. The emphasis is breech birth to include vaginal
and caesarean section and to include those babies when external
cephalic version has been performed near to and at term for breech
presentation. When oligohydramnios is featured, look for structural or
positional talipes (equino-varus/calcaneo-valgus) or a combination of
these two presentations
2. Genetic predisposition. There is a higher proportion of identical twins
with DDH compared to non-identical twins
3. Family history of dislocation of the hip/DDH
4. Ligament hyperlaxity can lead to full abduction in the presence of a
dislocated hip
5. Geographical variation where abduction of the child's hips is a strong
cultural feature, with an incidence of 0.25 per 1000 live births;
however, where swaddling the legs together (usually for warmth) is
the cultural norm, the incidence rises to 10/1000.
Source: Dove et al 2011
With the baby lying on its back and legs bent at the knee with feet on the surface, an
initial inspection should look for any asymmetry in the appearance of the legs and
groin skin folds. Examination of the knees may show uneven knee height. O n the
affected side, the knee is lower because the head of the femur has dropped into the
soft tissues because it is not being held by the bony acetabulum. However, equal knee
height could indicate either normality of both hips or bilateral dislocation of both
hips. Pulling the legs straight to measure leg length, should be done after the hip
examination as this manoeuvre stimulates flexor tone resistance, which is enough to
upset a settled baby and render the examination less valid.
The modified O rtolani and Barlow manoeuvres are referred to as thecombined stress
test and are performed to diagnose the subluxatable (dislocatable) or dislocated hip
and make it possible to notice the presence or absence of knee and hip clicks. The
range of abduction in flexion is also a useful sign to indicate the degree (if any) of
abnormality.
The O rtolani manoeuvre is described for examination of the left hip, using the
examiner's right hand. The examiner steadies the pelvis between the thumb of the left
hand on the baby's symphasis pubis and fingers under the sacrum. With the baby's
left leg flexed in the palm of the right hand, the head of the femur is held between the
examiner's right thumb on the inner side of the thigh opposite the lesser trochanter
and the middle longest finger over the greater trochanter. I n an a empt to relocate a
posteriorly displaced head of the femur forwards into the acetabulum, the middle
finger applies gentle pressure upon the greater trochanter. The baby's thighs are
flexed forward (to the head of the baby) onto the abdomen and rotated and abducted
through an angle of 70–90° towards the examining surface. I f the hip is dislocated, a
clunk will be felt (and sometimes heard) as the head of the femur slips into the
acetabulum. A high-pitched click is probably a product of soft tissue structures
moving over bony prominences. Remember Ortolani – Out to In (Baston and D urward
2010).
The Barlow manoeuvre is described for examination of the left hip and the
examiner's right hand. From a position of abduction, the hip is adducted to 70° and
gentle pressure is exerted by the examiner's right thumb on the lesser trochanter in a
backward and lateral direction. I f the thumb is felt to move backwards over the
labrum (the fibro-cartilaginous rim of the acetabulum) onto the posterior aspect of the
joint capsule, a clunk may be heard as the head of the femur dislocates out of the
acetabulum. England (2010c) describes the noise as a deeper clunk with significant
movement. The dislocatable hip can feel strangely soft with li le or no resistance. The
O rtolani manoeuvre will then be performed to return the head of femur to the
acetabulum. To examine the right hip the role of the examiner's hands is reversed.
D ove et al (2011) support the view that it is acceptable for the experienced examiner to
undertake the O rtolani and Barlow manoeuvres sequentially on both hips
simultaneously.
The Barlow and O rtolani tests involve gentle manoeuvres. The softer the touch, the
more information is secured; indeed very li le pressure is needed to dislocate the
head of femur because the acetabulum is so shallow. A heavy-handed approach will
often make the baby stiffen and resist being touched. I n this circumstance the
examiner needs to abandon the examination, talk to the baby (and parents) in an
a empt to relax him (and them) and then a empt a further examination. A useful
analogy is a gear stick in a car. Gentle manipulation of the baby's legs in a circular
rotation helps to reduce muscle and nerve tension. Likewise, the lightest of touch can
help guide that gear stick home.
D ocumentation of findings in the Personal Child Health record should offer details
and be explained to the parents. Dove et al (2011) assert that it is not enough to place a
tick against the word hips. W hen an abnormality is found an example of the record
may be wri en thus: ‘The right hip abducted fully in flexion; is stable and the
combined stress test O rtolani/Barlow manoeuvre was negative with no shortening on
knee height inspection. The left hip shows shortening on knee height inspection with
resistance to abduction, which resulted in an O rtolani clunk as the head of femur
returned to the acetabulum. The findings were confirmed by D r S mith (neonatal
registrar). D ouble nappies were applied. Referral arranged for a 2 week follow-up for
ultrasound scan and appointment with orthopaedic consultant. Both parents were
present at the examinations and have been informed of the clinical findings and
referral arrangements.’ A n entry that communicates health must reflect that both hips
abduct fully in flexion and there is no apparent shortening on knee height inspection.
I t should be clear that both hips are stable and the combined stress test comprising
the O rtolani and Barlow manoeuvres is negative for both hips. The parents should be
told that on this examination/occasion, their baby's hips appear healthy.
Examination of the genitalia
This examination will repeat the previous examinations reported in this chapter and
review any new developments.
Neurological examination
The neurological examination will be performed continuously throughout the
examination, noting how the baby handles and behaviourly tolerates the examination.
The healthy term baby will make eye-to-eye contact, fix and follow a face when held 30
centimetres from the examiner. There should be natural facial movements with
blinking of the eyes. W hen lying supine the baby will be flexed at the knees with hips
abducted; the head turned to one side. Movements are smooth, symmetric and varied.
The baby should be able to demonstrate a rooting reflex. Coordinated movements of
lip, tongue, palate and pharynx are required to suck and swallow successfully. Failure
to suck when the stomach is empty is indicative of abnormal function and an
important sign of brain stem damage.
Primary (primitive) reflexes (see Box 28.4) are best performed at the end of the N I PE
screen as they will usually unse le, even distress the baby. They provide information
about lower motor neuron activity and muscle tone. Persistence beyond the normal
age suggests that higher cortical centres are not gaining control of tone and movement
as expected and can be an early sign of cerebral palsy. Extremes of tone (rag doll
floppiness) or persistent extension of the back (opisthotonus) are both abnormal.
Flexed arms and extended legs is also an abnormal posture. J i eriness is a feature of
the healthy baby and can be stopped by touching the affected area. I rritability in the
form of repetitive movements, for example an eyelid or finger, could represent a
convulsion in a baby and warrants referral.
Box 28.4
N e urologica l re fle x e s in t he ne wborn
• Placing reflex. Whilst the baby is being held upright, the top of the foot is
touched by the edge of a surface and the baby will lift and place its foot on
the surface. Presents from 36 weeks' gestation and disappears at 3 months
of age.
• Palmar and plantar grasps. Flexion of fingers/toes when an object is
placed in the palm of the hand/on the ball of the foot. Presents at 28
weeks' gestation and disappears by 2–3 months.
• Asymmetric tonic neck reflex (the fencing sign). When the head is turned
to one side, the arm and leg on that side extend, while the arm and leg on
the other side remain flexed. Established from 36 weeks' gestation and
disappears at 6 months.
• Moro (startle) reflex. On sudden head extension, symmetrical abduction
and extension followed by flexion and adduction of the arms, with
accompanying cry. Present at 37 weeks' gestation and disappears around 4
months of age. Absent in heavy sedation or hypoxic, ischaemic
encephalopathy. Unilateral presentation implies fractured clavicle,
hemiplegia, brachial plexus palsy.
• Rooting reflex. Stroking the baby's cheek with a finger causes the head to
turn towards the stimulation and the mouth will open. Established at 34
weeks' gestation and disappears at 4 months of age, when visual cues take
over.
• Sucking reflex. Elicited to assess the strength and coordination of the
sucking reflex by placing a clean finger in the mouth. Disappears by age
of 12 months.
For visual display of reflexes go to www.youtube.com/watch?
v=Sv5SsLH70mY
At present N I PE training is largely regarded as an expanded role of the registered
midwife. However the Midwifery 2020 report (D epartment of Health 2010)
recommends that overall care of the neonate needs to be improved, and according to
Lumsden (2012), N I PE training is now becoming part of pre-registration midwifery
education. There is a requirement for all midwives to further develop their neonatal
knowledge in recognizing health, by knowing and understanding the abnormal. This
will involve enhancing their communication and examining skills in being able to
conduct all three screening examinations discussed in this chapter, in order to provide
truly holistic, individualized care that will place the midwife as the lead practitioner
for the healthy baby.
References
Baston H, Durward H. Examination of the newborn. A practical guide. Routledge:
London; 2010.
Bedford CD. Cardiovascular and respiratory assessment of the baby. Lomax A.
Examination of the newborn. An evidence-based guide. Wiley–Blackwell:
Chichester; 2011.
Bedford CD, Lomax A. Development of the heart and lungs and transition to
extrauterine life. Lomax A. Examination of the newborn. An evidence-based guide.
Wiley–Blackwell: Chichester; 2011.
Blackburn ST. Maternal fetal and neonatal physiology. Saunders Elsevier:
Philadelphia; 2007.
Blake D. Assessment of the neonate: involving the mother. British Journal of
Midwifery. 2008;16(4):224–226.
Brown VD, Landers S. Heat balance. Gardner SL, Carter BS, Enzman-Hines M, et
al. Neonatal intensive care. Mosby: St Louis; 2011.
Davies N. Abnormalities of the foot. Lomax A. Examination of the newborn. An
evidence-based guide. Wiley–Blackwell: Chichester; 2011.
Department of Health. Midwifery 2020: delivering expectations.
www.midwifery2020.org.uk; 2010 [(accessed 4 March 2013)] .
Dove R, Hunter J, Wardle S. Nottingham neonatal service clinical guidelines.
Screening for developmental dysplasia of the hip. Nottingham University Hospital
NHS Trust; 2011.
England C. Neonatal respiratory problems. Lumsden H, Holmes D. Care of the
newborn by ten teachers. Hodder Arnold: London; 2010.
England C. Care of the jaundiced baby. Lumsden H, Holmes D. Care of the
newborn by ten teachers. Hodder Arnold: London; 2010.
England C. Physical examination of the neonate. Marshall JE, Raynor MD.
Advancing skills in midwifery practice. Churchill Livingstone: London; 2010.
England C, Morgan R. Communication skills for midwives. Challenges in everyday
practice. Open University Press/McGraw-Hill Education: Maidenhead; 2012.
Foundation for Sudden Infant Death. http://fsid.org.uk; 2013 [(accessed 2 April
2013)] .
Fox G, Hoque N, Watts T. Oxford handbook of neonatology. Oxford University
Press: Oxford; 2010.
Gill D, O’Brien N. Paediatric clinical examination made easy. Churchill Livingstone:
London; 2007.
Gordon M. Examination of the newborn abdomen and genitalia. Lomax A.
Examination of the newborn. Wiley–Blackwell: Oxford; 2011.
Gordon M, Lomax A. The neonatal skin: examination of the jaundiced newborn
and gestational age assessment. Lomax A. Examination of the newborn. Wiley–
Blackwell: Oxford; 2011.
Griffith R. Safeguarding children from significant harm. British Journal of
Midwifery. 2009;17(1):58–59.
Horrox F. Manual of neonatal and paediatric heart disease. Whurr Publishers:
London; 2002.
Jones AJ. Hip screening in the newborn. A practical guide. Butterworth–Heinemann:
Oxford; 1998.
Kasser JR. Orthopaedic problems. Cloherty JP, Eichenwald EC, Hansen AR, et al.
Manual of neonatal care. Lippincott. Williams and Wilkins: Philadelphia; 2012.
Lumsden H. Examination of the newborn. Lumsden H, Holmes D. Care of the
newborn by ten teachers. Hodder Arnold: London; 2010.
Lumsden H. Embedding NIPE into the pre-registration midwifery programme.
Midwives. 2012;1:42–43.
Lwaleed BA, Kazmi R. An overview of haemostasis. Hall M, Noble A, Smith S. A
foundation for neonatal care. A multidisciplinary guide. Radcliffe: Oxford; 2009.
Noonan C, Rowe FJ, Lomax A. Examination of the head, neck and eyes. Lomax A.
Examination of the newborn. Wiley–Blackwell: Oxford; 2011.
Park MK. Pediatric cardiology for practitioners. Mosby: Philadelphia; 2008.
Paterson L. Infections in the newborn period. Lumsden H, Holmes D. Care of the
newborn by ten teachers. Hodder Arnold: London; 2010.
Paton RW. Developmental dysplasia of the hip. Lomax A. Examination of the
newborn. Wiley–Blackwell: Oxford; 2011.
Resuscitation Council UK. Newborn life support. 3rd edn. 2011.
Roth DA, Hildesheimer M, Bardenstein S, et al. Periauricular skin tags and ear
pits are associated with permanent hearing impairment in newborns.
Paediatrics. 2008;122:884–890.
Sinha S, Miall L, Jardine L. Essential neonatal medicine. Wiley–Blackwell:
Chichester/Oxford; 2012.
Trotter S. Neonatal skincare. Lumsden H, Holmes D. Care of the newborn by ten
teachers. Hodder Arnold: London; 2010.
UK National Screening Committee. Newborn and infant physical examination:
standards and competencies NHS. http://newbornphysical.screening.nhs.uk; 2008
[(accessed 3 February 2013)] .
UK National Screening Committee. NSC policy database. Hearing (newborn).
www.screening.nhs.uk/hearing-newborn; 2012 [(accessed 28 October 2012)] .
Wassner AJ, Spack NP. Disorders of sex development. Cloherty JP, Eichenwald
EC, Hansen AR. Manual of neonatal care. Lippincott, Williams and Wilkins:
Philadelphia; 2012:791–807.
Further reading
Bedford CD, Lomax A. Development of the heart and lungs and transition to
extrauterine life. Lomax A. Examination of the newborn. An evidence-based guide.
Wiley–Blackwell: Chichester; 2011.
This chapter provides a detailed exploration of the fetal circulation and the adaptations
that occur with the first breath at birth. It also integrates the impact of
hypoglycaemia, hypoxia and hypothermia on these transitional events and offers a
useful discussion on the energy triangle..
McCallum L. www.slideshare.net/Prezi22/physical-examination-of-the-
newborndoc; 2010.
This text offers useful information on examination of the newborn and could be used as
a revision script..
Quarrell C. Examining the neonate in the hospital and community: child
protection issues. Lomax A. Examination of the newborn: an evidence-based guide.
Wiley–Blackwell: Chichester; 2011.
This chapter asserts that the midwife is the baby's advocate and safeguarding
considerations should be integral to the examination of the newborn by ensuring that
the baby remains the focus of the examination. Does the evidence observed fit with the
parent's account? Who is the midwife's designated referral professional in
safeguarding situations? These questions are well addressed..
Useful websites
Resuscitation Council (UK). www.resus.org.uk.
The Resuscitation Council in the definitive resource for keeping up to date on techniques
and information about neonatal resuscitation..
The Auscultation Assistant. www.wilkes.med.uncla.edu/inex.htm.
A good site to listen to and differentiate the different heart sounds and murmurs..
C H AP T E R 2 9
Resuscitation of the healthy baby at birth
The importance of drying, airway management and
establishment of breathing
Carole England
CHAPTER CONTENTS
Drying the baby 611
Airway management and breathing 612
Difficulties in establishing an open airway 613
Parental support through effective communication 614
References 614
Further reading 615
Midwives are the lead practitioners in normal birth and attend most births in
the hospital and home setting. It is therefore important that they have
applicable knowledge and skills of resuscitation to enable them to care for
the newborn baby (and parents) in a competent supportive manner. The aim
of this chapter is to uphold the principles of care offered by the
Resuscitation Council United Kingdom [RCUK] (2011) and explore the
specific role of the midwife in drying the baby and airway management.
Noting the time of birth and starting the clock on the resuscitaire (if
applicable) is always the starting point for care and documentation
requirements. Requesting assistance from the multiprofessional team at any
stage of the process is recognized as an essential component.
The chapter aims to:
• emphasize the importance of thoroughly drying the baby to prevent heat loss
• support the principle of enabling the baby to resuscitate itself by placing its head in the
neutral position
• detail how to open the airway by giving inflation breaths in order to clear the lung fluid
• reiterate the importance of starting and maintaining a record of the events of the
resuscitation process
• highlight the need to ask for help from the multiprofessional team at any stage of the
process.
Drying the baby
Thoroughly drying of the baby is always the first step to management of resuscitation
at birth. Taking the time to dry the baby's head, to include the face alongside the arm
and leg creases, is sometimes not performed as thoroughly as it should be. A ccording
to Connolly (2010), heat loss and cooling of the baby is inevitable but failure to spend
time doing this task meticulously can result in the baby using oxygen and glucose to
maintain or raise its metabolic rate. A lso, in order to place a baby in skin-to-skin
contact with its mother, the baby needs to be thoroughly dry; furthermore, the mother
needs to be dry so that the baby can benefit from conductive heat gains.
D uring this time of drying, which can take up to a minute, the midwife should
assess the baby for its colour and muscle tone. The A pgar score is used as a
communication tool to inform other team members should it be necessary. A score at
1, 5 and 10 minutes is entered into the record (N ursing and Midwifery Council [N MC]
2009). Most babies will be blue at birth, which indicates that there is accumulation of
carbon dioxide (CO2) in the blood and tissues. I t is important to remember that CO2 is
a stimulant to the respiratory centre in the medulla oblongata, so blue skin is a normal
physiological sign and most babies will not require resuscitating. However, too much
CO2 will depress respiration and this may account for why the baby may be showing
li le or no respiratory effort. W hite or mo led grey skin is an indication of peripheral
shut down as the baby is responding to low oxygen levels and is conserving the
available oxygen for the heart and brain by diverting blood away from the skin and
other non-essential organs (Leone and Finer 2012). This is the baby that needs to be
thoroughly dried as their reserves of oxygen cannot be wasted on a empting to keep
warm. S o, the rule of thumb must be the poorer the colour, the more thorough the drying
process should be. The midwife should not let their own anxiety or that of others hurry
them in this drying process. A ll wet towels should be discarded and the baby covered
in warmed dry ones. I dentification name bands should also be placed on the baby in
the hospital se ing, should there be need to separate the baby from the mother at any
time.
A ccording to Rennie and Kendall (2013), the assessment of muscle tone indicates to
what degree the nerves are stimulating the skeletal muscles. W hen a baby is well
toned for its gestational age, this signals that the baby is generally in good condition
even though they may not be breathing. A baby that is both white and floppy reflects
the possibility of long-term hypoxia as a result of the labour process or some other co-
existing factor, for example, infection. The midwife should simultaneously assess
whether the baby is breathing by assessing the presence or absence of chest
movement and any other signs, such as gasping. I f the baby is crying, the baby has an
open airway. This assessment is followed by auscultation of the chest to assess the
heart rate. Dawson et al (2010) argue that the midwife needs to establish whether there
is a heart rate and, if so, if it is above or below 60 beats per minute (bpm). I n the first
minute, the average heart rate of a healthy term baby is below 100 bpm, however by
the second minute it has usually risen to around 140 bpm and by 5 minutes to
160 bpm. D awson et al (2010) consider that the heart rate is the most important
indicator of health in newborn babies and this is why it is so important to make a
regular assessment, hence the 1 and 5 minutes time-frame of the A pgar score (Apgar
1952). D uring this time of assessment, the umbilical cord can remain uncut so that
extra red blood cells can be transported to the baby and enhance the baby's oxygen-
carrying capacity. Even if the heart rate is really slow, opening the airway must be the
first task to achieve. Without an open airway, the baby has no way of being
oxygenated, as this is the only means of assisting the heart to function. Hence the
midwife should note the Airway, Breathing and Circulation of resuscitation when C
must follow B and B must follow A: there is no room for any short cuts.
Airway management and breathing
I f the baby is not breathing, opening the airway is always the first step . A flat surface is
needed so the umbilical cord can be cut and secured. I n the home se ing, the floor is a
tempting location to place the baby, especially if the room is clu ered. However, the
floor is not ideal, as even in the summer it is often cold and draughty and therefore
likely to cool the baby. Furthermore, in any resuscitation situation, the first consideration is
practitioner safety. The midwife must always make sure the environment is safe for her
to function, and bad posture in particular can contribute to poor performance and
awkward communications. I t is therefore be er to clear a table or use the seat of a
firm chair to place the baby on.
The prominence of the neonatal occipital protuberance can affect the natural
position of the baby's head, when lying on its back, with the result of either the chin
falling down to the chest in flexion or extending into the chin-up position. Both
postures consequently close the airway. The head should be placed in the neutral
position (Fig. 29.1) with the nose uppermost, the ideal situation being when another
person can hold the baby's head for the midwife (Tracy et al 2011).
FIG. 29.1 Neutral position.
A lternatively, a small sheet/towel or equivalent can be placed under the neck of the
baby to secure the neutral position (sniffing position) (Fig. 29.2).
FIG. 29.2 Small towel under the neck (sniffing position).
I ntermi ent positive pressure ventilation (I PPV) will then be commenced using a
bag and mask if available or a T-piece, mask and resuscitaire in the hospital. The mask
must be the correct size for the baby to prevent any leaks of air to occur on inflation of
the bag. The mask should be rolled onto the face from the chin, using the stem of the
mask (like a champagne glass) to hold it in position. The soft part of the mask should
not be touched as this may distort its shape and lead to leakage of air (Fig. 29.3).
FIG. 29.3 Bagging demonstration.
The bag when manually compressed will deliver positive pressure of air at
30 cmH2O . Given that the alveoli are filled with lung fluid, this pressure should be
applied for 3 seconds, which is the time it takes to steadily count ‘1–2–3’, to begin the
process of forcing the lung fluid into the lymphatic channels of the lungs. The bag
should be allowed to refill before giving the second breath, ‘2–2–3’, the third breath,
‘3–2–3’, ‘4–2–3, and finally ‘5–2–3’. Five inflation breaths should be sufficient to clear the
lung fluid to make room for the air . W hile these inflation breaths are being given, the
baby should be covered but with the chest exposed so that any chest movement (which
is the sign of an open airway) can be seen and noted. I t must be appreciated that while
there is an exchange of one substance with another, i.e. lung fluid with air, there is no
accumulation of air to lift the chest until the 4th or 5th inflation breath . This can be a
nervous time for the midwife because it is natural to think that the chest will rise on
the first inflation and it is easy for midwives to blame their own technique. O nce chest
movement has been seen, the facemask should be removed to assess if the baby is
spontaneously breathing. The heart rate can also be assessed at this time to establish
whether the rate has increased.
Babies that are blue with good muscle tone and a heart rate above 60 bpm often do
not need any further assistance. A s soon as normal respiratory effort is established
and their heart rate is over 100 bpm, they can be given to their mother for skin-to-skin
contact. However, some babies in this category may not be breathing spontaneously
because there remains too much CO2 in their blood and tissues (hypercapnoea) that is
depressing their respiratory effort. Ventilatory breaths are then commenced to provide
oxygen (21% in air) and blow off the excess CO2. Given at a rate of 30 breaths per
minute, these breaths are therefore 2 seconds in duration. I t is important to assess the
baby every 30 seconds to see if they are making spontaneous efforts to breathe. I t is
vital that the midwife does not over-ventilate the baby and reduce their CO2 too much
and cause apnoea. Babies should be allowed to resuscitate themselves, noting the time
when the baby is breathing spontaneously. (See Box 29.1.)
Box 29.1
R e fle ct ive que st ion
‘If a baby is not breathing, is it acceptable to blow oxygen onto
the baby’s face instead of using IPPV with a bag and mask?’
This is totally inappropriate for two reasons:
1. You must first establish that the airway is open. The only way to do
this is by giving five inflation breaths and seeing the chest rise by the
fifth inflation breath. The time you spend not giving IPPV is wasted and
the baby is not receiving any benefit from you.
2. Resuscitation gas now consists of air as standard not oxygen. Air is a
cold gas and if you blow this onto the face of the baby, you will quickly
cool the baby.
Difficulties in establishing an open airway
I f there is no chest movement after five inflation breaths, this indicates that the airway
is not open, so the alveoli will remain filled with lung fluid. This is a good time to
consider calling for medical assistance because failure of the following interventions
may result in the need for tracheal intubation (RCUK 2011). I n the home, paramedic
support will take longer to arrive so early anticipation of problems is considered good
practice. I f the baby has a poor colour and muscle tone, this may indicate that the
position of their head has not been maintained in the neutral position and there is a
definite need for a second person's help both to hold the head and apply jaw thrust.
The jaw of a floppy baby can fall backwards and as the tongue is a ached to the jaw,
the tongue falls back into the airway, blocking the airway. A second person, with their
fingers on each side of the jaw, can push the jaw forwards and hold it in that position.
This is an easily performed manoeuvre because the baby does not offer any muscle
tone resistance. Five inflation breaths should then be given. I f there is still no chest
movement, suction to the oropharynx under direct vision using the light of a
laryngoscope may be considered should there be an obstruction. O ccasionally if there
is maternal bleeding at the birth, some blood may have entered the baby's mouth,
initially as fluid but then over time may have clo ed. ( Please note: The management of
meconium is not considered in this context, as the resuscitation would be approached in a
different way: Chapters 32 and 33). A fter this intervention five inflation breaths are
given. I f not successful, an oropharyngeal (Guedel) airway can be inserted to open the
airway mechanically, especially in babies who may have congenital abnormalities such
a s choanal atresia and/or micrognathia. The correct sizing of the airway is vital. W hen
held along the line of the lower jaw with the flange at the level of the middle of the
lips, the end of the airway should reach the angle of the jaw. The airway is slipped over
the tongue in the same a itude that it will finally lie. The midwife should make sure
that the tongue is not pushed back into the back of the mouth. O nce in situ the mask
can be placed over the airway (both the mouth and nose) and a further five inflation
breaths should be given. I f the chest fails to rise after these interventions, intubation
of the trachea will be required and an experienced neonatal registrar will be needed to
assist.
Parental support through effective communication
A ccording to England and Morgan (2012) resuscitation of the baby occurs in the
presence of the parents, so a clear, simple explanation in a calm tone should be given
to inform and support them during the process. Parental stress and anxiety will affect
how the couple are able to receive information and respond to it. N on-verbal
communication is more influential in informing the parents of the midwife's state of
mind. D ocumentation should always reflect obtained consent and specific aspects of
the resuscitation, including any interactions between the parents and
multiprofessional team that have occurred (N MC 2008, 2009, 2012). I t is important to
recognize that records should always be sequentially detailed enough, should they be
required to support the midwife's actions at a later date and read out in court or at the
NMC.
References
Apgar V. Proposal for a new method of evaluation of newborn infants.
Anaesthesia and Analgesia. 1952;32:260–267.
Connolly G. Resuscitation of the newborn. Boxwell G. Neonatal intensive care
nursing. Routledge: London; 2010:65–86.
Dawson JA, Kamlin C O F, Wong C, et al. Changes in heart rate in the first
minutes after birth. Archives of Disease in Childhood Fetal and Neonatal Edition.
2010;95(3):F177–F181.
England C, Morgan R. Communication skills for midwives: challenges in everyday
practice. McGraw–Hill/Open University Press: Maidenhead; 2012.
Leone TA, Finer NN. Resuscitation in the delivery room. Gleason CA, Devaskar
SU. Avery's diseases of the newborn. Elsevier: Philadelphia; 2012:328–340.
NMC (Nursing and Midwifery Council). The Code: standards of conduct, performance
and ethics for nurses and midwives. NMC: London; 2008.
NMC (Nursing and Midwifery Council). Record keeping. Guidance for nurses and
midwives. NMC: London; 2009.
NMC (Nursing and Midwifery Council). Midwives rules and standards. NMC:
London; 2012.
RCUK (Resuscitation Council UK). Newborn life support. RCUK: London; 2011.
Rennie JM, Kendall GS. A manual of neonatal intensive care. Taylor and Francis:
London; 2013.
Tracy MB, Klimek J, Coughtrey H, et al. Mask leak in one-person mask ventilation
compared to two-person in a newborn infant manikin study. Archives of Disease
in Childhood Fetal and Neonatal Edition. 2011;96(3):F195–F200.
Further reading
England C, Morgan R. Communication skills for midwives: challenges in everyday
practice. McGraw–Hill/Open University Press: Maidenhead; 2012.
Chapter 7 provides details regarding personal interactions in acute clinical situations
and explores in depth how the midwife should communicate with parents and
members of the multiprofessional team in the neonatal resuscitation situation..
Mosley C M J, Shaw B N J. A longitudinal cohort study to investigate the
retention of knowledge and skills following attendance on the Newborn Life
Support course. Archives of Disease in Childhood. 2013;98(8):582–586.
This article reports that practitioners following specialist training, over time experience
deterioration in neonatal resuscitation ability and technique, especially if they are not
exposed to clinical resuscitation situations on a regular basis. Practitioners failed on
simple but essential interventions such as not removing the wet towel from the baby
and not assessing the baby's heart beat. It is suggested that practitioners should
attend resuscitation updates on a regular basis to maintain and hone their skills,
which should improve confidence..
C H AP T E R 3 0
The healthy low birth weight baby
Carole England
CHAPTER CONTENTS
Classification of babies by gestation and weight 617
Gestational age 618
Birth weight 618
Small for gestational age (SGA) 618
Types of intrauterine growth restriction rate (IUGR) 619
The preterm baby 621
Characteristics of the preterm baby 621
Care of the healthy LBW baby 622
Management at birth 622
Assessment of gestational age 622
Thermoregulation 623
Hypoglycaemia 623
Feeding 624
Optimizing the care environment for the healthy LBW baby 625
Handling and touch 625
Noise and light hazards 626
Sleeping position 626
References 626
Further reading 628
Useful websites 628
Between 6% and 7% of all babies born in the United Kingdom (UK) weigh
<2500 g at birth. Preterm babies make up two-thirds of low birth weight
(LBW) babies, with the other one-third being small for their gestational age
(SGA), some of which will be born at term.
It is now common practice for healthy LBW babies from 32 weeks' gestation
with a birth weight of 1.7–2.5 kg to be cared for on a postnatal ward with
their mother. The majority of these babies remain well, will have minimal or
no illness in the neonatal period and can be cared for by midwives as the
lead practitioner (Department of Health [DH] 2010). This chapter will examine
the role of the midwife in supporting parents to care for their healthy LBW
baby and the specific knowledge and skills the midwife requires to fulfil this
effectively.
The chapter aims to:
• examine the terminology and classifications of babies in relation to gestational age and
birth weight
• critically discuss the importance of skin-to-skin contact and early feeding in the
prevention of cold stress and hypoglycaemia
• discuss the provision of an accommodating environment that supports the developing
needs of the LBW baby on the postnatal ward.
Classification of babies by gestation and weight
D efinitions of gestational age disregard any considerations of birth weight and
likewise definitions of LBW are based upon weight alone and do not consider the
gestational age of the baby.
Gestational age
A ccording to S mith (2012), babies should preferably be classified by gestational age,
as this is a be er physiological measure compared to birth weight. A preterm baby is
born before completion of the 37th gestational week (259 days), which is calculated
from the first day of the mother's last menstrual period (LMP) and has no relevance to
the baby's weight, length, head circumference, or indeed any other measurement of
fetal or neonatal size. S mith (2012) further asserts that gestational age estimates by
first-trimester ultrasonography are accurate within 4 days, so that the combination of
fetal crown–rump length and menstrual history are now considered more accurate
indices for estimating gestational age.
Birth weight
The W orld Health O rganization W ( HO 1997a) recommend that babies who weigh
<2500 g should be called low birth weight (LBW ). A s neonatal care has become more
effective and babies are surviving at earlier gestations, new LBW categories are now
recognized:
• very low birth weight (VLBW) babies are those weighing below 1500 g at birth
• extremely low birth weight (ELBW) babies are those who weigh below 1000 g at birth.
I t is the relationship between weight (for assessment of growth) and gestational age
(for assessment of maturity) that is of great importance. This relationship can be seen
plo ed on centile charts (Fig. 30.1) to visually demonstrate that growth is appropriate,
excessive or diminished for gestational age and that the baby is either preterm, term
or post-term. Growth charts, however, should be derived from studies of local
populations, because genetically derived growth differences exist between countries,
cultures and lifestyles.
FIG. 30.1 A centile chart, showing weight and gestation.
Various presentations of LBW babies can be described as follows:
1. Babies whose rate of intrauterine growth is normal at the moment of birth. They are
small because labour began before the end of the 37th gestational week. These
preterm babies are appropriately grown for their gestational age (AGA). Their weight
is between the 90th and 10th centiles for their gestation age.
2. Babies whose rate of intrauterine growth has slowed down and who are born at, or
later than, term. These term or post-term babies are under-grown for gestational age
and are consequently small for their gestational age (SGA). Their weight is below
the 10th centile for their gestational age.
3. Babies whose rate of intrauterine growth has slowed down and who are also born
before term. These preterm babies are small by virtue of both their early birth and
impaired intrauterine growth. They are both pre-term and SGA babies because their
weight will be below the 10th centile for their reduced gestational age.
Babies are considered large for their gestational age (LGA) when their weight
exceeds the 90th centile. Consequently, it should be recognized that both term and
preterm babies can fall into the category of AGA, SGA, or LGA (Fig. 30.2).
FIG. 30.2 Centile charts that illustrate how low birth weight babies are categorized by weight
and gestation. (A) Low birth weight. (B) Preterm gestation. (C) Small for gestational age. (D) Co-
existence of preterm gestation and small for gestational age.
Small for gestational age (SGA)
Babies that are small for their gestational age are of a size that is smaller when
compared to other babies. I f a baby is under-grown and below the 10th centile for
weight, historically there has been for some an automatic assumption that as a fetus the
baby has experienced intrauterine growth restriction (I UGR).Wilkins-Haug and
Heffner (2012) define I UGR as a rate of fetal growth that is less than the normal
growth potential for a specific baby. However, this does not mean that all S GA babies
are small as a result of I UGR. S ome small babies are genetically small because they
have small parents or grandparents and this familial factor determines their
smallness. They are well, healthy babies who need to be treated accordingly.
Centile charts can act only as guides. Tro er (2009) states that maternal
characteristics, obstetric history and birth details in addition to the appearance and
behaviour of the baby should determine what care is required. S hould a baby be born
at 36 weeks' gestation with a birthweight of 2100 g, which according to weight, is well
below the 50th centile, this baby would not fall below the 10th centile line for weight,
so should not be identified as S GA but may be under-grown. S imilarly it should not be
assumed that all infants of diabetic mothers (I D M) are macrosomic and only fall into
the LGA category. D iabetes and obesity are conditions that deleteriously affect
maternal circulation and perfusion, so some babies will suffer from I UGR and could
be small for their gestational age.
Types of intrauterine growth restriction (IUGR)
There are two recognized types of I UGR. The causes and predisposing factors are seen
as multi-factorial (Box 30.1).
Box 30.1
C a use s of int ra ut e rine growt h re st rict ion ( I U G R )
Fetal growth is regulated by maternal, placental and fetal factors and
represents a mix of genetic mechanisms and environmental influences
through which growth potential is expressed. The mechanisms that appear
to limit fetal growth are multifactorial.
Maternal factors
• Pregnancy-induced hypertension, pre-eclampsia, to include HELLP
syndrome
• Congenital and acquired heart disease, to include chronic hypertension
• Diabetes mellitus
• Undernutrition, to include obesity. Underweight mother/small stature.
Eating disorders
• Smoking, alcohol misuse
• Drugs: therapeutic (anticancer, thyroid medication), recreational
(narcotic, prescription)
• Renal disease, collagen disorders, anaemia, thyroid disorders and
epilepsy
• Genetic diseases such as maternal phenylketonuria and cystic fibrosis
• Extremes in young and elderly mothers
• Poor obstetric history that includes preterm labour
• Respiratory disorders, to include asthma
• Maternal work and ability to rest
Fetal factors
• Multiple gestation
• Chromosomal/genetic abnormality (particularly trisomy conditions),
including inborn errors of metabolism, dwarf syndromes
• Intrauterine infection: toxoplasmosis, rubella, cytomegalovirus, herpes
simplex (ToRCH) and syphilis
Placental factors
• Abruptio placenta
• Placenta praevia
• Chorioamnionitis
• Abnormal cord insertion
• Oligohydramnios
Sources: Nodine et al 2011; Smith 2012
IUGR that begins early in the first trimester caused by a combination
of intrinsic and extrinsic factors, results in symmetrical fetal growth
I n this scenario, the fetus suffers significant interruption to hyperplastic cell division
(Fig. 30.3). A s a result, the head circumference, length and weight are all
proportionately reduced for gestational age. The main causes are referred to as
intrinsic factors that operate from within the fetus and cause symmetrical growth
restriction, often as a result of transplacental infections or chromosomal/genetic
defects. I n addition, the deleterious effects of maternal lifestyle where a poor quality
diet may be in combination with smoking, drug and/or alcohol misuse, can impact on
fetal growth and development. These examples are referred to as extrinsic factors that
can act upon the fetal environment and contribute to congenital malformations that
culminate in conditions such as fetal alcohol syndrome (FA S ) or chronic hypoxia
associated with maternal smoking. A ffected babies suffer interruption to hyperplastic
(new cell) division, therefore look small and do not have the potential for normal
growth. Remember a small head equates to a small brain. These babies make up 10–
30% of all SGA babies in Western societies (Sinha et al 2012).
FIG. 30.3 Graph to show hyperplastic and hypertrophic cellular growth from conception to 2
years.
IUGR that begins in the last trimester, caused by extrinsic factors,
results in asymmetrical fetal growth
This type of fetus has been growing normally then starts to experience interruption to
hypertrophic cell growth (Fig. 30.3). This is influenced by extrinsic factors in its
intrauterine environment that cause disruption to placental perfusion of oxygen and
nutrients. W hen serial ultrasound scans of head and abdominal circumference in
addition to D oppler measurements indicate poor and disproportionate growth, the
birth of many affected fetuses are expedited early, usually by elective caesarean
section. For those women where an early birth is not possible (the smaller twin or
triplet; a concealed pregnancy or through failing to access antenatal care), their baby
will to varying degrees have a characteristic brain-sparing appearance. The baby's head
appears relatively large compared to the body (see Fig. 30.4); however, the head
circumference is usually within normal parameters and brain growth is usually spared.
The skull bones are within gestational norms for length and density but the anterior
fontanelle may be larger than expected, owing to diminished bone formation. The
abdomen appears sunken owing to shrinkage of the liver and spleen, which surrender
their stores of glycogen and red blood cell mass respectively as the fetus adapts to the
adverse conditions of the uterus. A s subcutaneous fat is used as a source of glucose
and ketones, the skin becomes loose, giving the baby a wizened, old appearance.
Vernix caseosa is frequently reduced or absent as a result of diminished skin
perfusion. I n the absence of this protective covering, the skin is continuously exposed
to amniotic fluid and its cells will begin to desquamate (shed) so that the skin appears
pale, dry and coarse. I f the baby is of a mature gestation and has passed meconium in
utero, the skin may be stained with meconium. Fetal distress in labour and
hypoglycaemia are more likely to be seen in this group of babies. Unless severely
affected, these babies appear hyperactive and hungry, with a lusty cry.
FIG. 30.4 Baby with asymmetrical growth restriction. Note the apparently large head compared
with the undergrown body.
The preterm baby
The preterm baby is born before the end of the 37th gestational week, regardless of
birth weight. Most of these babies are appropriately grown, some are S GA and a small
number are LGA . The factors that play a role in the initiation of preterm labour are
largely unknown and mainly overlay with factors that impair fetal growth. They are
divided into those labours that commence spontaneously and those where a decision
is made to terminate a viable pregnancy before term: referred to as elective causes (Box
30.2).
Box 30.2
C a use s of pre t e rm la bour
Spontaneous causes
• 40% unknown
• Multiple gestation – the higher the multiple the greater the chance
• Hyperpyrexia as a result of viral or bacterial infection, often urinary tract
infections
• Premature rupture of the membranes caused by maternal infection,
especially chorioamnionitis. Also polyhydramnios
• Maternal short stature, age (<18 or > 35years) and parity
• Maternal uterine malformation; often bicornuate or significant fibroids
• Poor obstetric history; history of preterm labour
• Cervical incompetence, history of cone biopsy
• Maternal substance abuse, particularly alcohol and cigarette smoking
Elective causes
• Pregnancy-induced hypertension, pre-eclampsia, chronic hypertension
• Maternal disease: renal, heart
• Placenta praevia, abruptio placenta
• Rhesus incompatibility
• Congenital abnormality of the baby
• IUGR
Sources: Sinha et al 2012; Smith 2012
Characteristics of the preterm baby
The appearance of the preterm baby at birth will depend upon the gestational age. The
following description will focus upon the baby born from 32 weeks' gestation. Preterm
babies rarely grow large enough in utero to develop muscular flexion and fully adopt
the fetal position. A s a result their posture appears fla ened, with hips abducted,
knees and ankles flexed. Lissauer and Faranoff (2011) describe a generally hypotonic
baby with a weak and feeble cry. The head is in proportion to the body, the skull bones
are soft with large fontanelles and wide sutures. The chest is small and narrow and
appears underdeveloped. The abdomen is prominent because the liver and spleen are
large and abdominal muscle tone is poor (Fig. 30.5). The liver is large because it
receives a good supply of oxygenated blood and is active in the production of red
blood cells. The umbilicus appears low in the abdomen because linear growth is
cephalo-caudal, being more apparent nearer to the head than rump, by virtue of fetal
circulation oxygenation. S ubcutaneous fat is laid down from 28 weeks' gestation,
therefore its presence and amount will affect the redness and transparency of the skin.
Vernix caseosa is abundant in the last trimester and tends to accumulate at sites of
dense lanugo growth, such as the face, ears, shoulders and sacral region, protecting
the skin from amniotic fluid maceration. The ear pinna is flat with li le curve, the eyes
bulge and the orbital ridges are prominent. The nipple areola is poorly developed and
barely visible. The cord is white, fleshy and glistening. The plantar creases are absent
before 36 weeks' gestation but soon begin to appear, as fluid loss occurs through the
skin. I n girls the labia majora fail to cover the labia minora and in boys the testes
descend into the scrotal sac at about the 37th gestational week.
FIG. 30.5 Healthy preterm baby born at 32 weeks' gestation. Note the presence of a nasogastric
tube. The thermocouple of the servo-mode is taped to the skin of the baby's upper abdomen.
Care of the healthy LBW baby
Many of the care issues relevant to the LBW baby apply to both the preterm and the
SGA infant. Where differences do exist, these will receive further consideration.
Management at birth
Given the unpredictability of the birth process on growth and maturity, the role of the
midwife in the birthing room is to prepare the environment, staff and parents for
certain eventualities. This takes the form of informing members of the
multiprofessional team such as a second midwife, neonatal practitioner and neonatal
nurse, to be on standby for the birth. The incidence of perinatal asphyxia and
congenital malformation is greater in S GA babies and the baby with a scaphoid
abdomen could be physically normal, albeit thin, but could also deteriorate quickly if
presenting with a diaphragmatic hernia. The midwife should be fully aware of the
availability of cots in the neonatal intensive care unit (N I CU), transitional care unit or
postnatal ward according to the condition of the baby and their potential care
demands following birth. The labour room ambient temperature should ideally be
between 23 and 26 °C and the neonatal resuscitaire and accompanying equipment
should be ready for use.
It is particularly important that the midwife attaches the correct labels to the baby at
birth in case separation from the mother should occur at any time if the baby's
condition becomes unstable. The midwife should cut the cord and leave an extra
length to allow for easy access to the umbilical vessels in case they are needed at a
later time. At birth, the midwife should ensure that the baby is thoroughly dried
before skin-to-skin contact is a empted, in order to prevent evaporative heat losses.
S kin-to-skin contact for a period of up to 50 minutes is recommended to secure the
baby's conductive heat transfer gains and help the baby to become physically
stabilized to feed. I f the mother chooses not to engage in skin-to-skin contact, the
father may wish to do so (Chin et al 2011) but if not, the baby can be dressed, wrapped
and held by the parents. The baby's axilla temperature should be maintained between
36.5 °C and 37.5 °C. Early a empts at breastfeeding should be encouraged (Pollard
2012).
Assessment of gestational age
With developments of more accurate dating by antenatal ultrasound techniques, it is
argued by S mith (2012) that there is less justification for a full assessment of
gestational age in healthy LBW babies. The exception is applied when the mother
deliberately conceals her pregnancy or has difficulty/is unable to communicate. The
neonatal practitioner, with the view that no harm is caused as a result of the process,
should carefully conduct any assessments that are carried out. S asidharan et al (2009)
considers that the Ballard S core (Ballard et al 1991) can give an accurate assessment of
gestational age until at least 7 days of life and continues to be the most widely used
tool.
The Department of Health (DH 2009) states that W HO has introduced growth charts
based on exclusively breastfed babies. A chart specifically for preterm babies 32–36
weeks has also been devised that has no centile lines between birth and the first two
weeks of neonatal life and the 50th centile has been de-emphasized to be er reflect
the natural weight losses and gains of this category of baby. I t is important that
midwives are educated to use these specialized charts efficiently so that the baby's
subsequent growth and development can be monitored effectively (DH 2009).
Thermoregulation
Thermoregulation is the balance between heat production and heat loss. The
prevention of cold stress, which may lead to hypothermia – which is a body
temperature below 35 °C – is critical for the intact survival of the LBW baby. N ewborn
babies are unable to shiver, move very much or seek extra warmth for themselves and
therefore rely upon physical adaptations that generate heat by raising basal metabolic
rate and utilize brown fat deposits. Thus, exposure to cool environments can result in
multisystem changes. A s body temperature falls, tissue oxygen consumption rises as
the baby a empts to burn brown fat to generate energy and heat. D iversion of blood
away from the gastrointestinal tract reduces all forms of digestion. A empting to warm
a cold baby by feeding is ineffectual and carries the danger of milk inhalation. Care measures
should aim to provide an environment that supports the neutral thermal environment.
This environment constitutes a range of ambient temperatures within which the
metabolic rate is minimal, the baby is neither gaining nor losing heat, oxygen
consumption is negligible and the core-to-skin temperature gradient is small
(Blackburn 2007).
I n the baby, the head accounts for at least one-fifth of the total body surface area
and brain heat production is thought to be 55% of total metabolic heat production.
Rapid heat loss due to the large head-to-body ratio and large surface area is
exaggerated. Wide sutures and large fontanelles add to the heat-losing tendency. O nce
the baby is thoroughly dried, which includes the face, a pre-warmed hat will minimize
heat loss from the head. A symmetric S GA babies have increased skin maturity but
often depleted stores of subcutaneous fat, which are used for insulation. Their raised
basal metabolic rate helps them to produce heat but their high energy demands in the
presence of poor glycogen stores and minimal fat deposition can soon lead to
hypoglycaemia (<2.6 mmol/l) followed by physiological cooling (<36 °C) to reach a state
of hypothermia (<35 °C) (Bedford and Lomax 2011).
A ll preterm babies are prone to heat loss because their ability to produce heat is
compromised by their immaturity, so factors such as their large ratio of surface area to
weight, their varying amounts of subcutaneous fat and their ability to mobilize brown
fat stores will be affected by their gestational age (Blackburn 2007). D uring cooling,
immaturity of the heat-regulating centres in the hypothalamus and medulla oblongata
causes failure to recognize the need to act. I n addition, preterm babies are unable to
increase their oxygen consumption effectively through normal respiratory function
and their calorific intake is often inadequate to meet increasing metabolic
requirements. Furthermore, their open resting postures increase their surface area
and, along with insensible water losses, these factors render the preterm baby more
susceptible to evaporative heat losses. Fellows (2010) argues that when the baby is not
receiving skin-to-skin contact with either parent and the baby is under 2 kg, the warm
conditions in an incubator can be achieved either by heating the air to 30–32 °C (air
mode) or by servo-mode: controlling the baby's body temperature at a desired set point
(36 °C). I n servo-mode, a thermocouple is taped to the upper abdomen and the
incubator heater maintains the skin at that site at a preset constant temperature (Fig.
30.4). Within the incubator, the baby is clothed with bedding, in a room temperature
of 26 °C. Most preterm babies between 2.0 kg and 2.5 kg will be cared for in a cot, in a
room temperature of 24 °C.
Hypoglycaemia
The term hypoglycaemia refers to a low blood glucose concentration and is usually a
feature of failure to adapt from the fetal state of continuous transplacental glucose
consumption to the extrauterine pa ern of intermi ent milk supply ( W HO 1997b).
Within the first hour of life the blood glucose levels fall, which triggers the pancreas to
stimulate the alpha cells of the I slets of Langerhans to produce glucagon, with the
consequential effect of releasing glucose from glycogen stores in the liver to maintain
the blood glucose levels within safe limits. However, it is generally questioned whether
LBW babies are as effective in this metabolism compared to appropriately grown term
babies and some caution is recommended (W HO 1997b). A symmetrical S GA babies
may have greater brain-to-body mass with a tendency towards polycythaemia, which
increases their energy demands, and since both the brain and the red blood cells are
obligatory glucose users, these factors can increase glucose requirements. Glycogen
storage is initiated at the beginning of the third trimester of pregnancy but may be
incomplete as a result of preterm birth or, in the asymmetrical S GA baby, may have
been drawn upon before birth.
Hypoglycaemia in healthy LBW babies is more likely to occur in conditions where
they become cold or where the initiation of early feeding (within the first hour) is
delayed. However, hypoglycaemia is associated with mild to moderate perinatal
asphyxia and maternal history of beta-blocker use (e.g. labetolol) as it causes
hyperinsulinism and interferes with glycogenolysis. The midwife should consider that
there may be some underlying medical condition that may call for more thorough
investigation (Chapter 33).
The signs of hypoglycaemia are varied and Wilker (2012) acknowledges that
hypoglycaemia can present with no or few clinical signs. The clinical picture of tremor
and irritability may occasionally lead to convulsion and decreased consciousness. A
high-pitched cry, hypotonia, unexplained apnoea and bradycardia with central
cyanosis are also recognized as serious signs of deterioration in the baby's health and
need referral to a medical practitioner. J i eriness is not a sign of hypoglycaemia
(United N ations Childrens Fund [UN I CEF] 2010 ). The aim of management is to
maintain the true blood glucose level above 2.6 mmol/l, which is considered to be the
lowest level of normal in the first few days of life (W HO 1997b; Lissauer and Fanaroff
2011).
Healthy LBW babies who show no clinical signs of hypoglycaemia, are demanding
and taking nutritive feeds on a regular basis and maintaining their body temperature,
do not need screening for hypoglycaemia. The emphasis of care is placed upon the
concept of adequate feeding and the cornerstone of success is the midwife's ability to
assess whether the baby is feeding sufficiently well to meet energy requirements. The
preterm baby may be sleepy and a empts to take the first feed may reflect its
gestational age. Midwives should be guided by the local policies within their
employing organization regarding use of reagent strips to assess for hypoglycaemia,
but prior to the baby's second feed is the best time to ascertain whether the first feed
was effective in maintaining the capillary blood glucose level above 2 mmol/l. I f a
baby, despite being fed, presents with clinical signs of hypoglycaemia, a venous sample
should be taken by the medical practitioner to assess the true blood glucose level
which should be dispatched to the laboratory. A true blood glucose level that remains
<2.6 mmol/dl, despite the baby's further a empts to feed by breast or take colostrum
by cup, may warrant transfer to the N I CU, because glucose by intravenous bolus may
be necessary to correct the metabolic disturbance. Healthy mature S GA babies with an
asymmetrical growth pa ern will usually breastfeed within the first 30–60 minutes of
birth and will demand feeds every 2–3 hours thereafter. For the majority of LBW
babies, hypoglycaemia is relatively short-lived and limited to the first 48 hours
following birth.
Feeding
A ccording to J ones and S pencer (2008) both preterm and S GA babies benefit from
human milk because it contains long chain polyunsaturated omega-3 fatty acids, which
are thought to be essential for the myelination of neural membranes and for retinal
development. Preterm breast milk has a higher concentration of lipids, protein,
sodium, calcium and immunoglobulins, alongside lipases and enzymes that improve
digestion and absorption. The uniqueness of the mother's milk for her own baby
cannot be overstated but she needs to understand what her baby may be able to
achieve related to the stage of their development, which is based upon the combined
influences of their gestational age at birth and their neonatal age.
For a baby to feed for nutritive purposes, the coordination of breathing with suck
and swallow reflexes reflects neurobehavioural maturation and organization, which is
thought to occur between 32 and 36 weeks' gestation. Blackburn (2007) argues that
preterm babies are limited in their ability to suck because they lack cheek pads, which
leads to a weaker suck, coupled with weak musculature and flexor control, which are
important for firm lip and jaw closure.
A ls and Butler (2006) believe that parents should provide physical support for head,
trunk and shoulders as sucking is part of the flexor pa ern of development and may
be enhanced by giving the baby something to grasp. The preterm baby's head is very
heavy for the weak musculature of the neck and would, if not supported, result in
considerable head lag, so correct positioning and a achment to the breast can be
made much more difficult to achieve. Poor head alignment can result in airway
collapse, which may lead to apnoea and bradycardia, therefore support from the
midwife is essential when initiating breastfeeding.
I f the baby requires feeding via a nasogastric tube, it is now common practice for
parents to feed their own baby. Tube feeding has the advantage that the tube can be
left in situ during a cup or breastfeed and has been shown to eliminate the need to
introduce bo les into a breastfeeding regimen. However, babies are preferential nose
breathers and the presence of a nasogastric tube will inevitably take up part of their
available airway. Flint et al (2007) argue that the prolonged use of nasogastric tubes
has been associated with delay in the development of a baby's sucking and swallowing
reflexes simply because the mouth is bypassed. For these reasons, cup feeding has
been used in addition or as an alternative to tube feeding, in order to provide the baby
with a positive oral experience, to stimulate saliva and lingual lipases to aid digestion
and to accelerate the transition from naso/oro-gastric feeding to breastfeeding. O ral
gastric tubes have been associated with vagal stimulation and have resulted in
bradycardia and apnoea.
Pollard (2012) reports that certain behaviours, such as licking and lapping, are well
established before sucking and swallowing, and when babies are given the opportunity
it is not unusual to see them as early as 28 and 29 weeks licking milk that has been
expressed onto the nipple by their mother. Thus, babies between 30 and 32 weeks'
gestation can be given expressed breastmilk (EBM) by cup.Pollard (2012) makes a
further point that tongue movement is vital in the efficient stripping of the milk ducts,
so cup-feeding can be seen as developmental preparation for breastfeeding. Between
32 and 34 weeks' gestation, cup-feeding can act as the main method of feeding, with
the baby taking occasional complete breastfeeds. The baby uses less energy to take its
feed by cup compared to bo le, which supports their general wellbeing and
homeostasis.
A preterm baby of <35 weeks' gestation can be gently wrapped/swaddled prior to a
feed and this is thought to provide reassurance and comfort, not unlike the unique
close-fi ing tactile stimulation of the uterus. McGrath (2004) argues that this approach
supports development of flexion as well as decreasing disorganized behaviours that
could detract from feeding success. A preterm baby may easily tire and the mother can
be taught to start the flow of milk by hand expressing, before a empting to a ach her
baby to the breast. Long pauses between sucks are to be expected. This burst–pause
pa ern is a signal of normal development and seems to occur earlier with
breastfeeding. The baby may appear to be asleep and a change in position may remind
them of the task in hand, but it is thought to be a mistake to force a reluctant baby to
feed. I f it is obvious that the baby is more interested in sleeping, the mother can
complete the feed by nasogastric tube. Feeding frequency can vary between 8 and 10
feeds per day. The baby should be left to establish their own volume requirements and
feeding pa ern. I f necessary, the mother should use a breast pump to maintain her
lactation to reflect her baby's feeding style.
Optimizing the care environment for the healthy LBW
baby
The normal sensory requirements of the developing neonatal brain depend upon
subtle influences, first from the uterus and then from the breast ( Reid and Freer 2010).
A ny disruption to this natural arrangement renders the LBW baby vulnerable to
influences in the care environment that can result in poor coordination as a result of
delays in the development of different subsystems (autonomic, motor, sensory, etc.).
Reid and Freer (2010) believe maternal role development depends upon the mother's
self-esteem and her perception of mothering. By a empting to adapt the care
environment to be more like the intrauterine environment, the midwife can help
parents to become aware of their baby's behavioural and autonomic cues and utilize
them in organizing care according to their baby's individual tolerance. The ethos of
care is for them to listen and learn from their baby, to come to know and see them as
an individual, competent for their stage of development and not merely a baby born too
early, or a dysfunctional term baby. They should be encouraged (but not cajoled) into
taking a major role in their baby's emerging developmental agenda, enabling them to
understand the situation in which they find themselves, so they are further able to
reset their expectations and thus provide more baby-led support (Teti et al 2005; Reid
and Freer 2010).
A ccording to McGrath (2004), the emerging task of the term newborn baby is
increasing alertness, with growing responsiveness to the outside world. By
comparison, a preterm baby is at a stage of development that is more concerned with
their internal world. Term babies have stable function of the autonomic and motor
systems. Preterm babies will be at different stages of this development, depending on
their gestational age and health status. They will spend more time in rapid eye
movement (REM) sleep or drowsy states and have difficulty in achieving deep sleep.
They are unable to shut out stimulation that prevents them from sleeping and resting,
and sudden noise hazards provoke stress reactions, which can adversely affect
respiratory, cardiovascular and digestive stability. The term baby is able to shut out
such stimuli for rest and sleep purposes. The degree to which S GA term babies have
been affected by their unique intrauterine experience is difficult to assess in the short
term, but hyperactivity is seen as a feature of an adaptive stress reaction. These babies,
like their preterm counterparts, need an environment that supports their level of
robustness. Environmental disturbances, excessive or prolonged handling and even
activities like feeding may add extra physiological burden to an already compromised
state. S ocial contact is considered a vital element for the development of parent–baby
interaction, yet stereotypical notions of social contact that revolve around practical
caregiving and feeding may not be suitable for some babies and when these activities
are pooled together, may draw too heavily on the baby's physical resources. W hen the
baby is overstimulated and wishes to terminate the interaction, certain cues are known
as coping signals and are recognized as fist clenching, furrowing of the brow, gaze aversion,
splayed fingers and yawning. Should the baby wish to initiate or continue an interaction,
they tend to demonstrate approach signals such as raised eyebrows, head raising and
engagement in different degrees of eye contact with their social partners. The midwife can
reassure parents that by paying a ention to their baby's behaviour they can work with
their baby's capabilities, which is crucial for maintaining the baby's healthy status (Als
and Butler 2006).
Handling and touch
Kangaroo care (KC) is used to promote closeness between a baby and mother and
involves placing the nappy-clad baby upright between the maternal breasts for skin-to-
skin contact (Fig. 30.6). The LBW baby can remain beneath the mother's clothing for
varying periods of time that suit the mother. S ome mothers may have repeated
contacts throughout the day, others may prefer specific periods around which they
plan their daily activities. There are no rules or time limitations applied, but contact
should be reviewed if there are any clinical signs of neonatal distress. Hake-Brooks
and A nderson (2008) found that preterm babies of 32–36 weeks' gestation who had
unlimited skin-to-skin contact, breast fed for longer compared to those who had
traditional nursery care. Conde-A gudelo and Belizan (2009)support this view and also
consider that the baby remained more physiologically stable, with less reported
incidence of infection.
FIG. 30.6 Kangaroo care.
Noise and light hazards
The time spent in a postnatal ward should be a time of rest and recuperation for both
the mother and her LBW baby. A ll extraneous noises should be eliminated from
clinical areas, such as musical toys and mobiles, harsh cla ering footwear, telephones,
radios, intercom systems and raised voices. Clinicians should be aware of noise
hazards, such as the closing of incubator portholes, use of peddle bins, ward doors
and general equipment. Ward areas may be carpeted and quiet signs can be posted to
remind visitors not to disrupt the peace. I n dimmed lighting conditions preterm
babies are more able to improve their quality of sleep and alert status. Reduced light
levels at night will help to promote the development of circadian rhythms and diurnal
cycles. Light levels can be adjusted during the day with curtains or blinds to shade
windows and protect the room from direct sunlight. S creens to shield adjacent babies
from phototherapy lights are also essential.
Sleeping position
Hunter (2004) reports that preterm babies have reduced muscle power and bulk, with
flaccid muscle tone, therefore their movements are erratic, weak or flailing. They exert
energy to maintain their body position against the pull of gravity. N esting preterm
babies into soft bedding, in addition to the use of close flexible boundaries, helps to
keep their limbs in midline flexion, however it is vital that they are nursed in a supine
position to prevent asphyxia. The supine position is also thought to be effective in
promoting engagement in self-regulatory behaviours such as exploration of the face
and mouth, hand and foot clasping, boundary searching, flexion and extension of the
limbs. Pressure on the occiput should, over time, ensure a more rounded head.
Placing healthy LBW babies to sleep in the prone position has been theoretically
eradicated from neonatal practice and Warwood (2010) reiterates that all babies
should be placed in the supine position, and it is incumbent upon midwives to
accustom the baby and educate the parents in adopting this approach. Teaching
resuscitation to parents is part of routine preparation for transfer home, although
according to Younger et al (2007) this degree of preparedness can empower some
parents but frighten others. The decision to receive training should be the parent's
choice (Resuscitation Council United Kingdom 2011).
The importance of providing an appropriate environment for the healthy LBW baby
cannot be overstressed and the ideal environment should resemble home, which
provides a cycle of day and night, regular nourishment, rest, stimulation and loving
a ention. The midwife's role is to create such an environment, primarily for the
physical development of the baby but at the same time to provide psychological
support for the mother and her family. A ccording to Fleury et al (2010) the mother
should be encouraged to rely upon her own instincts and common sense so that the
rhythm of total care she adopts in hospital will thoroughly prepare her for when she
goes home. Gambini et al (2011) make the point that often the difference between
early and late transfer home is more dependent upon the mother's positive a itude
and skill development than the baby's maturity and inherent abilities.
References
Als H, Butler S. Neurobehavioural development of the pre-term infant. Faranoff
and Martin's neonatal–perinatal medicine. Diseases of the fetus and infant. Elsevier
Mosby: London; 2006:1051–1068. Martin RJ, Fanaroff AA, Walsh MC. Faranoff
and Martin's neonatal–perinatal medicine. Diseases of the fetus and infant. vol 2.
Ballard JL, Khoury C, Wedig K, et al. New Ballard Score expanded to include
extremely premature infants. Journal of Paediatrics. 1991;119:417–423.
Bedford CD, Lomax A. Development of the heart and lungs and transition to
extrauterine life. Lomax A. Examination of the newborn: an evidence-based guide.
Wiley–Blackwell: Chichester; 2011:47–58.
Blackburn ST. Maternal, fetal and neonatal physiology: a clinical perspective. Mosby
Saunders: St Louis; 2007.
Chin R, Hall P, Daiches A. Father's experience of their transition to fatherhood: a
metasynthesis. Journal of Reproductive and Infant Psychology. 2011;29(1):4–18.
Conde-Agudelo A, Belizan J. Kangaroo mother care to reduce morbidity and
mortality in low birthweight infants. Cochrane Database of Systematic Reviews.
2009.
DH (Department of Health). Using the new UK–World Health Organization 0–4
years growth charts. DH: London; 2009 www.dh.gov.uk/publications.
DH (Department of Health). Midwifery 2020: delivering expectations. DH: London;
2010 www.midwifery2020.org.uk.
Fellows P. Management of thermal stability. Boxwell G. Neonatal intensive care
nursing. Routledge: London; 2010.
Fleury C, Parpinelly M, Makuch MY. Development of the mother–child
relationship following pre-eclampsia. Journal of Reproductive and Infant
Psychology. 2010;28(3):297–306.
Flint A, New K, Davies M. Cup feeding versus other forms of supplemental
enteral feeding for newborn infants unable to fully breastfeed. Cochrane
Database of Systematic Reviews. 2007.
Gambini I, Soldera G, Benevento B, et al. Postpartum psychosocial distress and
late preterm birth. Journal of Reproductive and Infant Psychology. 2011;29(5):472–
479.
Hake-Brooks S, Anderson G. Kangaroo care and breastfeeding of mother–
preterm infant dyads 0–18 months: a randomised controlled trial. Neonatal
Network. 2008;27:151–159.
Hunter J. Positioning. Kenner C, McGrath JM. Developmental care of newborns and
infants: a guide for health care professionals. Mosby: St Louis; 2004:299–320.
Jones E, Spencer A. Optimising the provision of human milk in preterm infants.
MIDIRS Midwifery Digest. 2008;18(1):118–121.
Lissauer T, Fanaroff AA. Neonatology at a glance. Wiley–Blackwell: Chichester;
2011.
McGrath JM. Feeding. Kenner C, McGrath JM. Developmental care of newborns and
infants: a guide for health care professionals. Mosby: St Louis; 2004:321–342.
Nodine PM, Arrruda J, Hastings-Tolsma M. Prenatal environment: effect on
neonatal outcome. Gardner SL, Carter BS, Enzman-Hines M, et al. Merenstein
and Gardner's handbook of neonatal intensive care. Mosby Elsevier: London;
2011:13–38.
Pollard M. Evidence-based care for breastfeeding mothers. Routledge: London; 2012.
Reid T, Freer Y. Developmentally focused nursing care. Boxwell G. Neonatal
intensive care nursing. Routledge: London; 2010:16–39.
Resuscitation Council UK (RCUK). Newborn life support. 3rd edn. RCUK: London;
2011.
Sasidharan K, Dutta S, Narang A. Validity of New Ballard Score until 7th day of
postnatal life in moderately preterm infants. Archives of Diseases in Childhood
Fetal and Neonatal Edition. 2009;94:39–44.
Sinha S, Miall L, Jardine L. Essential neonatal medicine. 5th edn. Wiley–Blackwell:
Chichester; 2012.
Smith VC. The high-risk newborn: anticipation, evaluation, management and
outcome. Cloherty JP, Eichenwald EC, Hansen AR, et al. Manual of neonatal
care. Wolters Kluwer Lippincott Williams and Wilkins: London; 2012:74–90.
Teti DM, Hess CR, O’Connell M. Parental perceptions of infant vulnerability in a
preterm sample: prediction from maternal adaptation to parenthood during
the neonatal period. Journal of Development and Behavioral Paediatrics.
2005;26:283–292.
Trotter CW. Gestational age. Tappero EP, Honeyfield ME. Physical assessment of
the newborn. NICU INK: California; 2009:21–40.
UNICEF (United Nations Children's Fund). Guidance on the development of policies
and guidelines for the prevention and management of hypoglycaemia of the newborn.
[Available at] www.babyfriendly.org.uk; 2010 [(accessed 12 April 2013)] .
Warwood G. Teaching resuscitation to parents. Lumsden H, Holmes D. Care of
the newborn by ten teachers. Hodder Arnold: London; 2010:168–177.
Wilker RE. Hypoglycaemia and hyperglycaemia. Cloherty JP, Eichenwald EC,
Hansen AR, et al. Manual of neonatal care. Wolters Kluwer Lippincott Williams
and Wilkins: London; 2012:284–296.
Wilkins-Haug LE, Heffner LJ. Fetal assessment and prenatal diagnosis. Cloherty
JP, Eichenwald EC, Hansen AR, et al. Manual of neonatal care. Wolters Kluwer
Lippincott Williams and Wilkins: London; 2012:1–10.
WHO (World Health Organization). Manual of international statistical
classification of diseases, injuries and causes of death. [vol 11] WHO: Geneva; 1997.
WHO (World Health Organization). Hypoglycaemia of the newborn: review of the
literature. WHO: Geneva; 1997.
Younger JB, Kendell MJ, Pickler RH. Mastery of stress in mothers of preterm
infants. Journal of Specialist Paediatric Nursing. 2007;2:29–35.
Further reading
McInnes R, Chambers J. Supporting breastfeeding mothers: qualitative
synthesis. Journal of Advanced Nursing. 2008;62(4):407–427.
These authors focus upon practices that support breastfeeding in neonatal and
transitional care units. This article reflects the mothers’ perspectives and can inform
the midwife on whether the women felt supported..
Useful websites
[Ballard Score] www.ballardscore.com.
The New Ballard Score assesses physical and neuromuscular maturity to assess
gestational age..
[Growth charts] www.growthcharts.rcph.ac.uk.
Materials for training on how to use the charts can be downloaded on this website..
C H AP T E R 3 1
Trauma during birth, haemorrhages and
convulsions
Claire Greig
CHAPTER CONTENTS
Trauma during birth 629
Trauma to skin and superficial tissues 629
Muscle trauma 631
Nerve trauma 631
Fractures 633
Haemorrhages 633
Haemorrhages due to trauma 633
Haemorrhages due to disruptions in blood flow 635
Haemorrhages related to coagulopathies 637
Haemorrhages related to other causes 639
Convulsions 639
Support of parents 641
References 641
Further reading 643
Useful websites 643
This chapter focuses on complications occurring in specifically vulnerable
babies; the midwife's awareness of this vulnerability may prevent such
complications. If a complication does occur, the midwife must report it to
the baby's doctor and may work with that doctor and/or a wider
multiprofessional team to diagnose it and implement effective treatment.
Parents may be distressed when their baby suffers a complication and the
midwife helps them to understand the complication, facilitating their
discussions with the multiprofessional team members, and assisting them to
care for their baby.
The chapter presents information on:
• trauma during birth to skin and superficial tissues, muscle, nerves and bones
• major types of neonatal haemorrhage due to trauma, disruptions in blood flow,
coagulopathies and other causes
• neonatal convulsions
• specific interventions with parents.
Trauma during birth
D espite skilled midwifery and obstetric care in developed, Western societies and a
reduction in the incidence, birth trauma still occurs. Efforts continue to reduce the
incidence even further.
Trauma during birth includes:
• trauma to skin and superficial tissues
• muscle trauma
• nerve trauma
• fractures.
Trauma to skin and superficial tissues
Skin
S kin damage is often iatrogenic, resulting from forceps blades (Fig. 31.1), vacuum
extractor cups, scalp electrodes and scalpels. Poorly applied forceps blades or vacuum
extractor cup may result in scalp abrasions (Fig. 31.2), although less so with softer
vacuum extractor cups. Forceps blades may cause bruising, scalp electrodes cause
puncture wounds, as do fetal blood sampling techniques. O ccasionally laceration of
the baby's skin may occur during uterine incision at caesarean section. W hile rare,
subcutaneous fat necrosis may result from the pressure of forceps blades as well as
following severe asphyxia/hypoxaemia, meconium aspiration syndrome and
hypothermia (Pride 2012).
FIG. 31.1 Forceps abrasion on cheek. Reproduced from Thomas and Harvey 1997, with permission of
Elsevier.
FIG. 31.2 Scalp abrasion during vacuum-assisted birth. Note the chignon. Reproduced from
Thomas and Harvey 1997, with permission of Elsevier.
W hile superficial fat necrosis usually presents between days 1 and 28 with well-
defined areas of induration (Pride 2012), all other skin injuries should be detected
during the midwife's detailed examination of the baby immediately after birth (see
Chapter 28). A ll trauma should be indicated to parents and reported to the
paediatrician and General Practitioner (GP).
A brasions and lacerations should be kept clean and dry. I f there are signs of
infection, further medical consultation should be sought by the midwife or parents.
A ntibiotics may be required. D eeper lacerations may require closure with bu erfly
strips or sutures. Healing is usually rapid with no residual scarring (S orantin et al
2006). I f related causes are successfully treated, fat necrosis should spontaneously
resolve (Pride 2012).
Superficial tissues
This trauma involves oedematous swellings and/or bruising. D uring labour the fetal
part overlying the cervical os may be subjected to pressure, a ‘girdle of contact’, with
reduced venous return and resultant congestion and oedema.
Caput succedaneum
With cephalic presentation, there may be a diffuse oedematous swelling under the
scalp but above the periosteum, called a caput succedaneum (Fig. 31.3). With an
occipitoanterior position, one caput succedaneum may present. With an
occipitoposterior position, a caput succedaneum may form, but if the occiput rotates
anteriorly a second caput succedaneum may develop. I f, during the second stage of
labour, the birth of the head is delayed, the perineum may act as another ‘girdle of
contact’ with a second caput succedaneum forming. A ‘false’ caput succedaneum can
also occur if a vacuum extractor cup is used; because of its distinctive shape, the
swelling is known as a ‘chignon’ (see Fig. 31.2).
FIG. 31.3 Caput succedaneum.
A caput succedaneum is present at birth, thereafter decreasing in size. This swelling
can ‘pit’ on pressure, can cross a suture line, may be discoloured or bruised, may be
associated with increased moulding and the oedema may move to the dependent area
of the scalp (Lee 2011). The baby may appear to experience discomfort and, although
care continues as normal, gentle handling is appropriate. A brasion of a chignon is
possible.
The swelling is usually self-limiting, resolving within 36 hours, with no longer-term
consequences (S orantin et al 2006; Lee 2011). A n abraded chignon usually heals
rapidly if the area is kept clean, dry and is not irritated.
Other injuries
The cervical os may also restrict venous return when the fetal presentation is not
cephalic. W hen the face presents, it becomes congested, bruised and the eyes and lips
become oedematous. I n a breech presentation bruised and oedematous genitalia and
bu ocks may develop. I n both instances there may be discomfort and pain, therefore
gentle handling is essential and mild analgesia may be required.
For babies with bruised or oedematous bu ocks, maintaining nappy area hygiene is
important and must be accomplished without inflicting further skin trauma. Barrier
ointment or cream applications may be required if disposable nappies designed to
limit the contact of urine and faecal fluid with the skin are not available. I f skin
excoriation does occur, the infection risk increases and consultation with a wound care
specialist nurse may be required to ensure best skin care practice.
Uncomplicated oedema and bruising usually resolve within days. However, if the
baby suffers significant trauma during a vaginal breech birth, resulting serious
complications require specific treatment and take longer to resolve. These
complications may include excessive haemolysis resulting in hyperbilirubinaemia;
excessive blood loss resulting in hypovolaemia, shock, anaemia and disseminated
intravascular coagulation (D I C); and damage to muscles resulting in difficulties with
micturition and defecation.
Muscle trauma
Injuries to muscle result from tearing or when the blood supply is disrupted.
Torticollis
Torticollis is the result of tightness and shortening of one sternomastoid
(sternocleidomastoid) muscle. The right and left sternomastoid muscles run from the
respective side of the top of the sternum, along the right or left side of the neck and
are inserted into the mastoid process of the right or left temporal bone. W hen
contracted simultaneously, these muscles allow the head to flex. W hen contracted
separately, each turns the head to the opposite side.
The aetiology of torticollis is not fully understood. O ne type may result when the
muscle is torn due to excessive traction or twisting during the birth of the anterior
shoulder of a fetus with a cephalic presentation, or during rotation of the shoulders
when the fetus is being born by vaginal breech or caesarean section.
A 1–3 cm, apparently painless, hard lump of blood and fibrous tissue is felt on the
affected sternomastoid muscle. The muscle length is shortened, therefore the neck is
twisted to the affected side: a torticollis or wry neck. I f the techniques for assisting at
the above stages of birth are correctly applied, torticollis may be preventable (Saxena
2010).
Torticollis management involves carers and parents performing passive muscle-
stretching exercises initially under the guidance of a physiotherapist, actively
encouraging the baby to move the neck. The swelling usually resolves over several
weeks to months with minimal sequelae. Surgical intervention is required if there is no
resolution by one year. Follow-up to ensure achievement of normal movement is
recommended (Saxena 2010).
Nerve trauma
The nerves most commonly traumatized are the facial and brachial plexus nerves.
S pinal cord injury is very rare and is not discussed here; an excellent explanation is
given in Brand (2006).
Facial nerve
The facial or seventh (VI I ) cranial nerve runs close to the skin surface and is
vulnerable to compression resulting in unilateral facial palsy. Compression may occur
in the uterus but is more likely during birth by the maternal sacral promontory or by a
misapplied forceps blade, especially when the baby is macrosomic. O n the affected
side, the baby appears to have no nasolabial fold, the eyelid remains open and the
mouth is drawn over to the unaffected side (Fig. 31.4). The baby will drool excessively,
may be unable to form an effective seal on the breast or teat, resulting in initial
feeding difficulties, and may also have difficulty swallowing (Bruns 2012).
FIG. 31.4 Right-sided facial palsy. Note that the eye is open on the paralysed side and the
mouth is drawn over to the non-paralysed side. Reproduced from Thomas and Harvey 1997, with
permission of Elsevier.
There is no specific treatment. I f the eyelid remains open, regular instillation of eye
drops lubricate the eyeball. Feeding difficulties are usually overcome by the baby's
own adaptation, although alternative feeding positions may help. S pontaneous
resolution is usual within weeks; this may extend to months or years if the damage is
severe. Cosmetic surgical interventions for the most severely affected babies may be
required (Bruns 2012).
Brachial plexus
N erve roots exiting from the spine at the fifth to eighth cervical (C5–C8) and the first
thoracic (T1) vertebrae form a matrix of nerves in the neck and shoulder: the brachial
plexus. Brachial plexus trauma was thought to result from excessive lateral flexion,
rotation or traction of the head and neck during vaginal breech birth or when shoulder
dystocia occurred. However, the incidence of brachial plexus injury is relatively stable
despite interventions such as elective caesarean section, less traction force and
increased skill in the manoeuvers used to manage shoulder dystocia. Therefore it may
be that brachial plexus trauma is related more to the force exerted by the uterus
(Benjamin 2005; Sandmire and DeMott 2009).
The possible trauma to the brachial plexus ranges from oedema to haemorrhage to
tearing of the nerves and occurs most commonly in babies born at term (Blackburn
and D i enberger 2007) . Foad et al (2009) explain four types of trauma using the
N arakas classification. Trauma to C5–C6 results in Erb's (Erb–D uchenne/D uchenne–
Erb) palsy where there is paralysis of the shoulder muscles, biceps, elbow flexor and
forearm supinator muscles. The baby's affected arm is limp, inwardly rotated, the
elbow extended and the wrist pronated. W hen C7 is also traumatized, an extended
Erb's palsy presents in which the wrist and finger extensor muscles are affected,
resulting in wrist and finger flexion – the ‘waiter’s tip position’ (Fig. 31.5).
FIG. 31.5 Erb's palsy. Reproduced from Thomas and Harvey 1997, with permission of Elsevier.
W hen there is trauma to C8–T1, Klumpke's palsy presents. The shoulder and upper
arm are unaffected but the lower arm, wrist and hand are paralysed, resulting in wrist
drop, no grasp reflex and a claw-like appearance of the hand. I f there is associated
trauma to the cervical sympathetic nerves, Horner's syndrome may present with no
sensation on the affected side, pupil constriction and eyelid ptosis.
I f there is trauma to C5–T1, the result is total brachial plexus palsy (Erb–Klumpke)
where there is complete paralysis of the shoulder, arm and hand, lack of sensation and
circulatory problems. Horner's syndrome may also occur. I f there is bilateral paralysis,
spinal injury should be suspected (Benjamin 2005; Foad et al 2009; Semel-Concepcion
2012).
A ll types of brachial plexus trauma require further investigations, including X-ray
and ultrasound scanning (US S ) of the clavicle, arm, chest and cervical spine, and
assessment of the joints. Magnetic resonance imaging (MRI ) and electromyography
may assist in definitive diagnosis. Unnecessary and extremes of movement of the
affected arm should be avoided and care taken when holding or moving the baby to
avoid the arm dangling. The baby should not be lifted by the arms or axilla and the
affected arm should be dressed first and undressed last. A fter approximately 2 weeks,
when any inflammation should have subsided, passive range of movement exercises
are initiated under the direction of a physiotherapist.
Regular functional follow-up assessments are essential to gauge recovery. Most
babies with brachial plexus trauma recover completely within 3 weeks. Babies with no
recovery of biceps' function by 3 months and those with total brachial plexus injury
with Horner's syndrome and no recovery by 1 month may be referred for surgical
exploration and/or require microsurgical nerve repair. These babies are more likely to
have ongoing functional deficits and may require further surgery (Benjamin 2005; Foad
et al 2009; British Medical Journal [BMJ] Evidence Centre 2012).
Fractures
Fractures are rare but the most commonly affected bones are the clavicle, humerus,
femur and those of the skull. With all such fractures, a ‘crack’ may be heard during the
birth.
Clavicle
Clavicular fractures, the most common fractures, may occur with shoulder dystocia,
vaginal breech birth, or if the baby is macrosomic. The affected clavicle is usually the
one that was nearest the maternal symphysis pubis. Brachial plexus and phrenic nerve
injuries should be excluded in the affected baby (Laroia 2010; Mavrogenis et al 2011;
Vorvick and Kaneshiro 2011).
Humerus
Midshaft humeral fractures can occur with shoulder dystocia or during a vaginal
breech birth if the extended arm is forced down and born (Laroia 2010).
Femur
Midshaft femoral fractures can occur during vaginal breech birth if the extended legs
are forced down and born (Laroia 2010).
With most fractures, distortion, deformity, swelling or bruising are usually evident
on examination; crepitus may be felt; the baby appears to be in pain and is reluctant to
move the affected area. An X-ray examination may confirm the diagnosis.
The baby requires gentle handling to avoid further pain and a mild analgesic may be
necessary. Fractures of the clavicle require no specific treatment. To immobilize a
fractured humerus, place a pad in the axilla and firmly splint the arm with the elbow
bent across the chest with a bandage, ensuring respirations are not embarrassed.
I mmobilize a fractured femur using a splint and bandage. Traction and plaster casting
may be required. S table union of a fractured clavicle usually occurs in 7–10 days, while
the humerus and femur take 2–4 weeks (Laroia 2010).
Skull
A lthough rare, these fractures, linear or depressed, may occur during prolonged or
difficult instrumental births. There may be no signs but an overlying swelling,
cephalhaematoma, or signs of associated complications such as intracranial
haemorrhage or neurological disturbances, may suggest the presence of a fracture.
X-ray examination may confirm the fracture. A n ultrasound scan (US S ) may help
diagnose associated haemorrhage. A simple linear fracture usually requires no
treatment and heals quickly with no sequelae. Treatment of a depressed fracture
depends on the depth of the concavity. S hallow depressions in asymptomatic babies
usually resolve spontaneously. With a deeper depression or where there are signs of
complications, the fracture requires surgical repair. Contamination or evidence of
cerebrospinal fluid (CS F) leakage via the ear or nose require antibiotic therapy.
Treatment of associated complications is necessary. Babies who have a depressed skull
fracture have an optimistic outcome except if complications occur, when permanent
neurological damage is likely (Qureshi 2012).
Haemorrhages
Blood volume in the term baby is approximately 80–100 ml/kg and in the preterm baby
90–105 ml/kg, therefore even a small haemorrhage may be potentially fatal. I n this
section, haemorrhages are discussed according to their principal cause, or in relation
to other factors. Haemorrhages may be due to:
• trauma
• disruptions in blood flow
or can be related to:
• coagulopathies
• other causes.
Haemorrhages due to trauma
Cephalhaematoma
A cephalhaematoma (cephalohaematoma) is an effusion of blood under the
periosteum that covers the skull bones (Fig. 31.6). D uring a vaginal birth if there is
friction between the fetal skull and maternal pelvic bones, such as in cephalopelvic
disproportion or precipitate labour, the periosteum may be torn from the bone,
causing bleeding underneath. Cephalhaematomas may also occur during vacuum-
assisted births. Because the fetal or newborn skull bones are not fused, and as the
periosteum is adherent to the edges of the skull bones, a cephalhaematoma is
confined to one bone. However, more than one bone may be affected; therefore
multiple cephalhaematomas may develop. A double cephalhaematoma is usually
bilateral (Fig. 31.7). A caput succedaneum can co-exist with a cephalhaematoma.
FIG. 31.6 Cephalhaematoma.
FIG. 31.7 Bilateral cephalhaematoma.
Unlike caput succedaneum, a cephalhaematoma is not present at birth; the swelling
appears after 12 hours, grows larger over subsequent days and can persist for weeks.
The swelling is firm, does not pit on pressure, does not cross a suture and is fixed
(Blackburn and Ditzenberger 2007).
N o treatment is necessary and the swelling subsides when the blood is reabsorbed.
Hyperbilirubinaemia may complicate recovery due to haemolysis of the extravasated
blood. More rarely complications such as sepsis, osteomyelitis and meningitis may
occur. A s skull fractures may be associated with a cephalhaematoma, they should be
excluded (Paul et al 2009; Laroia 2010).
Subaponeurotic haemorrhage
S ubaponeurotic (subgaleal) haemorrhage is rare. Under the scalp, the epicranial
aponeurosis, a sheet of fibrous tissue that covers the cranial vault allowing for muscles
to a ach to the bone, provides a potential space above the periosteum through which
veins travel. Excessive traction on these veins results in haemorrhage, the epicranial
aponeurosis is pulled away from the periosteum of the skull bones and swelling is
evident (Fig. 31.8). S ubaponeurotic haemorrhage may occur spontaneously with any
type of birth but is more often associated with forceps and vacuum-assisted births,
and severe dystocia (Reid 2007).
FIG. 31.8 Subaponeurotic haemorrhage.
The swelling is present at birth, increases in size and is a firm, fluctuant mass. The
scalp is movable rather than fixed. The swelling can cross sutures and extend into the
subcutaneous tissue of neck and eyelids. The baby may appear pale, be hypotonic,
tachycardic and tachypnoeic and demonstrate discomfort or pain with head movement
or handling of the swelling. A caput succedaneum and/or a cephalhaematoma may co-
exist with a subaponeurotic haemorrhage.
I f the subaponeurotic haemorrhage is excessive, there is the potential for severe
shock, disseminated intravascular coagulation (D I C) and death. This emergency
situation requires immediate medical assistance, resuscitation, stabilization and full
supportive care, including blood transfusion (Blackburn and Ditzenberger 2007).
With a smaller haemorrhage and in the babies who survive a larger haemorrhage,
the blood is reabsorbed and the swelling and bruising resolve over 2–3 weeks.
Hyperbilirubinaemia complicates recovery (Reid 2007; Schierholz and Walker 2010).
Subdural haemorrhage
A sickle-shaped, double fold of dura mater, the falx cerebri, dips into the fissure
between the cerebral hemispheres. A ached at right angles to the falx cerebri,
between the cerebrum and the cerebellum, is a horseshoe-shaped fold of dura mater –
the tentorium cerebelli. I n these folds of dura run large venous sinuses draining blood
from the brain.
N ormally, moulding of the skull bones and stretching of the underlying structures
during birth are well tolerated. Trauma to the fetal head, such as excessive
compression or abnormal stretching, may tear the dura, particularly the tentorium
cerebelli, rupturing venous sinuses and resulting in a subdural haemorrhage.
Predisposing factors include rapid, abnormal or excessive moulding, such as in
precipitate labour or rapid birth, malpositions, malpresentations, cephalopelvic
disproportion, or undue compression during forceps manoeuvres (Barker 2007).
I f the haemorrhage is excessive, there is the potential for severe shock, D I C and
death. This emergency situation requires immediate medical assistance –
resuscitation, stabilization and full supportive care, including blood transfusion
(Blackburn and Ditzenberger 2007).
A baby with a small haemorrhage may demonstrate no signs and resolution is
spontaneous. A lternatively, the haemorrhage may initially be small but if blood
continues to leak, signs develop over several days. A s blood accumulates, there is
cerebral irritation, cerebral oedema and raised intracranial pressure. The baby is likely
to vomit, be unresponsive and have a bulging anterior fontanelle, hypotonia,
hyperthermia, apnoea, bradycardia and convulsions.
Blood in a non-traumatic lumbar puncture may assist in diagnosis as may cranial
US S , computerized tomography (CT) or magnetic resonance imaging (MRI )
S upportive treatment focuses on replacing blood volume and controlling the
consequences of asphyxia and raised intracranial pressure. S urgery to relieve pressure
or subdural taps or shunt placement to drain large collections of blood may be
required. A shunt is a drainage tube surgically inserted and connected to a one-way
valve placed subcutaneously behind the ear. The valve's outflow tube is a ached to a
catheter allowing drainage into a large vein in the neck, or into the peritoneum,
allowing reabsorption and elimination (Blackburn and D i enberger 2007). The
prognosis for all affected babies except those with massive haemorrhage is usually
good (Barker 2007).
Haemorrhages due to disruptions in blood flow
Subarachnoid haemorrhage
A primary subarachnoid haemorrhage involves bleeding directly into the
subarachnoid space. Preterm babies who suffer perinatal hypoxia resulting in
disruption of cerebral blood flow are most often affected. A secondary haemorrhage
involves leakage of blood into the subarachnoid space from an intraventricular
haemorrhage. A lthough classified here as a haemorrhage due to a disruption in blood
flow, a subarachnoid haemorrhage may also occur due to birth trauma similar to that
which results in subdural haemorrhage.
D epending on extent of the haemorrhage, the affected baby may demonstrate no
signs while others may have generalized convulsions from the second day of life and
have apnoeic episodes. A lthough rare, a massive subarachnoid haemorrhage may
occur and is usually fatal despite emergency resuscitation and stabilization efforts.
Blood in a non-traumatic lumbar puncture may assist in diagnosis, as may cranial
US S , CT or MRI . S upportive treatment focuses on replacing blood volume and
controlling the consequences of asphyxia and raised intracranial pressure. S urgery to
relieve pressure or subdural taps or shunt placement to drain large collections of
blood may be required (Barker 2007).
The condition is usually self-limiting. I f post-haemorrhagic hydrocephalus occurs,
drainage via a shunt may be required. The prognosis is usually very good for all
affected babies except those with related damage due to hypoxia (Barker 2007).
Germinal matrix haemorrhage, intraventricular haemorrhage and
periventricular haemorrhagic infarction (intraparenchymal lesion)
Germinal matrix haemorrhage (GMH), intraventricular haemorrhage (I VH) and
periventricular haemorrhagic infarction (PHI ), also known as intraparenchymal
lesions (I PL), primarily affect babies born at less than 32 weeks' gestation and those
weighing less than 1500 g at birth, although term babies may be affected. The
incidence and severity of these haemorrhages/lesions are inversely correlated with
gestational age.
There are three grades of GMH and I VH. A grade 1 haemorrhage into the germina
matrix is a germinal matrix, periventricular or subependymal haemorrhage. Extension
of the haemorrhage into the lateral ventricle(s), results in an I VH or grade 2
haemorrhage. The choroid plexus of the lateral ventricles normally produces CS F. I f a
grade 2 haemorrhage is complicated by blockage to the outflow of CS F, post-
haemorrhagic hydrocephalus develops and the ventricles dilate; a grade 3
haemorrhage (Annibale 2012).
I nitially it was understood that a grade 3 haemorrhage may extend into the cerebral
tissue, resulting in a parenchymal haemorrhage, known as a grade 4 haemorrhage
(Papile et al 1978) . Volpe (1997) proposed that the intraventricular clot in a grade 3
haemorrhage disrupts venous drainage, causing stasis and infarction. Reperfusion of
the area causes haemorrhage into the infarcted area and necrotic damage of the white
ma er. Therefore a grade 4 haemorrhage was reclassified as a complication of a grade
3 IVH, referred to as a PHI with IPL used interchangeably.
The stage of brain development is a crucial factor in the aetiology of GMH, I VH and
PHI /I PL. The two lateral ventricles are lined with ependymal tissue. Tissue lying
immediately next to the ependyma is the germinal matrix, also known as the
subependymal layer. From 8 to 32 weeks' gestation, neuroblasts and glioblasts are
produced in the germinal matrix and migrate to the cerebral cortex. N euronal
migration is complete by 20 weeks' gestation but glial cell development and migration
continues until approximately 32 weeks' gestation. D uring this period, a rich blood
supply is provided to the germinal matrix through fragile immature capillaries that
lack supporting muscle or collagen fibres. These vessels are particularly vulnerable to
fluctuations in cerebral blood flow and pressure, rupturing easily causing
haemorrhage. The ability of preterm babies to autoregulate cerebral blood flow and
pressure is immature, resulting in an increased vulnerability to haemorrhage. A fter 32
weeks' gestation the germinal matrix becomes less active and by term has almost
completely involuted; the capillaries become more stable and autoregulation becomes
established; therefore GMH, I VH and PHI /I PL in more mature babies are les
common than in those babies born at less than 32 weeks' gestation (Annibale 2012).
The venous drainage from white ma er and the deep areas of the brain, including
the lateral ventricles, involves a peculiar U-turn route in the area of the germinal
matrix. D isruptions to venous flow lead to congestion, with a risk of venous infarctions
and ischaemia. With reperfusion of these ischaemic areas, there may be haemorrhage
demonstrated as PHI (Volpe 2008).
Multiple factors may compromise cerebral haemodynamics resulting in GMH, I VH
and PHI /I PL. Early factors include obstetric haemorrhage, lack of antenatal steroids
low one minute A pgar score and low umbilical artery pH. Later risk factors include
acidosis, hypotension, hypertension, mechanical ventilation, apnoea, rapid volume
expansion, rapid administration of hyperosmolar solutions, pneumothorax and
tracheal suctioning. A lso implicated are excessive handling, exposure to light and
noise, lateral flexion of the baby's head and crying (Annibale 2012; Blackburn 2013).
Most affected babies show no signs or signs that are non-specific therefore the
haemorrhage/infaction/lesion is detectable only on US S . I f the haemorrhage is larger
or extends, the clinical features may gradually appear and worsen, including apnoeic
episodes that become more frequent and severe, bradycardia, pallor, falling packed
cell volume, tense anterior fontanelle, metabolic acidosis and convulsions. The baby
may be limp or unresponsive. I f the haemorrhage is large and sudden in onset, apnoea
and circulatory collapse may present (A nnibale 2012). At-risk babies should be
screened by 7 days of life for GMH, I VH or PHI /I PL using cranial US S . S erial scanni
may determine any increase, extension or complication.
Care of at-risk babies is focused on prevention (Blackburn and D i enberger 2007).
The birth should be in a regional obstetric unit with neonatal intensive care facilities.
Prenatal maternal steroids and postnatal surfactant replacement therapy should be
administered. Postnatally, haemodynamic stability is essential, as is prevention of
complications. Prevention of hypoxic events and blood flow and pressure fluctuations
is essential. Care is focused on maintaining normothermia, normoglycaemia,
oxygenation and comfort. S ophisticated monitoring equipment and the judicious use
of analgesic, sedative and inotropic drugs may assist achieving and maintaining
stability. The baby's developmental needs should be met, particularly in relation to
supportive flexed positioning, reduction in bright lighting, a quiet, undisturbed
environment and appropriate interaction with parents and others (Blackburn and
Ditzenberger 2007).
D espite preventative measures, babies do develop GMH, I VH and PHI /I PL. Th
outcome depends on the nature of the haemorrhage/lesion and associated
conditions/complications. The neurological prognosis for babies with a GMH or a
small I VH is usually good. A n I VH associated with ventricular dilatation may resolve
spontaneously with no long-term consequences. However, with a large I VH and
ventricular dilatation, the accumulating CS F may require temporary drainage using
ventricular taps or external ventricular drainage. S ome babies may require permanent
CS F drainage via a shunt. A pproximately 30–40% of these babies will have cognitive or
motor disabilities. A pproximately 50–80% of babies who have a large I VH with either
PHI /I PL or periventricular leukomalacia will die; survival is usually complicated in the
majority by significant cognitive and motor disabilities. Long-term follow-up is
essential and parents need much support (Blackburn and Ditzenberger 2007; Annibale
2012).
Periventricular leucomalacia
A lthough not a haemorrhage, periventricular leucomalacia (PVL) is included here
because of its association with GMH, I VH and PHI /I PL. Between 27 and 30 week
gestation, the area of white ma er around the lateral ventricles and within the
watershed area of the deep cerebral arteries is undergoing considerable development.
I t is sensitive to any insult that results in reduced cerebral perfusion, such as those
associated with GMH, I VH, PHI /I PL and chorioamnionitis. The cerebral blood flo
autoregulation ability in preterm babies is limited, increasing their risk of developing
PVL. Reduced perfusion results in areas of ischaemia and degeneration of the nerve
fibre tracts, disrupting nerve pathways between areas of the brain and between the
brain and spinal cord. This softening and necrosis of the white ma er is PVL; it may
be a classic focal necrotic cystic type or a diffuse non-cystic type. O nly the former is
seen on US S but MRI may detect both types Blackburn
( and D i enberger 2007; Volpe
2008; Zach 2012).
S imilar pathogenesis is seen in the older preterm and term baby, but the lesion
occurs in the subcortical region rather than the periventricular region. This is because
the watershed moves away from the ventricles to the cortex once the germinal matrix
involutes. These lesions are known as subcortical leucomalacia (Volpe 1997).
Care instituted to reduce the incidence of GMH, I VH and PHI /I PL may reduce th
incidence of PVL or the severity of the related ischaemic damage. The prognosis is
variable; some babies have li le resulting impairment, others develop cognitive and
neurodevelopmental impairment while the most severely affected babies may develop
spastic diplegic cerebral palsy (Blackburn and Ditzenberger 2007; Zach 2012).
Haemorrhages related to coagulopathies
These haemorrhages occur due to disruption of the baby's blood-clotting abilities.
Vitamin K deficiency bleeding
Vitamin K deficiency bleeding (VKD B) may occur up to 6 months of age, although it
more commonly occurs between birth and 8 weeks of life. I t was previously known as
haemorrhagic disease of the newborn (HD N ). S everal proteins, factor I I
(prothrombin), factor VI I (proconvertin), factor I X (plasma thromboplastin
component), factor X (thrombokinase) and proteins C and S , require vitamin K for
their conversion to active clo ing factors. A deficiency of vitamin K, as in VKD B, leads
to a deficiency of these clotting factors and resultant bleeding.
Vitamin K1 (phytomenadione/phytonadione/phylloquinone) is poorly transferred
across the placenta and fetal liver stores are low. A ny stores are quickly depleted after
birth and for normal clo ing to occur, the baby must receive dietary vitamin K1, the
absorption of which requires fat and bile salts. Vitamin K2 (menaquinone) is
synthesized by bowel flora and may assist in the conversion of proteins to active
clo ing factors. Because the neonate's bowel is sterile, vitamin K2 production is
restricted until colonization has occurred. Therefore all newborns are deficient in
vitamin K and vulnerable to VKDB.
There are three forms of VKD B that were first described byLane and Hathaway
(1985):
• ‘early’ (0–24 hours)
• ‘classical’ (1–7 days)
• ‘late’ (1–6 months, although the peak onset is before 8 weeks).
Early VKD B is rare, principally affecting babies born to women who during
pregnancy have taken anticonvulsants, e.g. phenytoin, barbiturates or carbamazepine;
antitubercular drugs, e.g. rifampin, isoniazid; or vitamin K antagonists, e.g. warfarin
(contraindicated during pregnancy) for treatment of their medical conditions. As these
drugs interfere with vitamin K metabolism, avoidance during pregnancy reduces the
risk of early VKD B. Taking vitamin K1 supplements during the last two weeks of
pregnancy may prevent early VKDB (Nimavat 2012).
The babies most susceptible to developing classic VKD B are those with birth
trauma, asphyxia, postnatal hypoxia and those who are preterm, or of low birth weight.
They are more likely to spontaneously bleed or have invasive interventions resulting in
bleeding that cannot be controlled. D isruptions to the colonization of the bowel due to
antibiotic therapy, or lack of or poor enteral feeding, may also result in classic VKDB.
The bowel of a breastfed baby colonizes with lactobacilli that do not synthesize
menaquinone. The amount of vitamin K1 in breastmilk is naturally low, although
colostrum and hindmilk do contain higher levels than foremilk. The vitamin K1 in
breastmilk is considered insufficient for the exclusively breastfed baby's needs.
A rtificial infant formulae are fortified with vitamin K1, offering some prophylaxis
against VKD B B ( lackburn 2013). Therefore late VKD B occurs almost exclusively in
breastfed babies. However, babies who have liver disease or a condition that disrupts
vitamin K1's absorption from the bowel, for example cystic fibrosis, may develop late
VKDB (Blackburn 2013).
The baby who has VKD B may have bruising; or bleeding from the umbilicus,
puncture sites, the nose or the scalp; or severe jaundice for more than one week and/or
persistent jaundice for more than 2 weeks. Gastrointestinal bleeding manifests as
melaena and haematemesis. I n early and late VKD B, there may be extracranial and
intracranial bleeding. With severe haemorrhage, circulatory collapse occurs. Late
VKD B is associated with higher mortality and morbidity. Blood tests reveal prolonged
prothrombin time (PT) and partial thromboplastin time (PTT), with a normal platelet
count (Nimavat 2012).
Babies diagnosed with VKD B require investigation and monitoring to assess their
need for treatment. With all forms of VKD B, the baby will require administration of
vitamin K1, 1–2 mg intramuscularly. I n severe cases, when coagulation is grossly
abnormal and there is severe bleeding, replacement of deficient clo ing factors is
essential. I f circulatory collapse and severe anaemia occur, blood transfusion or
exchange transfusion may be required. A ffected babies usually require other
supportive therapy to assist in their recovery.
A s VKD B is a potentially fatal condition, prophylactic administration of vitamin K is
recommended for all babies and is administered to all preterm and sick babies as part
of their treatment regime (N imavat 2012; Blackburn 2013). For otherwise healthy term
babies the N ational I nstitute for Health and Clinical Excellence (N I CE) (2006
recommends that vitamin K1 1 mg given intramuscularly after birth is the most
effective prophylaxis for prevention of early onset VKD B. S ome vitamin K1 remains
within the muscle and acts as a slow release depot, providing prophylaxis for classic
and probably also for late VKDB (Hey 2003).
W hile there are arguments against routine prophylaxis (Midwives I nformation and
Resource S ervice [MI D I RS ] Essence 2009 ), for healthy term babies whose parents
decline a single intramuscular injection of vitamin K1, an oral prophylaxis regimen is
recommended (N I CE 2006), although consensus on the most effective oral regime
appears elusive. I t is suggested that whatever oral regime is used, multiple doses are
required in the first week of life and if the baby is breastfed, a further dosing regime is
required until at least 12 weeks of age, if not longer. S uch prophylaxis should reduce
the risk of all forms of VKD B, however this is dependent on the involvement,
motivation and compliance of healthcare professionals and parents. Medical advice
should be sought if the baby vomits within one hour of oral administration or is too
unwell to take the preparation orally.
A ll parents should be given the opportunity to discuss vitamin K1 prophylaxis
during pregnancy, understand the specific management of preterm, sick and ‘at-risk’
babies, and agree on their choice of prophylaxis. They should also understand the
signs and treatment of VKD B, especially if their baby has one or more of the risk
factors (NICE 2006; MIDIRS Essence 2009).
Thrombocytopenia
Thrombocytopenia results from a decreased rate of formation of platelets or an
increased rate of consumption and is defined as a platelet count of less than 150 ×10 9/l,
and severe thrombocytopenia is a platelet count of less than 50 ×109/l (Bagwell 2007;
Roberts and Murray 2008).
Thrombocytopenia may be classified according to fetal, neonatal and late onset
causes. Fetal causes include alloimmunity, congenital infection and trisomies. Early
onset (less than 72 hours) neonatal causes include placental insufficiency, perinatal
asphyxia, perinatal infection, D I C and alloimmunity. Late onset (after 72 hours)
neonatal causes include late onset sepsis, necrotizing enterocolitis, congenital
infection and autoimmunity.
The most at-risk babies are those with an older sibling who was diagnosed with
thrombocytopenia, babies born preterm who have had chronic intrauterine hypoxia
such as with pregnancy induced hypertension or diabetes and associated intrauterine
growth restriction (Roberts and Murray 2008).
N eonatal alloimmune thrombocytopenia (N A I T) occurs when there is
incompatibility between maternal and fetal platelets. Maternal antibodies cross the
placenta destroying the fetal platelets – a mechanism similar to that of haemolytic
disease of the newborn. I f the fetus is severely affected, an intracranial haemorrhage
may result in fetal death. I f a previous sibling has developed N A I T, in subsequent
pregnancies the fetus will be monitored using fetal blood sampling and/or US S to
determine the need for maternal immunoglobulin administration and/or steroids
and/or intrauterine platelet transfusions, and possibly elective birth at 32–34 weeks'
gestation (Roberts and Murray 2008). I f diagnosed with N A I T postnatally, babies
usually require platelet transfusions to achieve and maintain a platelet count within
normal limits.
N eonatal autoimmune thrombocytopenia may occur in babies whose mothers have
autoimmune conditions such as idiopathic thrombocytopenic purpura or systemic
lupus erythematosis. The antibodies produced by the mother against her own platelets
may cross the placenta, destroying the baby's platelets. The resultant
thrombocytopenia is usually mild, but in severe cases, immunoglobulin
administration is effective (Roberts and Murray 2008).
Thrombocytopenia may appear as a petechial rash, presenting in a mild case with a
few localized petechiae. I n a severe case there is widespread and serious haemorrhage
from multiple sites. I ntracranial haemorrhage may be fatal. D iagnosis is based on
history, clinical examination and a reduced platelet count. I t is differentiated from
other haemorrhagic disorders because coagulation times, fibrin degradation products
and red blood cell morphology are normal. Mild or moderate thrombocytopenia is
usually self-limiting and requires no treatment. I n severe cases, the treatment usually
includes platelet concentrate transfusion/s, although the optimum regime is yet to be
determined (Roberts and Murray 2008).
Disseminated intravascular coagulation (consumptive coagulopathy)
D isseminated intravascular coagulation (D I C), also known as consumptive
coagulopathy, is an acquired coagulation disorder associated with the release of
thromboplastin from damaged tissue, stimulating abnormal coagulation in the
microcirculation as well as excess fibrinolysis. There is excessive consumption of
clo ing factors and platelets, predisposing the baby to haemorrhage. D I C is secondary
to primary conditions. Maternal causes of neonatal D I C include pre-eclampsia,
eclampsia and placental abruption. Fetal causes include severe fetal compromise, the
presence of a dead twin in the uterus and traumatic birth. N eonatal causes include
conditions resulting in hypoxia and acidosis, severe infections, hypothermia,
hypotension and thrombocytopenia (Bagwell 2007; Levi 2012).
A s clo ing factors and platelets are depleted and fibrinolysis is stimulated, the baby
will develop a generalized purpuric rash and bleed from multiple sites. With
stimulation of the clo ing cascade, multiple microthrombi may occlude vessels, with
organ and tissue ischaemia, particularly affecting the kidneys, resulting in haematuria
and reduced urine output. A s the cycle of consumptive coagulopathy continues,
multiorgan failure results (Bagwell 2007; Levi 2012). The diagnosis is made from
clinical signs and laboratory findings that show a low platelet count, low fibrinogen
level, distorted and fragmented red blood cells, low haemoglobin and raised fibrin
degradation products (FDPs) with a prolonged PT and PTT (Bagwell 2007).
Treatment must focus on correction of the underlying cause if possible and full
supportive care will be required. Control of D I C requires transfusions of fresh frozen
plasma, concentrated clo ing factors and platelets. Cryoprecipitate is an excellent
source of fibrinogen. I f anaemia is diagnosed, transfusions of whole blood or red cell
concentrate are required. O ccasionally an exchange transfusion of fresh heparinized
blood may be performed, to remove FD Ps while replacing the clo ing factors. I f
treatment of the primary disorder and/or replacement of clo ing factors is ineffective,
the administration of heparin may reduce fibrin deposition (Levi 2012).
The prognosis depends on the severity of the primary condition, as well as of the
DIC, and the baby's response to treatment.
Haemorrhages related to other causes
Umbilical haemorrhage
This usually occurs as a result of a poorly applied cord ligature. The use of plastic cord
clamps has almost eliminated this type of haemorrhage, although it is essential to
avoid catching or pulling the clamp. Tampering with partially separated cords before
they are ready to separate is discouraged. Umbilical haemorrhage is a potential cause
of death. A purse-string suture should be inserted if bleeding continues after 15 or 20
minutes of manual pressure.
Vaginal bleeding
A small temporary vaginal discharge of bloodstained mucus occurring in the first days
of life, pseudomenstruation, is due to the withdrawal of maternal oestrogen. This is a
normal expectation but is included here for completeness. Parents need to know that
this is a possibility and is self-limiting. Continued or excessive vaginal bleeding
warrants further investigation to exclude pathological causes.
Haematemesis and melaena
These signs may present when the baby has swallowed maternal blood during birth,
or from cracked nipples during breastfeeding. The diagnosis must be differentiated
from VKD B, from other causes of haematemesis that include oesophageal, gastric or
duodenal ulceration, and from other causes of melaena, that include necrotizing
enterocolitis and anal fissures. These causes need specific and usually urgent
treatment.
I f the cause is swallowed blood, the condition is self-limiting and requires no
specific treatment. I f the cause is cracked nipples, appropriate treatment for the
mother must be implemented.
Haematuria
Haematuria may be associated with coagulopathies, urinary tract infections and
structural abnormalities of the urinary tract. Birth trauma may cause renal contusion
and haematuria. O ccasionally, after suprapubic aspiration of urine, transient mild
haematuria may be observed. Treatment of the primary cause should resolve the
haematuria.
Bleeding associated with intravascular access
S ome sick or preterm babies require the insertion of catheters, lines or cannulae into
central or peripheral arteries or veins, or both, to provide routes for blood sampling,
blood pressure monitoring or the infusion of fluids and drugs. However, there is a risk
of severe external haemorrhage if there is dislodgement of these from the vessel or
accidental disconnection from the sampling or infusion equipment, and of severe
haemorrhage if a central vessel is punctured internally.
S killed technique, close observation and careful handling of babies with
intravascular access are imperative to prevent potentially fatal haemorrhage. I f an
external haemorrhage does occur, continuous pressure should be applied to the site
until natural haemostasis occurs or until haemostatic sutures are inserted. I f there is
external bleeding from an umbilical vessel, the cord stump should be squeezed
between the fingers until haemostasis occurs. A replacement transfusion of whole
blood or packed red cells may be required. I nternal haemorrhage may require surgical
intervention.
Convulsions
A convulsion (seizure/fit) is a sign of neurological disturbance, not a disease, and the
occurrence of a convulsion is a medical emergency. Because the newborn brain is still
developing, its function is immature and there is an imbalance between stimulation
and inhibition of neural networks. Convulsions present quite differently in the
neonate and may be more difficult to recognize than those of later infancy, childhood
or adulthood (Volpe 2008).
Convulsive movements can be differentiated from jitteriness or tremors in that, with
the la er two, the movements are rapid, rhythmic, equal, are often stimulated or made
worse by disturbance and can be stopped by touching or flexing the affected limb.
They are normal in an active, hungry baby and are of no consequence, although their
occurrence should be documented. Convulsive movements tend to be slower, less
equal, are not necessarily stimulated by disturbance, cannot be stopped by restraint,
may be accompanied by abnormal eye movements and cardiorespiratory changes and
are always pathological. Convulsive movements should also be differentiated from the
benign bilateral or localized jerking that occurs normally in neonatal sleep,
particularly rapid eye movement sleep (Prasad 2012).
A bnormal, sudden or repetitive movements of any part of the body that are not
controlled by repositioning or containment holds require investigation. Volpe (2008)
suggests that the type of movement can help classify the convulsion as subtle, tonic,
clonic or myoclonic:
• Subtle convulsions include movements such as blinking or fluttering of the eyelids,
chewing and cycling movements of the legs, and apnoea. There may or may not be
associated abnormal electroencephalogram (EEG) activity.
• Focal tonic convulsions affect one extremity and abnormal brain electrical activity can
be detected on EEG. With generalized tonic convulsions, that are more common than
focal tonic convulsions, the baby sustains a rigid extended posture, similar to
decerebrate posturing, that is not usually detected on EEG.
• Focal clonic convulsions are unilateral, affecting the face, neck or trunk or upper or
lower extremity whereas multifocal clonic convulsions affect several areas of the body
that jerk asynchronously and migrate. The movements are slow (one to three jerks
per second), rhythmic and are most likely to be associated with EEG activity.
• Myoclonic convulsions differ from clonic convulsions in that they are faster and are
not associated with EEG activity. Focal myoclonic convulsions affect the upper body
flexor muscles. Multifocal myoclonic convulsions affect several parts of the body with
asynchronous jerks. Generalized myoclonic convulsions affect the upper and
sometimes lower extremities with jerking flexion movements.
D uring a convulsion the baby may have tachycardia, hypertension, raised cerebral
blood flow and raised intracranial pressure, which predispose to serious
complications.
A s convulsions may be difficult to recognize, all at-risk babies must be continuously
assessed. The underlying conditions that may result in a convulsion are classified as
central nervous system, metabolic, other and idiopathic conditions (Table 31.1).
Convulsions may be acute, recurrent or chronic (Blackburn and Ditzenberger 2007).
Table 31.1
Selected causes of neonatal convulsions
I f a convulsion is suspected, a complete history and physical and laboratory
investigations related to the possible cause would be undertaken. A n EEG may help
detect abnormal electrical brain activity and guide treatment. I mmediate treatment
necessitates obtaining assistance from a doctor while ensuring that the baby has a
clear airway and adequate ventilation, either spontaneously or mechanically. The baby
can be turned to the semi-prone position, with the head in a neutral position. Gentle
oral and nasal suction may be required to remove any milk or mucus. I f the baby is
breathing spontaneously but is cyanosed, facial oxygen is given. A ctive resuscitation
may be required. The need for intravenous access should be assessed. A ny necessary
handling must be gentle and the baby is usually nursed in an incubator to allow for
observation and temperature regulation.
I t is important that the nature of the convulsion is documented, noting the type of
movements, the areas affected, its length, the baby's state of consciousness, colour
change, alteration in heart rate, respiratory rate or blood pressure and immediate
sequelae (Blackburn and Ditzenberger 2007).
The aims of care are to treat the primary cause/s (details of which are not discussed
in this chapter), and the pharmacologic control of the convulsions. The la er is
controversial due to the potential for damage from the drugs versus the potential
damage from the convulsion on the developing brain (Rennie and Boylan 2007; Volpe
2008). W hile there is li le robust research evidence for the use of any anticonvulsants
in neonates, there is consensus for the use of such drugs, particularly when the baby
experiences prolonged or frequent convulsions (Volpe 2008; Jensen 2009).
I f pharmacological treatment is prescribed, the drugs most commonly used are
phenobarbital and phenytoin; less frequently benzodiazepines may be used. N ewer
anticonvulsants such as topiramate and levetiracetam are still being evaluated (Rennie
and Boylan 2007; Volpe 2008; J ensen 2009). A nticonvulsant therapy may be
discontinued when convulsions cease, preferably before the baby is transferred home.
The outcome for babies who have convulsions is likely to depend on the cause,
onset, type of convulsion and frequency, whether it was demonstrated on EEG and
whether the tracing became normal following treatment, what type of treatment was
used and how long it was before any treatment was successful. A good prognosis is
usual if convulsions were due to hypocalcaemia, hyponatraemia or an uncomplicated
subarachnoid haemorrhage. Much poorer prognoses are associated with severe
hypoxic ischaemia, severe I VH, severe infections and central nervous system
congenital abnormalities (Blackburn and D i enberger 2007). Complications of
neonatal seizures may include cerebral palsy, hydrocephalus, epilepsy and spasticity
(Sheth 2011).
Support of parents
The care of parents is more comprehensively discussed elsewhere therefore in this
section only specific aspects will be summarized. Trauma during birth, haemorrhages
and convulsions are unexpected complications and parents may be shocked and
anxious, and perhaps find themselves in a crisis situation. However, not all parents
experience such feelings and some can adapt quickly to their baby's condition (Fowlie
and McHaffie 2004; Carter et al 2005; McGrath 2007).
The extent of the midwife's and other professionals' contact with parents will
depend on circumstances but the experiences parents have at this time have longer-
term implications for them, their response to the situation, their relationships with the
multiprofessional teams involved in their care as well as their interaction with and
care of their baby (McGrath 2007).
O ne of the most important aspects of caring for the parents is in relation to
communication. A ll parents are entitled to be given information about their baby's
condition, treatment and care in ways that are considered best practice. The ‘Right
from the S tart template’ (S cope 2003) provides an excellent guide, and the principles
related to the baby, parents and family are summarized in Box 31.1.
Box 31.1
S um m a ry of ke y principle s re la t e d t o t he ba by,
pa re nt s a nd fa m ily
The baby must be valued as a baby by:
• using the baby's name
• not predicting the future
• when sharing information, keeping the baby with the parents if possible.
The parents and family must be respected by:
• facilitating parental support and empowerment
• acknowledging cultural and religious differences
• listening to their views and taking their concerns seriously
• giving information honestly and sensitively using uncomplicated
language
• ensuring understanding and giving opportunities for questions
• facilitating follow-up and providing further information when required.
Source: Scope 2003
Parental involvement in their baby's care is essential and the family-centered
care/partnership with parents approach should now pervade all midwifery and
neonatal se ings. Midwives and neonatal nurses have an important role in promoting
adaptive coping mechanisms and guiding parents to appropriate resources and
support services (PO PPY S teering Group 2009 ). The baby charity BLI S S offers helpful
information for parents and its website includes a parent message board. A dditional
support and information is available from specialized outside agencies and the charity
Contact a Family is a useful resource in the longer term. (See Useful Websites, below.)
References
Annibale DJ. Periventricular hemorrhage–intraventricular hemorrhage.
http://emedicine.medscape.com/article/976654; 2012 [(accessed June 2013)] .
Bagwell GA. Haematological system. Kenner C, Lott JW. Comprehensive neonatal
care: an interdisciplinary approach. 4th edn. Saunders/Elsevier: Philadelphia;
2007:245–251.
Barker S. Subdural and primary subarachnoid haemorrhages: a case study.
Neonatal Network. 2007;26(3):143–151.
Benjamin K. Part 2: Distinguishing physical characteristics and management of
brachial plexus injuries. Advances in Neonatal Care. 2005;5(5):240–251.
Blackburn ST. Maternal, fetal and neonatal physiology: a clinical perspective. 4th
edn. Elsevier: Philadelphia; 2013.
Blackburn ST, Ditzenberger GR. Neurologic system. Kenner C, Lott JW.
Comprehensive neonatal care: an interdisciplinary approach. 4th edn.
Saunders/Elsevier: Philadelphia; 2007:277–294.
BMJ (British Medical Journal) Evidence Centre. Erb's palsy.
http://bestpractice.bmj.com/best-practice/monograph/746; 2012 [(accessed
January 2013)] .
Brand MC. Part 1: Recognizing neonatal spinal cord injury. Advances in Neonatal
Care. 2006;6(1):15–24.
Bruns AD. Congenital facial paralysis.
http://emedicine.medscape.com/article/878464; 2012 [(accessed June 2013)] .
Carter JD, Mulder RT, Bartram AF, et al. Infants in a neonatal intensive care unit:
parental response. Archives of Disease in Childhood, Fetal and Neonatal edition.
2005;90(2):F109–F113.
Foad SL, Mehiman CT, Foad MB, et al. Prognosis following neonatal brachial
plexus palsy: an evidence-based review. Journal of Children's Orthopedics.
2009;3(6):459–463.
Fowlie PW, McHaffie H. Supporting parents in the neonatal unit. British Medical
Journal. 2004;329:1336–1338.
Hey E. Vitamin K – what, why and when. Archives of Disease in Childhood Fetal and
Neonatal edition. 2003;88(2):F80–F83.
Jensen FE. Neonatal seizures: an update on mechanisms and management.
Clinics in Perinatology. 2009;36(4):881.
Lane PA, Hathaway WE. Vitamin K in infancy. Journal of Pediatrics. 1985;106:351–
359.
Laroia N. Pediatric cardiac birth trauma.
http://emedicine.medscape.com/article/980112; 2010 [(accessed June 2013)] .
Lee KG. Caput succedaneum.
www.nlm.nih.gov/medlineplus/ency/article/001587.htm; 2011 [(accessed June
2013)] .
Levi MM. Disseminated intravascular coagulation.
http://emedicine.medscape.com/article/199627; 2012 [(accessed June 2013)] .
Mavrogenis AF, Mitsiokapa EA, Kanellopoulos AD, et al. Birth fractures of the
clavicle. Advances in Neonatal Care. 2011;11(5):328–331.
McGrath JM. Family: essential partner in care. Kenner C, Lott JW. Comprehensive
neonatal care: an interdisciplinary approach. 4th edn. Saunders/Elsevier:
Philadelphia; 2007:491–506.
MIDIRS (Midwives Information and Resource Service) Essence. Vitamin K – the
debate and the evidence.
www.midirs.org/development/MIDIRSEssence.nsf/articles/336837BED2143BE58
2009 [(accessed June 2013)] .
NICE (National Institute for Health and Clinical Excellence). Routine postnatal
care of women and their babies. NICE: London;
2006 www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf.
Nimavat EJ. Hemorrhagic disease of the newborn.
http://emedicine.medscape.com/article/974489; 2012 [(accessed June 2013)] .
Papile LA, Burnstein J, Burnstein R, et al. Incidence and evolution of
subependymal and intraventricular hemorrhage: a study of infants with birth
weights less than 1500 g. Journal of Pediatrics. 1978;92(4):529–534.
Paul SP, Edate S, Taylor TM. Cephalhaematoma – a benign condition with
serious complications: case report and literature review. Infant. 2009;5(5):146–
148.
POPPY Steering Group. Family-centred care in neonatal units. A summary of
research results and recommendations from the POPPY project. National Childbirth
Trust: London; 2009.
Prasad M. Neonatal seizure: what is the cause?.
www.bmj.com/content/345/bmj.e6003; 2012 [(accessed June 2013)] .
Pride H. Superficial fat necrosis of the newborn.
http://emedicine.medscape.com/article/1081910; 2012 [(accessed June 2013)] .
Qureshi NH. Skull fracture. http://emedicine.medscape.com/article/248108; 2012
[(accessed June 2013)] .
Reid J. Neonatal subgaleal haemorrhage. Neonatal Network. 2007;26(4):219–227.
Rennie JM, Boylan G. Treatment of neonatal seizures. Archives of Disease in
Childhood, Fetal and Neonatal edition. 2007;92(2):F148–F150.
Roberts I, Murray NA. Neonatal thrombocytopenia. Seminars in Fetal and
Neonatal Medicine. 2008;13(4):256–264.
Sandmire HF, DeMott RK. Controversies surrounding the causes of brachial
plexus injury. International Journal of Gynecology and Obstetrics. 2009;104(1):9–
13.
Saxena AK. Paediatric torticollis surgery.
http://emedicine.medscape.com/article/939858; 2010 [(accessed June 2013)] .
Schierholz E, Walker SR. Responding to traumatic birth. Advances in Neonatal
Care. 2010;10(6):311–315.
Scope. Right from the start template. www.scope.org.uk/help-and-
information/publications/right-start-template; 2003 [(accessed June 2013)] .
Semel-Concepcion J. Neonatal brachial plexus palsies.
http://emedicine.medscape.com/article/317057; 2012 [(accessed June 2013)] .
Sheth RD. Neonatal seizures. http://emedicine.medscape.com/article/1177069;
2011 [(accessed June 2013)] .
Sorantin E, Brader P, Thimary F. Neonatal trauma. European Journal of Radiology.
2006;60(2):199–207.
Thomas R, Harvey D. Colour guide: neonatology. 2nd edn. Churchill Livingstone:
Edinburgh; 1997.
Volpe JJ. Brain injury in the premature infant. Clinics in Perinatology.
1997;24(3):567–587.
Volpe JJ. Neurology of the newborn. 5th edn. Elsevier Health Sciences:
Philadelphia; 2008.
Vorvick LJ, Kaneshiro NK. Fractured clavicle in the newborn.
www.nlm.nih.gov/medlineplus/ency/article/001588.htm; 2011 [(accessed June
2013)] .
Zach T. Pediatric periventricular leukomalacia.
http://emedicine.medscape.com/article/975728; 2012 [(accessed June 2013)] .
Further reading
Boxwell G. Neonatal intensive care nursing. 2nd edn. Routledge: London; 2010.
This book is primarily written for neonatal nurses and teachers. Student midwives and
midwives would benefit from the additional more detailed information about many of
the conditions addressed in this present chapter. Chapters 3, 8, 9 and 18 are
recommended..
Meeks M, Hallsworth M, Yeo H. Nursing the neonate. 2nd edn. Wiley–Blackwell:
Malaysia; 2010.
Written primarily for neonatal nurses and midwives, it provides a resource for other
professionals working in neonatal care. Chapters 4, 14 and 17 are recommended..
Rennie JM. Rennie and Roberton's Textbook of neonatology. 5th edn. Elsevier:
London; 2012.
A classic textbook that gives excellent explanations of physiology and discusses the
management of neonatal complications, albeit from a mainly medical perspective..
Useful websites
Advances in Neonatal Care (journal).
http://journals.lww.com/advancesinneonatalcare.
Archives of Disease in Childhood (journal). http://adc.bmj.com.
BLISS: (premature and sick baby charity). www.bliss.org.uk.
Contact a Family. www.cafamily.org.uk.
Infant (journal for neonatal nursing and paediatric healthcare professionals).
www.infantgrapevine.co.uk.
Medscape. http://emedicine.medscape.com.
C H AP T E R 3 2
Congenital malformations
Judith Simpson, Kathleen O'Reilly
CHAPTER CONTENTS
Communicating the news 646
Palliative care 646
Definition and causes 647
Chromosomal abnormalities 649
Trisomy 21 (Down syndrome) 649
Trisomy 18 (Edwards syndrome) 650
Trisomy 13 (Patau syndrome) 650
Turner syndrome (XO) 650
Gastrointestinal malformations 650
Gastroschisis and exomphalos 650
Atresias 650
Anorectal malformations 652
Malrotation/volvulus 652
Meconium ileus (cystic fibrosis) 653
Hirschsprung's disease 653
Cleft lip and cleft palate 653
Pierre Robin sequence 654
Malformations relating to respiration 654
Diaphragmatic hernia 654
Congenital pulmonary airway malformation (CPAM) 655
Choanal atresia 655
Laryngeal stridor 656
Congenital cardiac defects 656
Causes 656
Prenatal detection 656
Postnatal recognition 656
Cardiac defects presenting with cyanosis 656
‘Acyanotic’ cardiac defects 658
Central nervous system malformations 658
Anencephaly 659
Spina bifida 659
Spina bifida occulta 659
Hydrocephalus 660
Microcephaly 660
Musculoskeletal deformities 660
Polydactyly/syndactyly 660
Limb reduction deficiencies 660
Talipes 661
Developmental dysplasia of the hip 661
Achondroplasia 662
Osteogenesis imperfecta 662
Abnormalities of the skin 662
Vascular naevi 662
Capillary malformations 662
Capillary haemangiomata (‘strawberry marks’) 662
Pigmented (melanocytic) naevi 663
Genitourinary system 663
Potter syndrome 663
Posterior urethral valves 663
Cystic kidneys 663
Hypospadias 664
Cryptorchidism 664
Disorders of sexual development (DSD) 664
Congenital adrenal hyperplasia 664
Androgen insensitivity syndrome 664
Teratogenic causes 664
Fetal alcohol syndrome/spectrum 664
Support for the midwife 665
References 665
Further reading 666
Useful websites 666
The incidence of major congenital malformations is 2–3% of all births,
although this figure is subject to familial, cultural and geographic variations.
It is therefore likely that every practising midwife will at some time in their
career be confronted with the challenge of providing appropriate care and
support for such babies and their families.
The chapter aims to:
• address issues such as who should tell the parents and how and when they should be
told
• describe and explain specific congenital anomalies
• consider the psychological impact on staff and the strategies that could be put in place
to minimize the accompanying stress.
Communicating the news
I mproved prenatal screening and diagnostic techniques (see Chapter 11) have led to
the increased recognition of malformations, particularly in early pregnancy. A s a
result some women may make the decision to have their pregnancy terminated, whilst
for others it provides time to adjust to and begin to come to terms with the news that
their baby will be born with a particular problem. O ne advantage of prenatal diagnosis
is that, if necessary, arrangements can be made for the mother to give birth in a unit
where appropriate specialist neonatal services are available. The disadvantage of such
a transfer is that the mother may then be separated from family, friends and the
support of the midwives she knows best. This makes it all the more imperative that
the staff in these units are sensitive to the needs of such women.
However, even with universal fetal screening not all malformations will be identified
prenatally and in this situation it is often the midwife who first notices an anomaly
either at birth or on routine newborn examination. W hilst all anomalies should be
notified to medical staff there is sometimes uncertainty as to who should
communicate the news to the parents.
There is a very strong argument for suggesting that this should be done by the
midwife present at the birth. The midwife–mother relationship is, or ought to be, one
of mutual trust and respect. Honesty is an implicit tenet of such a relationship. I t is
well recognized that one of the first questions a mother will ask the midwife after the
birth is ‘is the baby all right?’ For the midwife to be non-commi al or economical with
the truth is to betray that trust. I t is preferable that the midwife tells both parents
sensitively but honestly that she has concerns, and shows them any obvious anomaly
in the baby.
W here there is doubt in the midwife's mind, for example in cases of suspected
chromosomal disorders, it could be argued that the issue is less clear cut. D iscretion
could therefore be exercised in the precise form of words used, but the intention of
inviting a second opinion should be made clear to the parents. I t is advisable that both
the parents and the midwife are present when an experienced paediatrician examines
the baby and that the midwife is present during any dialogue between the parents and
medical staff so that she is aware of exactly what has been said. S he is then in a
position to clarify or repeat any points that were not fully understood. O pportunities
for follow-up consultation with the paediatrician should be offered as and when the
parents desire. Patience, tact and understanding are prerequisites for midwives caring
for these families.
S ome malformations may appear minor to staff; however, it is important to
appreciate that parental perceptions may be quite different and that the degree of
distress can be unrelated to the apparent severity of the anomaly. The psychological
impact on parents of being told or shown, or both, that their baby has a congenital
malformation has been likened to the grieving process discussed in Chapter 26. Great
sensitivity is therefore required on the part of the midwife when communicating with
the parents for the first time.
W hatever the anomaly, it is essential that families receive accurate, consistent and
appropriate information about their baby's condition. S ince a comprehensive
discussion of every malformation is clearly not possible, selection has therefore been
made of those the midwife is most likely to encounter.
Palliative care
There are a number of severe congenital malformations which are incompatible with
sustained life, such as anencephaly. Many of these conditions are diagnosed
antenatally and, whereas some parents opt for termination of the pregnancy, others
choose palliative care after birth. I t is important that parents feel supported in the
choices they make. W hen parents opt to continue with the pregnancy, where possible,
a plan should be made antenatally with the parents for care of the baby when he or
she is born. D iscussion with the parents should explore any anxieties they may have,
e.g. pain relief for the baby. I t should also include factual information about the likely
clinical course including how long the baby may survive and a gentle explanation of
the process of death. I t is important to be honest in cases where there is uncertainty. I t
may also be appropriate at this time to explore any specific wishes the parents may
have, regarding religious ceremonies for example.
A fter birth priority should be given to ensuring the comfort of the baby whilst at the
same time supporting the parents. I n cases where the baby survives for longer than
expected the specific aspects of the care plan may need to be reviewed and discussed
with parents (e.g. feeding). I t is important to treat the parents and the baby with
kindness and dignity at all times and to remember that the life of the baby is precious
to the parents no matter how short that life is.
Providing end of life care for infants with severe congenital malformations can be
difficult and emotionally draining for staff. I t is essential that staff caring for the baby
feel comfortable with clinical decisions and able to discuss any concerns they have. A
formal debrief within the multi-professional team may be useful.
Definition and causes
By definition, a congenital malformation is any defect in form, structure or function.
Identifiable defects can be categorized as follows (Fig. 32.1):
• chromosomal abnormalities
• single gene defects
• mitochondrial deoxyribonucleic acid (DNA) disorders
• teratogenic causes
• multifactorial causes
• unknown causes.
FIG. 32.1 Causes of congenital abnormalities. Adapted from Beattie J, Carachi R (eds) 2005 Practical
paediatric problems: a textbook for MRCPCH. Hodder Education, London.
Chromosomal abnormalities
D efinitions of terms used in this and subsequent sections are provided in the Glossary
at the end of the book.
Every human cell carries a blueprint for reproduction in the form of 44
chromosomes (autosomes) and two sex chromosomes. Each chromosome comprises a
number of genes, which are specific sequences of D N A coding for particular proteins.
The zygote should have 22 autosomes and one sex chromosome from each parent.
S hould a fault occur in either the formation of the gametes or following fertilization
(see Chapter 5), abnormalities in chromosome number (aneuploidies) or structure
(deletions, duplications, inversions, translocations) may occur. Each abnormal
chromosomal pa ern has a characteristic clinical presentation, the most common of
which will be discussed further.
Gene defects (Mendelian inheritance)
Genes are composed of D N A and each is concerned with the transmission of one
specific hereditary factor. Genetically inherited factors may be dominant or recessive.
A dominant gene will produce its effect even if present in only one chromosome of a
pair. A n autosomal dominant condition can usually be traced through several
generations although the severity of clinical expression may vary from generation to
generation. Congenital spherocytosis, achondroplasia, osteogenesis imperfecta, adult
polycystic kidney disease and Huntington's chorea are examples of dominant
conditions.
A recessive gene needs to be present in both chromosomes before producing its
effect. A n individual who is carrying only one abnormal copy of the gene (a
heterozygote) is unaffected. Examples of autosomal recessive conditions are cystic
fibrosis or phenylketonuria.
S ome congenital malformations are a consequence of single gene defects. I n a
dominantly inherited disorder the risk of an affected fetus is 1 : 2 (50%) for each and
every pregnancy. I n a recessive disorder, the risk is 1 : 4 (25%) for each and every
pregnancy. I n an X-linked recessive inheritance the condition affects almost
exclusively males, although females can be carriers. X-linked recessive inheritance is
responsible for conditions such as haemophilia A and B and D uchenne muscular
dystrophy. S pontaneous mutations commonly arise in X-linked recessive disorders.
W hen a woman is a carrier of an X-linked condition, there is a 50% chance of each of
her sons being affected and an equal chance that each of her daughters will be carriers.
W ork on the human genome continues to identify gene defects; for example,
polycystic kidney disease (see p. 663) arises from a mutation on chromosome 6 and
cystic fibrosis is due to a defect on chromosome 7. Recent advancements in our
understanding of inherited conditions have focused on epigenetics. This is the study
of factors other than D N A structure which can alter gene expression. Epigenetics is
involved in genomic imprinting and X-chromosome inactivation in humans.
Epigenetic factors influencing early development may be responsible for specific
congenital syndromes. Continuing research may offer further diagnostic and
treatment options in the future.
Mitochondrial inheritance
Mitochondria are cellular structures responsible for energy production. Mitochondria
are always inherited from the mother. S ymptoms and signs of mitochondrial disorders
can be diverse but tend to occur in tissues that have high energy requirements such as
the brain and muscles. Examples are very rare but include, mitochondrial
encephalomyopathy with la c t i c acidosis and stroke-like episodes (MELA S ) and
myoclonic epilepsy with ragged red fibres myopathy (MERRF) (Chinnery et al 1998).
Teratogenic causes
A teratogen is any agent that raises the incidence of congenital malformation. The list
of known and suspected teratogens is continually growing but includes: prescribed
drugs (e.g. anticonvulsants, anticoagulants and preparations containing large
concentrations of vitamin A such as those prescribed for the treatment of acne), drugs
used in substance abuse (e.g. heroin, alcohol and nicotine), environmental factors such
as radiation and chemicals (e.g. dioxins, pesticides), infective agents (e.g. rubella,
cytomegalovirus) and maternal disease (e.g. diabetes). I t should be borne in mind that
several factors influence the effect(s) produced by any one teratogen, such as
gestational age of the embryo or fetus at the time of exposure, length of exposure and
toxicity of the teratogen. D irect cause and effect is sometimes difficult to establish.
A ccurate recording of all congenital malformations on central registers, such as those
included in the British I sles N etwork of Congenital A nomaly Registers (BI N O CA R
www.binocar.org), facilitates the early recognition of new teratogens.
Multifactorial causes
These are due to interactions between specific genes (genetic susceptibility) and
environmental influences (teratogens).
Unknown causes
I n spite of a growing body of knowledge, the specific cause of many congenital
anomalies remains unspecified and they occur sporadically in families.
Chromosomal abnormalities
Trisomy 21 (Down syndrome)
The classic features of what is now known as D own (ubiquitously referred to as
D own's) syndrome were first described in 1866 by physician J ohn Langdon D own (Fig.
32.2). He recognized a commonly occurring combination of facial features among
individuals with low intelligence. Characteristic features of D own syndrome include:
upslanting palpebral fissures, a small head with flat occiput, small nose, small mouth
with relatively large tongue, short broad hands with an incurving li le finger
(clinodactyly), a single palmar (simian) crease, a wide space between the great toe and
second toe (sandal gap), Brushfield spots in the eyes and generalized hypotonia. N ot
all of these manifestations need be present and any of them can occur alone without
implying chromosomal aberration. Babies born with D own syndrome also have a
higher incidence of cardiac anomalies, cataracts, hearing loss, leukaemia and
hypothyroidism. Intelligence quotient is below average, at 40–80.
FIG. 32.2 (A) Baby with Down syndrome: note slant of eyes and incurving little finger. (B) With
good parental involvement and stimulus these infants can reach maximum potential. Photographs
courtesy of Scottish Down's Syndrome Association.
D own syndrome arising sporadically as a result of a non-disjunction process occurs
in 95% of cases. Unbalanced translocation occurs in 2.5% of cases, usually between
chromosomes 14 and 21. Mosaic forms also occur. There is no difference between the
types in clinical appearance. Parents who have a baby with D own syndrome, therefore,
should be offered genetic counselling to establish the risk of recurrence. The overall
incidence of Down syndrome is 1 in 700.
A lthough there may be li le doubt in the midwife's mind that a baby has D own
syndrome, she should be careful not to make any definitive statements. Family
likeness alone may explain some babies' appearance. Parents themselves may voice
their suspicions. I f they do not, a sensitive but honest approach should be made by
either the midwife or paediatrician to alert them to the possibility and to request
permission to conduct further investigations. It is inappropriate to transfer the baby to
the special care baby unit in order to carry out these investigations under the guise of
the baby being cold or sleepy. I nvestigations indicated include chromosome analysis
and echocardiography, because of the increased risk of congenital heart disease. S ome
centers offer rapid genetic diagnosis (see Chapter 11).
A n individual baby's needs will vary depending on whether there are any co-existing
anomalies. A lthough initial feeding problems are common owing to generalized
hypotonia, breastfeeding should be encouraged if that is what the mother had
planned. The parents are likely to require a great deal of emotional support in the first
few days following diagnosis. Providing audiovisual or reading material about D own
syndrome for the parents may be helpful, or the address of the local branch of the
Down Syndrome Association (see Useful Websites).
Trisomy 18 (Edwards syndrome)
This condition is found in about 1 in 5000 births. A n extra 18th chromosome is
responsible for the characteristic features. Facial features include a small head with a
fla ened forehead, a receding chin and frequently a cleft palate. The ears are low set
and maldeveloped. The sternum tends to be short, the fingers often overlap each other
and the feet have a characteristic rocker-bo om appearance. Malformations of the
cardiovascular and gastrointestinal systems are common. The lifespan for these
children is short and the majority die during their first year.
Trisomy 13 (Patau syndrome)
A n extra copy of the 13th chromosome leads to multiple abnormalities. These children
have a short life. O nly 5% live beyond 3 years. A ffected infants are small and are
microcephalic. Midline facial abnormalities such as cleft lip and palate are common
and limb abnormalities are frequently seen. Brain, cardiac and renal abnormalities
may co-exist with this trisomy.
Turner syndrome (XO)
I n this monosomal condition, only one sex chromosome exists: an X. The absent
chromosome is indicated by ‘O ’. The child is a girl with a short, webbed neck, widely
spaced nipples and oedematous feet. The genitalia tend to be underdeveloped and the
internal reproductive organs do not mature. The condition may not be diagnosed until
puberty fails to occur. Congenital cardiac defects may also be found. Mental
development is usually normal.
Gastrointestinal malformations
Most of the malformations affecting this system call for prompt surgical involvement,
for example atresias, gastroschisis and exomphalos. With increasing access to fetal
anomaly ultrasound screening at 18–20 weeks' gestation, many are likely to be
diagnosed prenatally (Haddock et al 1996). I f prenatal diagnosis has been made, the
parents will be at least partially prepared. They should have had the opportunity to
meet with the paediatric surgeon who will explain the probable sequence of events.
They should also have had the opportunity to visit the specialist neonatal unit in
which their baby will be cared for. O nce the baby is born, prior to obtaining their
consent for surgery, the paediatric surgeon will have a further discussion with the
parents. I f the baby's condition allows, the parents should be encouraged to hold the
baby and take photographs.
Gastroschisis and exomphalos
Gastroschisis (Fig. 32.3) is a paramedian defect of the abdominal wall with extrusion of
bowel that is not covered by peritoneum. Closure of the defect is usually possible; the
size of the defect will determine whether early primary closure is possible or whether
a temporary silo made from synthetic materials (e.g. S ilastic) is necessary until the
abdominal cavity is able to contain all the abdominal organs (Schlatter et al 2003).
FIG. 32.3 Gastroschisis showing prolapsed intestine to the right of umbilical cord. From Rennie J
M, Roberton N R C (eds) 1999 Textbook of neonatology, 3rd edn, with permission of Churchill Livingstone.
Exomphalos or omphalocele (Fig. 32.4) is a defect in which the bowel or other viscera
protrude through the umbilicus. Very often these babies have other anomalies, for
example heart defects, which require evaluation prior to surgery. The timing of
surgical closure is again determined by the size of the defect; small defects
(exomphalos minor) undergo early primary closure whilst a large defect (exomphalos
major) is encouraged to granulate over, prior to delayed closure at 6–12 months (Lee
et al 2006).
FIG. 32.4 Omphalocele defect with bowel visible through sac in the lower part and abnormally
lobulated liver in the sac in the upper part. From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.
The immediate management of both the above conditions is to cover the herniated
abdominal contents with clean cellophane wrap (e.g. Clingfilm) or warm sterile saline
swabs to reduce fluid and heat losses and to give a degree of protection. A n orogastric
or nasogastric tube should be passed and stomach contents aspirated. Transfer of the
baby to a surgical unit is then expedited.
Atresias
Oesophageal atresia
O esophageal atresia occurs when there is incomplete canalization of the oesophagus
in early intrauterine development. I t is commonly combined with a tracheo-
oesophageal fistula, which connects the trachea to the upper or lower oesophagus, or
both. The commonest type of malformation is where the upper oesophagus terminates
in a blind upper pouch and the lower oesophagus connects to the trachea. A round
50% of cases are associated with other malformations either as part of a chromosomal
disorder or a syndrome such as the VA CTERL spectrum vertebral ( anomalies, anal
anomalies, cardiac, tracheoesophageal, radial aplasia, renal and limb anomalies).
Further evaluation, particularly of the heart, is required prior to surgery (Pedersen
et al 2012).
O esophageal atresia should be suspected in the presence of maternal
polyhydramnios and should be screened for after birth in all such affected
pregnancies. At birth the baby may be described as ‘mucousy’ or may have ‘colour
changes’ associated with copious secretions. The midwife should a empt to pass a
wide bore orogastric tube but it may travel less than 10–12 cm. Radiography will
confirm the diagnosis (Fig. 32.5). The baby must be given no oral fluid but a wide bore
oesophageal tube should be passed into the upper pouch and connected to gentle
continuous suction apparatus. I deally a double lumen (Replogle) tube is used. The
baby should be transferred promptly to a surgical unit, ensuring that continuous
suction is available throughout the transfer. I t is usually possible to anastomose the
blind ends of the oesophagus. I f the gap in the oesophagus is too large a series of
bouginages can be carried out in an a empt to stretch the ends of the oesophagus,
stimulate growth and thereby eventually facilitate repair by end-to-end anastomosis.
Very rarely, if the repair is delayed, cervical oesophagostomy may be performed to
allow drainage of secretions. Meanwhile the baby will need to be fed via a gastrostomy
tube. This method of feeding obviously deprives the baby of oral stimuli. S uch a baby
may be given ‘sham’ feeds to allow him/her to taste the milk and to promote sucking,
swallowing and normal development of the mandible.
FIG. 32.5 Oesophageal atresia. Coiled feeding tube in proximal pouch. Note vertebral and rib
abnormalities. Distal gas confirms a tracheo-oesophageal fistula. From Rennie J M, Roberton N R C
(eds) 1999 Textbook of neonatology, 3rd edn, with permission of Churchill Livingstone.
Duodenal atresia
Atresia can occur at any level of the bowel but the duodenum is the most common
site. I f this has not already been diagnosed in the prenatal period, persistent vomiting
within 24–36 hours of birth will be the first feature encountered. The vomit may
contain bile unless the obstruction is proximal to the entrance of the common bile
duct, in which case it will be non-bilious. A bdominal distension is not necessarily
present and the baby may pass meconium. A characteristic double bubble of gas is
seen on radiological examination (Fig. 32.6). Treatment is by surgical repair. This
anomaly is commonly associated with chromosomal disorders, in particular trisomy
21, which accounts for 30% of cases of duodenal atresia.
FIG. 32.6 Double bubble of duodenal atresia. The stomach is overlapping the duodenum with
the second bubble being seen through the stomach. From Rennie J M, Roberton N R C (eds) 1999
Textbook of neonatology, 3rd edn, with permission of Churchill Livingstone.
Anorectal malformations
Careful examination of the perineum is an important aspect of any newborn
examination. A n imperforate anus should be obvious on examination at birth, but a
rectal atresia might not become apparent until it is noted that the baby has not passed
meconium. However, it is important to remember that a history of passing meconium
does not exclude a diagnosis of an anorectal malformation. O ccasionally meconium is
passed through a fistulous connection to the vagina, bladder or urethra and this may
mask an imperforate anus (Figs 32.7–32.9). W hatever the anatomical arrangement, all
babies should be referred for surgery.
FIG. 32.7 Imperforate anus with recto-vesical fistula (1). Reproduced with permission of Donna Bain.
FIG. 32.8 Imperforate anus with recto-vesical fistula (2). Reproduced with permission of Donna Bain.
FIG. 32.9 Imperforate anus with recto-vesical fistula and napkin containing meconium stained
urine. Reproduced with permission of Donna Bain.
Malrotation/volvulus
This is a developmental abnormality where incomplete rotation (malrotation) of the
small bowel has taken place. This predisposes the bowel to intermi ent episodes of
twisting (volvulus) and obstruction. A baby with a malrotation may be entirely
asymptomatic in the neonatal period, however episodes of obstruction can lead to
bilious vomiting and abdominal distension. D ue to the risks of severe, irreversible
bowel damage secondary to the obstruction of blood flow in the mesentery in
unrecognized volvulus, any newborn infant with bile-stained vomiting requires urgent
assessment. Surgical correction is necessary if a malrotation is confirmed.
Meconium ileus (cystic fibrosis)
S ome 15% of children with cystic fibrosis present with meconium ileus in the neonatal
period. This occurs because the meconium is particularly viscous and causes intestinal
obstruction. There is accompanying abdominal distension and bile-stained vomiting.
I ntravenous fluids and a Gastrografin enema may relieve the obstruction but
sometimes surgery is required. Histology of any resected bowel may indicate the
likelihood of cystic fibrosis, but genetic mutation analysis is required to confirm the
diagnosis. S ubsequent treatment of cystic fibrosis is supportive rather than curative
and involves optimized nutrition, administration of pancreatic enzymes and a rigorous
programme of chest physiotherapy and antibiotics.
Hirschsprung's disease
I n this disease, which has an incidence of 1 in 5000 live births, an aganglionic section
of the bowel is present. This means that peristalsis does not occur and the bowel
therefore becomes obstructed. The baby will present with any combination of delayed
(>24 hours) passage of meconium, abdominal distension and bile-stained vomiting.
Hirschsprung's disease is often suspected from radiography and contrast enema,
however a rectal biopsy is required to confirm the diagnosis. S urgical resection of the
aganglionic segment of bowel is indicated.
Cleft lip and cleft palate
The incidence of cleft lip occurring as a single malformation is 1.3 per 1000 live births.
This anomaly may be unilateral or bilateral. S ince it is very often accompanied by cleft
palate, both will be considered together.
Clefts in the palate may affect the hard palate, soft palate, or both. S ome defects will
include alveolar margins and some the uvula. The greatest problem for these babies
initially is feeding. I f the defect is limited to unilateral cleft lip, mothers who had
intended to breastfeed should be encouraged to do so. W here there is the additional
problem of cleft palate, arranging for the baby to be fi ed with an orthodontic plate
may facilitate breastfeeding but this obviously does not afford the same stimulus as
nipple-to-palate contact. Expressed breast milk via a cup is an alternative method but
for those who wish to bo le-feed there is a wide variety of specially shaped teats
available to accommodate the different sizes and positions of palate defects. A bove all
else, an unending supply of patience and reassurance is required. The midwife should
encourage the mother and father to find the most successful technique rather than
‘taking over’ since this may compound any feelings of guilt or inadequacy the parents
feel. Early referral to the cleft palate team of paediatric or plastic surgeon and
orthodontists should be arranged. These teams will also include specialist nursing
staff, speech and language therapists and audiologists.
Corrective surgery will be carried out at some stage, however agreement regarding
optimal timing remains elusive (Manna et al 2009). To some extent a compromise must
always be made regarding the balance of risk from surgery, the psychological impact
of the malformation, the effect on speech and language acquisition and future facial
growth. I n general, lips are repaired between 10 and 12 weeks and palates between 6
and 18 months. I t can be helpful for the midwife to show families ‘before and after’
photographs of babies for whom surgery has been a success (Fig. 32.10).
FIG. 32.10 (A) Cleft lip and palate. (B) The repaired cleft. From Raine P 1994 Cleft lip and palate, in
Freeman N V et al, Surgery of the newborn, ch 34, p 375, with permission of Churchill Livingstone.
Clearly, although the midwife may offer valuable support in these early days, she is
limited in the length of time she has available to help these families. Giving the
parents the address of a support group such as the Cleft Lip and Palate A ssociation
(CLAPA) is useful (see Useful Websites).
Pierre Robin sequence
Pierre Robin sequence is characterized by micrognathia (hypoplasia of the lower jaw),
posterior displacement of the tongue, which allows it to fall backward and occlude the
airway, and a central cleft palate. This triad of anomalies presents challenges for
nursing care, notably airway obstruction and feeding difficulties. A irway obstruction
can often be managed with fairly straightforward interventions, such as prone
positioning or the use of a nasopharyngeal airway. I n a minority of situations the
anatomical anomaly is so severe that surgery, for example jaw distraction or
tracheostomy is required (Bacher et al 2010). Feeding can be problematic with a high
risk of aspiration occurring. S ome of these babies may be fi ed with an orthodontic
plate to facilitate feeding. The action of sucking will encourage development of the
mandible. Parents will need considerable support during what may for some babies be
a protracted period of hospitalization.
Malformations relating to respiration
Making a successful transition from fetus to neonate includes being able to establish
regular respiration. A ny malformation of the respiratory tract or accessory respiratory
muscles is likely to hamper this process.
Diaphragmatic hernia
This malformation occurs in 1 in 2000 live births and consists of a defect in the
diaphragm that allows herniation of abdominal contents into the thoracic cavity (Fig.
32.11). The extent to which lung development is compromised as a result depends on
the size of the defect and the gestational age at which herniation first occurred. The
condition is increasingly diagnosed antenatally by ultrasound; where there is prenatal
diagnosis, birth in a specialist unit is advisable. At birth, the condition may be
suspected if the baby is cyanosed and unexpected difficulty is experienced in
resuscitation. I n addition, since the majority of such defects are left-sided, heart
sounds will be displaced to the right. The abdomen may have a flat or scaphoid
appearance. Chest X-ray will confirm the diagnosis. Babies with this condition usually
have significant respiratory distress and require intubation and mechanical
ventilation. A large bore nasogastric tube on free drainage should be used to minimize
gaseous distension of the displaced abdominal viscera. S urgical repair of the defect is
necessary, but this is not urgent. I t is more important to stabilize the baby's general
condition before surgery. I t is especially critical to deal with the problem of persistent
pulmonary hypertension and right-to-left shunting of blood within the heart. This may
necessitate the use of newer ventilation techniques and pharmacological agents such
as nitric oxide. Prognosis relates to the degree of pulmonary hypoplasia and
reversibility of the pulmonary hypertension. There is also the possibility of co-existent
problems such as cardiac defects or skeletal anomalies.
FIG. 32.11 Chest radiograph of infant at 1 hour of life, showing left diaphragmatic hernia,
displacement of air-filled viscera into the hemithorax and a marked shift of mediastinum and
heart. From Rennie J M, Roberton N R C (eds) 1999 Textbook of neonatology, 3rd edn, with permission of
Churchill Livingstone.
Congenital pulmonary airway malformations (CPAM)
These include lesions formally known as congenital adenomatous malformation
(CCA M), bronchopulmonary sequestration (BPS ) and congenital lobar emphysema
The incidence is thought to be around 1 in 2000 live births although an increasing
number are being detected prenatally by ultrasound scanning. A ntenatal
complications may include mediastinal shift and the development of hydrops,
although many lesions seem to regress during the third trimester. A lthough most
lesions are asymptomatic in the neonatal period, some lesions may expand rapidly
after birth leading to air trapping, over-inflation and respiratory compromise. I n such
cases urgent surgical removal of the abnormal lung tissue is necessary. Babies known
prenatally to have a CPA M should be monitored closely after birth for signs of
respiratory distress.
S ome CPA M have been reported to be associated with lung infection and malignant
change in later life. The true incidence of such complications is unknown but is likely
to be low. However, even in asymptomatic patients, surgical removal may be
undertaken in infancy in order to prevent long-term complications.
Choanal atresia
Choanal atresia describes a unilateral or bilateral narrowing of the nasal passage(s)
with a web of tissue or bone occluding the nasopharynx (Fig. 32.12). The incidence is 1
in 8000 live births. Tachypnoea and dyspnoea are cardinal features, particularly when a
bilateral lesion is present. The diagnosis is made relatively easily by noting that the
baby mouth-breathes and finds feeding impossible without cyanosis. I n addition,
nasal catheters cannot be passed into the pharynx and if a mirror or cold metal spoon
is held under the nose no vapour will collect. A helpful diagnostic aid is that the
baby's colour will improve with crying. A unilateral defect may not be noticed until the
baby feeds for the first time. The midwife should therefore bear in mind the
possibility of this problem if respiratory difficulty and cyanosis occur at this time.
Maintaining a clear airway is obviously essential and an oral airway may have to be
used to affect this. Surgery will be required to remove the obstructing tissue.
FIG. 32.12 Choanal atresia. A bony plate blocks the nose. From Rennie J M, Roberton N R C (eds)
1999 Textbook of neonatology, 3rd edn, with permission of Churchill Livingstone.
O ccasionally choanal atresia is associated with other anomalies such as CHA RGE
syndrome, a condition in which there are defects found in the eye (coloboma), the
heart, occasionally oesophageal atresia, usually growth restriction, plus genital and ear
abnormality.
Laryngeal stridor
This is a noise made by the baby, usually on inspiration and exacerbated by crying.
Most commonly the cause is laryngomalacia. This is due to laxity of the laryngeal
cartilage which collapses inwards during inspiration. A lthough it sounds distressing,
the baby generally is not at all upset. Laryngomalacia usually resolves over time and
intervention is only required in the most severe cases.
There are a number of other causes of stridor in the neonate which should be
considered, particularly if the stridor is accompanied by signs of respiratory distress or
feeding problems. O ther causes include subglo ic stenosis, laryngeal web, laryngeal
cleft, vocal cord paralysis and extrinsic compression by a vascular ring. I nvestigations
including laryngoscopy, bronchoscopy and barium swallow may be necessary in order
to establish the diagnosis in cases not typical of mild larynogomalacia.
Congenital cardiac defects
Babies born with congenital heart defects comprise the second largest group of babies
born with malformations. A pproximately 8 per 1000 live births have some degree of
congenital heart disease and about one-third of these babies will be symptomatic in
early infancy.
Causes
A pproximately 90% of cardiac defects cannot be a ributed to a single cause.
Chromosomal and genetic factors account for 8%, and a further 2% are thought to be
caused by teratogens. The critical period of exposure to teratogens in respect of
embryological development of cardiac tissue is from the 3rd to the 6th week of
gestation.
Prenatal detection
A n increasing number of cardiac problems are being identified by means of detailed
prenatal ultrasound scanning (see Chapter 11). For babies with complex congenital
heart disease this enables a multidisciplinary plan for birth and immediate neonatal
care, to be made well in advance of delivery. However, the detection of many defects is
still dependent upon accurate observations and examination during the neonatal
period.
Postnatal recognition
Babies with congenital heart disease can present in a number of ways: heart murmur,
cyanosis, tachypnoea, weak or absent femoral pulses. Those babies in whom the
pulmonary or systemic blood flow is dependent upon the arterial duct may present
with severe cyanosis or shock when the duct closes.
I t is obviously important to try to identify those infants with life-threatening cardiac
malformations prior to transfer home. A dditionally, early identification and referral of
babies with significant cardiac malformations is desirable. W hilst it must be
remembered that not all babies with heart murmurs have an underlying cardiac
malformation, it should also be noted that some babies with significant congenital
heart disease may have no abnormal findings at the time of their routine newborn
examination. A s an adjunct to routine newborn examination some units therefore also
measure oxygen saturations. This has been shown to improve the detection of some
duct dependent heart lesions (Ewer et al 2011).
I deally, every baby should be examined by a competent practitioner before going
home. A lthough changing pa erns of postnatal care often mean early transfer home, a
baby with suspected congenital heart disease should not be sent home until he/she
has been reviewed by an experienced paediatrician or a definitive diagnosis has been
made. A s some babies with significant congenital heart disease may have no clinical
signs prior to transfer, there is a need for community midwives to be observant and to
communicate effectively with parents. Parents who report any changes in the baby's
behaviour such as breathlessness or cyanosis should never be ignored, but rather
encouraged to seek medical advice promptly.
Traditionally, babies with cardiac anomalies have been divided into two groups:
those with central cyanosis and those without, i.e. cyanotic and acyanotic congenital
heart disease.
Cardiac defects presenting with cyanosis
Defects included in this group are:
• transposition of the great arteries
• pulmonary atresia
• tetralogy of Fallot
• tricuspid atresia
• total anomalous pulmonary venous drainage
• univentricular/complex heart.
A lthough cyanosis can be a presenting feature of a number of non-cardiac
conditions (e.g. respiratory disease, persistent pulmonary hypertension of the
newborn, sepsis), congenital heart disease should always be considered as a possible
explanation. A dministration of oxygen to babies with cyanotic heart disease may have
li le effect on their oxygen saturation levels. This observation, along with other
routine investigations excluding other causes of cyanosis, may suggest a diagnosis of
cyanotic heart disease. The definitive diagnostic investigation is echocardiography.
Cyanosis occurs when there is more than 5 g/dl of circulating deoxygenated
haemoglobin. I n congenital cyanotic heart disease, abnormal anatomy leads to mixing
of oxygenated and deoxygenated blood ± inadequate pulmonary blood flow or, in the
case of transposition of the great arteries, complete separation of the pulmonary and
systemic circulations. I n cases where there is severe obstruction to pulmonary blood
flow, e.g. pulmonary atresia, there is often early presentation with marked cyanosis.
The most common cyanotic heart conditions are transposition of the great arteries
and tetralogy of Fallot. Transposition of the great arteries is the most common
cyanotic heart condition presenting in the neonatal period. This is a condition wherein
the aorta arises from the right ventricle and the pulmonary artery from the left
ventricle (Fig. 32.13). Consequently, oxygenated blood is circulated back through the
lungs and deoxygenated blood back into the systemic circulation. I t is apparent
therefore that, unless there is an opportunity for oxygenated blood to access the
systemic circulation, either by means of a patent arterial duct or through an
accompanying septal defect, such a baby will die. I n congenital cardiac defects such as
this where the patency of the arterial duct is essential for survival (‘duct-dependent’
lesions), a prostaglandin infusion should be commenced in order to maintain ductal
patency pending more definitive management. For babies with transposition of the
great arteries a balloon septostomy is often performed to enlarge the foramen ovale
and allow mixing of oxygenated and deoxygenated blood at atrial level. Corrective
surgery (arterial switch operation) is then carried out, usually within a few weeks of
birth.
FIG. 32.13 Transposition of the great arteries. (A) Normal. (B) Transposition.
Tetralogy of Fallot has four anatomical components; pulmonary outflow tract
obstruction, a ventricular septal defect, right ventricular hypertrophy and an
overriding aorta (Fig. 32.14). I t seldom presents with cyanosis in the immediate
newborn period, but this may become apparent within a few weeks of birth.
I ncreasingly, the diagnosis is made prenatally. Most babies with this condition remain
well in the neonatal period. S urgical treatment options include a Blalock Taussig shunt
for cases where it is necessary to increase pulmonary blood flow, and corrective repair,
usually within the first year of life.
FIG. 32.14 Tetralogy of Fallot (VSD = ventricular septal defect).
A lthough prostaglandin infusion is life-saving for duct-dependent heart conditions
it should be noted that it may lead to apnoea, particularly when higher doses are
required. I t is essential that there are facilities to provide respiratory support available
for any baby on an infusion of prostaglandin.
‘Acyanotic’ cardiac defects
These congenital cardiac conditions include left-to-right shunt lesions and obstructive
lesions.
Left-to-right shunts
• Persistent arterial duct (also known as persistent ductus arteriosus)
• Ventricular or atrial septal defects.
These lesions may present with a murmur or, if the shunt is large, with symptoms
and signs of heart failure: tachypnea, poor feeding, sweating, precordial heave, gallop
rhythm or hepatomegaly.
A persistent arterial duct is more common in preterm infants and surgical closure is
sometimes necessary if medical treatment with ibuprofen or indomethacin is
ineffective. Term infants with a persistent arterial duct more usually undergo cardiac
catheterization with device closure in childhood.
Ventricular septal defects are a common cause of murmurs in the term infant. Many
of these defects are small, of no haemodynamic consequence and close spontaneously.
Larger defects may lead to heart failure and surgical closure may be necessary
although not usually in the neonatal period. (See Fig. 32.15.)
FIG. 32.15 Ventricular septal defect (VSD).
Obstructive lesions
• Coarctation of the aorta
• Pulmonary stenosis
• Aortic stenosis
• Hypoplastic left heart syndrome.
S ome of these lesions may be difficult to pick up clinically and a proportion of
serious left heart obstructive lesions are not diagnosed before transfer home. S uch
lesions should always be considered in the baby with poor volume femoral pulses or
unexplained tachypnoea, remembering that even severe lesions may have no
associated murmur. I f the obstruction is severe, e.g. critical aortic stenosis, then the
systemic blood flow is often dependent upon the arterial duct and the baby will
become very unwell when this closes. A s in the duct-dependent cyanotic heart
conditions, a prostaglandin infusion may be required whilst further investigations and
discussions regarding the possibility of surgical correction take place.
Coarctation of the aorta and aortic stenosis are usually amenable to surgical
correction. Hypoplastic left heart syndrome remains a major surgical challenge,
requiring a number of surgical procedures in childhood, with a poor long-term
outcome. Because of this, some parents opt for a palliative approach with no surgical
intervention. D eath usually occurs within a few days, although it may take
substantially longer in some cases, particularly if the baby is preterm. I f palliation is
the chosen care path, then the priorities are to ensure the comfort of the baby and to
support the family. W hatever treatment decisions they make, following confirmation
of such a diagnosis there is a substantial psychological impact on the parents, which
calls for particularly supportive management.
Central nervous system malformations
N eural tube defects are the commonest malformations of the central nervous system.
They arise from abnormalities during formation and closure of the neural tube, the
embryonic precursor of the central nervous system. I ngestion of folic acid
supplements prior to conception and during the early stages of pregnancy has helped
to reduce the incidence of such anomalies (Medical Research Council [MRC] Vitamin
S tudy Research Group 1991), however they have not provided the hoped-for panacea.
Prenatal screening is very effective at identifying these malformations (see Chapter 11)
and some parents choose selective termination of pregnancies where severe neural
tube defects are found. Many parents elect to continue with their pregnancy and data
from Wales suggest a rise in live births with spina bifida over the last decade (Czapran
et al 2011).
Anencephaly
This major anomaly describes the absence of the forebrain and vault of the skull. I t is
a condition that is incompatible with sustained life but occasionally such a baby is
born alive. The midwife should wrap the baby carefully before showing him/her to the
parents. I t is recognized that seeing and holding the baby will facilitate the grieving
process (Chapter 26). I t may be beneficial for the parents then to see the full extent of
the malformation, unpleasant though it is. S eeing the whole baby will help them to
accept the reality of the situation and prevent imagination of an even more gruesome
picture.
Spina bifida
S pina bifida results from failure of fusion of the vertebral column. I f there is no skin
covering the defect, there is protrusion of the meninges, hence the term meningocele
(Fig. 32.16). The meningeal membrane may be flat or appear as a membranous sac,
with or without cerebrospinal fluid, but it does not contain neural tissue. A
meningomyelocele, on the other hand, does involve the spinal cord (Fig. 32.17). This
lesion may be enclosed, or the meningocele may rupture and expose the neural tissue.
A meningomyelocele usually gives rise to neurological damage, producing paralysis
distal to the defect, and impaired bladder and bowel function. The lumbosacral area is
the most common site for these to present, but they may appear at any point in the
vertebral column. W hen the defect is at base of skull level it is known as an
encephalocele. The added complication here is that the sac may contain varying
amounts of brain tissue. N ormal progression of labour may be impeded by a large
lesion of this type.
FIG. 32.16 Various forms of spina bifida. After Wallis S, Harvey D 1979 Disorders in the newborn, Nursing
Times 75: 1315–27, with permission of Nursing Times.
FIG. 32.17 Baby with meningomyelocele. Reproduced with permission from Professor Robert Carachi.
I mmediate management involves covering open lesions with a non-adherent
dressing. Babies with enclosed lesions should be handled with the utmost care in an
a empt to preserve the integrity of the sac. This will limit the risk of meningitis
occurring. A paediatric surgeon or neurosurgeon should be contacted. S urgical
intervention for myelomeningocele carries a high rate of success of skin closure, but
has no impact on any damage already present in the cord or more distally. There is
associated hydrocephalus (see below) in up to 90% of cases, with the majority
requiring surgical shunting to prevent a rapid increase in the intracranial pressure. I t
is seldom necessary to close the back within 24 hours of birth and priority should be
given to stabilization of the baby and assessment of the defect (J ensen 2012).
Following examination of the baby, discussion with the parents will allow them to
make an informed choice about whether or not they wish their baby to have surgery.
Recent advances in the management of myelomeningocele include prenatal surgery
performed at around 26 weeks' gestation (A dzick et al 2011). Clearly this option is not
without risk to both mother and fetus and evidence of long-term benefit is yet to be
established.
Spina bifida occulta
Spina bifida occulta (see Fig. 32.16) is the most minor type of defect where the vertebra
is bifid. There is usually no spinal cord involvement. A tuft of hair or sinus at the base
of the spine may be noted on first examination of the baby. Ultrasound investigation
will confirm the diagnosis and rule out any associated spinal cord involvement.
Parents who have a baby with a neural tube defect should be offered genetic
counselling since there is a 50-fold increased risk of recurrence in future pregnancies
(Saleem et al 2009).
Hydrocephalus
This condition arises from a blockage in the circulation and absorption of
cerebrospinal fluid, which is produced from the choroid plexuses within the lateral
ventricles of the brain. The large lateral ventricles increase in size and eventually
compress the surrounding brain tissue. I t is a common accompaniment to the more
severe spina bifida lesions because of a structural defect around the area of the
foramen magnum known as the A rnold–Chiari malformation. Consequently,
hydrocephalus may either be present at birth or develop following surgical closure of a
myelomeningocele. I n the absence of a myelomeningocele, congenital aqueduct
stenosis is the commonest cause of hydrocephalus. The risk of cerebral damage may
be minimized by the insertion of a ventriculoperitoneal shunt. A s the baby grows, this
will need to be replaced. A endant risks with these devices are that the line blocks
and that the shunt is a source for infection leading to meningitis. The midwife must be
alert for the signs of increased intracranial pressure:
• large tense anterior fontanelle
• splayed skull sutures
• inappropriate increase in occipitofrontal circumference
• sun-setting appearance to the eyes
• irritability or abnormal movements.
Microcephaly
This is where the occipitofrontal circumference is more than two standard deviations
below normal for gestational age. The disproportionately small head may reflect a
familial pa ern of head growth, however it may also be a manifestation of abnormal
brain development. Underlying aetiologies include conditions that adversely affect the
early fetal brain, e.g. intrauterine infection, fetal alcohol exposure, or chromosomal
disorders. The longer-term neurodevelopmental sequelae are determined by the
underlying cause but may include learning difficulties, cerebral palsy and seizures.
Musculoskeletal deformities
These range from relatively minor anomalies, for example an extra digit, to major
deficits such as absence of a limb.
Polydactyly and syndactyly
Careful examination, including separation and counting of the baby's fingers and toes
during the initial examination, is important otherwise anomalies such as syndactyly
(webbing) and polydactyly (extra digits) may go unnoticed.
S yndactyly more commonly affects the hands. I t can appear as an independent
anomaly or as a feature of a syndrome such as A pert's syndrome; this is a genetically
inherited condition in which there is premature fusion of the sutures of the vault of
the skull, cleft palate and complete syndactyly of both hands and feet. W hether or not
any surgical division needs to be carried out depends on the degree of webbing or
fusion.
I n polydactyly the extra digit(s) may be fully formed or simply extra tissue a ached
by a pedicle. Even where there is only a rudimentary digit without bone involvement,
be er cosmetic results are obtained if the digit is surgically excised rather than ‘tied
off’. Surgical excision is mandatory in more complex cases.
A family history of either of these defects is common, and in this situation the
mother is often anxious to examine the baby for herself.
Limb reduction deficiencies
Limb reduction deficiencies describe the congenital absence or hypoplasia of a long
bone and/or digits. The prevalence is around 0.7 per 1000 live births and the most
common identifiable cause, present in a third of cases, is a vascular disruption defect
(Gold et al 2011). A n example of this is an amniotic band-elated deficiency where the
amnion is believed to wrap itself around a developing limb causing strangulation and
necrosis. O ther identifiable causes include teratogens (such as thalidomide), genetic
mutations, chromosomal disorders or as part of a syndrome such as the VA CTERL
spectrum described earlier in the chapter (see page 651) (McGuirk et al 2001).
Limb reduction deficiencies may also be classified by site (upper versus lower limb),
or by type (transverse versus longitudinal). I n a transverse defect the limb has
developed normally to a particular level beyond which no skeletal elements exist (Fig.
32.18), whilst in a longitudinal defect there is a reduction or absence of an element(s)
within the long axis of the limb (Gold et al 2011).
FIG. 32.18 A baby with a limb reduction defect quickly learns to adapt. Photograph courtesy of
Reach.
S pecific management plans are often reached only after detailed assessment by an
orthopaedic surgeon with a special interest in limb malformations. For those who
require them, different types of prostheses are available and can be fi ed as early as 3
months of age. I nnovative surgical techniques such as limb lengthening or the
transferring of toe(s) to hand to serve as substitute finger(s) are proving successful for
some children. O nce again one of the most helpful things the midwife can do in these
early days of parental adjustment is to offer the address of a support group such as
Reach (see Useful Websites). This appropriately named support group for parents of
children with upper limb deformities has branches throughout the United Kingdom
(UK).
Talipes
Talipes equinovarus (TEV, club foot) (Fig. 32.19) is the descriptive term for a deformity
of the foot where the ankle is bent downwards (plantar flexed) and the front part of
the foot is turned inwards (inverted). Talipes calcaneovalgus describes the opposite
position where the foot is dorsiflexed and everted. TEV is a relatively common
malformation, occurring in 1 in every 1000 live births. I t is bilateral in 50% of cases and
occurs in males more commonly than females, with a ratio of 2 : 1. Historically it was
thought that these deformities were more likely to occur when intrauterine space was
restricted, for example in multiple pregnancy or oligohydramnios. It is now recognized
that there is an important genetic element involved in their causation and parents who
have had a baby with TEV have a 1 in 30 risk of recurrence in future pregnancies. TEV
is also more likely to occur in conjunction with neuromuscular disorders such as spina
bifida. I n the mildest form, postural TEV, the foot may be easily returned to the
correct position. The midwife should encourage the mother to exercise the baby's foot
in this way several times a day. More severe forms will require one or more of
manipulation, splinting, or surgical correction. The advice of an orthopaedic surgeon
should be sought as soon as possible after birth as early treatment with manipulation
or splinting may enhance results and minimize the need for surgery. Care should be
taken to ensure that, for babies who have splints applied, the strapping is not too tight
and that the baby's toes are well perfused.
FIG. 32.19 Congenital talipes equinovarus.
Developmental dysplasia of the hip
Congenital hip dysplasia is an abnormality more commonly found where there has
been a breech presentation at term, oligohydramnios, a foot deformity or a family
history in a first-degree relative. I t most often occurs in primigravida pregnancies and
is commoner in girls than boys. The left hip is more often affected than the right. The
dysplastic hip may present in one of three ways: dislocated, dislocatable or with
subluxation of the joint. Prenatal diagnosis by ultrasound is possible; most, however,
are diagnosed incidentally during the routine newborn examination. A ny abnormal
findings should be reported and the baby referred for an orthopaedic opinion,
ultrasound scan of the hips, or both. W here the diagnosis is confirmed it is usual for
the baby to have a splint or harness such as the Pavlik harness (Fig. 32.20) applied,
which will keep the hips in a flexed and abducted position of about 60%. The splint
should not be removed for napkin changing or bathing. Parents will require additional
support in learning how to handle and care for their baby. Particular a ention should
be paid to skin care and checking for signs of rubbing or excoriation.
FIG. 32.20 Pavlik harness for congenital dislocation of hip. From Barr D G D et al 1998 Disorders of
bone, joints and connective tissue, in Campbell A G M, McIntosh N (eds) Forfar and Arneil's textbook of pediatrics,
ch 23, p 1628, with permission of Churchill Livingstone.
Achondroplasia
A chondroplasia is an autosomal dominant condition where the baby is generally small
with a disproportionately large head and short limbs. S ome 80% of cases are due to
new mutations of fibroblast growth factor receptor genes and hence these families
may have no anticipation of the disorder unless an antenatal diagnosis has been made.
Osteogenesis imperfecta
O steogenesis imperfecta (O I ) is sometimes referred to as bri le bone disease. I t is due
to a disorder of collagen production that can result in multiple fractures either in utero
or at birth. There are eight different types and the severity of symptoms varies
between types. I nheritance was originally believed to be autosomal dominant;
however it is now recognized that autosomal recessive forms exist as well as new
mutations arising in a third of cases (Basel and S teiner 2009). Recognition and genetic
counselling are therefore important for future pregnancies.
Abnormalities of the skin
Vascular naevi
These anomalies in the development of the skin can be divided into two main types,
which commonly overlap.
Capillary malformations
These are due to defects in the dermal capillaries. The most commonly observed are
‘stork marks’. These are usually found on the nape of the neck. They are generally
small and will fade. No treatment is necessary.
Port wine stain
This is a purple–blue capillary malformation affecting the face. I t occurs in
approximately 1 in 3000 live births. I t is generally fully formed at birth and does not
regress with time. However, laser treatment and the skilful use of cosmetics will help
to disguise the problem. The parents, and later the child, may need substantial
psychological support.
S hould the malformation mimic the distribution of the ophthalmic branch of the
trigeminal nerve, further malformations in the eyes (glaucoma), meninges or brain
(epilepsy) may be suspected. This is known as the Sturge–Weber syndrome.
Capillary haemangiomata (‘strawberry marks’)
Capillary haemangiomata are not usually noticeable at birth but appear as red, raised
lesions in the first few weeks of life (Fig. 32.21). These common lesions affect up to
10% of the population by the age of 1 year. They are five times more common in girls
than boys and are also commoner in preterm infants. They can appear anywhere in the
body but cause particular distress to the parents when they appear on the face.
However, parents may be reassured that, although the lesion will grow bigger for the
first few months it will then regress with associated central pallor (Fig. 32.22) and
usually disappears completely by the age of 5–6 years. N o treatment is normally
required unless the haemangioma is situated in an awkward area where it is likely to
be subject to abrasion, such as on the lip or around the eye where it may interfere with
vision. Treatment with propranolol, steroids or pulsed laser therapy is possible.
FIG. 32.21 Evolving capillary haemangioma. Reproduced with permission of Sharon Murphy.
FIG. 32.22 Regressing capillary haemangioma with typical pallor. Reproduced with permission of
Sharon Murphy.
Pigmented (melanocytic) naevi
These are brown, sometimes hairy, marks on the skin that vary in size and may be flat
or raised. A minority of this type of birthmark can become malignant. S urgical
excision may be recommended to pre-empt this.
I t is unlikely that treatment for any of these birthmarks will be carried out in the
immediate neonatal period except in the case of larger pigmented naevi. The midwife's
responsibilities are therefore to notify appropriate medical staff and offer parents
general emotional support.
Genitourinary system
I mproved prenatal screening and diagnostic techniques (see Chapter 11) mean that
information regarding urinary tract architecture is often available at birth. I n addition,
knowledge of liquor volume provides reassurance that fetal renal function is adequate.
I f an anomaly has been prenatally identified a plan regarding the timing of postnatal
investigation(s) and subsequent management should be available at birth.
O ccasionally renal tract malformations may be undiagnosed at birth, in which case the
absence of urine for 24 hours or a poor urinary stream may indicate underlying
problems.
Potter syndrome
The impact of fetal renal agenesis or severe hypoplasia was first described in a series
of stillborn infants by Edith Po er, a perinatal pathologist, in 1946. A characteristic
facial appearance due to the compressive effects of longstanding oligohydramnios is
seen in association with limb contractures. The presence of adequate liquor volume is
critical to the development of normal lungs and babies with renal agenesis will all die
at or shortly after birth as a consequence of lung hypoplasia.
Posterior urethral valve(s)
This is a malformation affecting boys where the presence of valves in the posterior
urethra obstructs the normal outflow of urine. A s a result, the bladder distends,
causing back pressure on the ureters and kidneys. This will ultimately cause bilateral
hydronephrosis and renal parenchymal damage. Prenatal diagnosis is common and in
utero intervention with the insertion of a shunt from the bladder to the amniotic fluid
is possible. I mproved long-term renal function following prenatal treatment is not
guaranteed and postnatal valve ablation remains the mainstay of treatment (Salam
2006). Unfortunately even with early identification and management many of these
boys will have life-long renal impairment.
Cystic kidneys
Cystic changes within the kidney(s) are often identified prenatally. Extensive bilateral
changes are likely to be associated with impaired renal function and oligohydramnios.
Unfortunately the prognosis in this situation is poor, with some babies dying at birth
and others developing renal failure. The severest forms of polycystic kidney disease
are usually linked to an autosomal recessive inheritance, but an autosomal dominant
variety also occurs with a less gloomy prognosis. Unilateral cystic changes, e.g.
multicystic dysplastic kidney, have a good prognosis assuming that the contralateral
kidney is normal. Postnatal renal imaging and follow-up is required but the baby is
usually well at birth.
Hypospadias
Examination of a baby boy may reveal that the urethral meatus opens on to the
undersurface of the penis. The meatus can be placed at any point along the length of
the penis and in some cases will open onto the perineum. This abnormality often co-
exists with chordee, in which the penis is short and bent and the foreskin is present
only on the dorsal side of the penis. I t is important that the parents are made aware
that circumcision should be deferred until consultation with the paediatric surgeon is
completed.
Cryptorchidism
Undescended testes may be unilateral or bilateral and occur in 1–2% of male infants. I f
on examination of the baby after birth the scrotum is empty, the undescended testes
may be found in the inguinal pouch. S ometimes the testis in this position can be
manipulated into the scrotal pouch. I f neither testis is palpable further investigation
to exclude endocrine or chromosomal causes is required. I n unilateral undescended
testis parents should be encouraged to have the baby examined at regular intervals. I f
descent of the testis has not occurred by the time the child is one year old,
arrangements for orchidopexy may be made.
Disorders of sex development (DSD)
D S D are a group of conditions in which the external genitalia and the reproductive
organs do not develop normally. They may present at birth when the baby's external
appearance is neither definitely male nor female. In this very challenging situation it is
vital that the midwife is positive, honest and does not assign a gender to the baby.
Examination of the baby may reveal any of the following: a small hypoplastic penis,
chordee, bifid scrotum, undescended testes (careful examination should be made to
detect undescended testes in the inguinal canal) or enlarged clitoris and incompletely
separated or poorly differentiated labia. I t can be impossible to differentiate by
clinical examination alone between female masculinization, male under-virilization or
mixed gender and expert clarification is always needed. The decision of gender
a ribution is made following chromosomal studies to determine genetic make-up,
hormone assays and consideration of the potential surgical options. I n the longer term
specialist multidisciplinary support, including clinical psychologists, is essential for
these children and their families.
Congenital adrenal hyperplasia
This is the commonest cause of female masculinization (i.e. genetically female with
male-looking genitalia). I n this inherited condition the adrenal gland is stimulated to
overproduce androgens because of a deficiency of an enzyme called 21-hydroxylase,
which is necessary for normal production of steroid from cholesterol. I f aldosterone
production is also reduced then these babies will rapidly lose salt and may present
collapsed and dehydrated. Urea and electrolyte levels, blood glucose and 17-hydroxy
progesterone concentrations should be measured and appropriate fluid replacement
given. Prenatal diagnosis by genetic mutation analysis is possible and facilitates
prenatal steroid treatment to minimize virilization in affected females (Forest 2004).
Androgen insensitivity syndrome
This is one of several causes of male under-virilization (genetically male with female-
looking genitalia). I n this condition cells are unresponsive to the effects of androgenic
hormones. I n the fetus this prevents normal masculinization of the external genitalia
despite the presence of a Y chromosome.
Teratogenic causes
Fetal alcohol syndrome/spectrum
Fetal alcohol exposure remains a leading cause of intellectual impairment despite
D epartment of Health recommendations to drink no alcohol at all during pregnancy.
This reflects the difficulties of translating health promotion objectives into successful
outcomes, particularly in an environment where the alcohol consumption of young
women is constantly increasing.
The teratogenic effects of alcohol include growth restriction, distortion of
craniofacial features and brain damage (D e S anctis et al 2011). The midwife may be
alerted to the possibility of a baby being born with this syndrome if there have been
concerns about in utero growth, particularly in the context of excess alcohol
consumption. Postnatally the following characteristics may be recognizable: a small
for gestational age infant with microcephaly, small palpebral fissures, a smooth
philtrum and a thin upper lip. These facial features may become less pronounced as
the child grows, however microcephaly, small stature and behavioural problems
remain. The midwife will need to exercise excellent counselling skills to provide much-
needed support for the mother. Collaboration with social services is usually called for
to ensure that the care options decided are in the best interests of the infant and
family.
Establishing such a direct link between a teratogen and a complex clinical pa ern
remains the exception rather than the rule although as mentioned earlier accurate
recording of all congenital malformations on a central register can aid early
recognition of potential new teratogens.
Support for the midwife
Caring for a mother whose baby has some major congenital malformation places extra
demands on the midwife. This stress is compounded if the anomaly was not
anticipated prior to birth or if the midwife has not previously encountered the
particular problem. The exercising of effective counselling and communication skills is
invaluable in helping the family to adjust and in facilitating appropriate lines of
support. The extra effort expended can be costly in terms not only of time but of the
emotional stress the midwife may experience.
I t is important that support is available for midwives in these situations and an
opportunity to debrief with a senior colleague(s) or named supervisor of midwives can
be helpful. Preparatory courses on grief and bereavement counselling are also of some
benefit as many parents with affected babies will experience many of these emotions
(Chapter 26). Midwives who have acquired experience in this realm should not,
however, automatically be targeted as the experts and always be called upon to fulfil
this role. Conversely, student midwives ought not to be deliberately shielded from
being involved in caring for such families. The provision of quality care for parents
who have a child with a congenital malformation is contingent upon meeting the
needs of the carers.
Midwives may also find information available via the I nternet, however, they should
be aware of the dubious quality of some of this information. They should therefore
exercise caution in how they utilize it. I t might also be wise to caution parents, who
often search the Internet for further information, of this potential risk.
References
Adzick NS, Thom E, Spong C, et al. A randomized trial of prenatal versus
postnatal repair of myelomeningocele. New England Journal of Medicine.
2011;364(11):993–1004.
Bacher M, Linz A, Buchenau W, et al. Treatment of infants with Pierre Robin
sequence. Laryngorhinootologie. 2010;89(10):621–629.
Basel D, Steiner RD. Osteogenesis imperfecta: recent findings shed new light on
this once well understood condition. Genetic Medicine. 2009;11(6):375–385.
Chinnery PF, Howell N, Lightowlers RN, et al. MELAS and MERRF: The
relationship between maternal mutation load and the frequency of clinically
affected offspring. Brain. 1998;121:1889–1894.
Czapran P, Gibbon F, Beattie B, et al. Neural tube defects in Wales: changing
demographics from 1998 to 2009. British Journal of Neurosurgery. 2011;26:456–
459.
De Sanctis L, Memo L, Pichini S, et al. Fetal alcohol syndrome: new perspectives
for an ancient and underestimated problem. Journal of Maternal Fetal and
Neonatal Medicine. 2011;24(1):34–37.
Ewer AK, Middleton LJ, Furmston AT, et al. Pulse oximetry screening for
congenital heart defects in newborn infants (Pulse Ox): a test accuracy study.
Lancet. 2011;378:785–794.
Forest MG. Recent advances in the diagnosis and management of congenital
adrenal hyperplasia due to 21-hydroxylase deficiency. Human Reproduction
Update. 2004;10(6):469–485.
Gold NB, Westgate MN, Holmes LB. Anatomic and etiological classification of
congenital limb deficiencias. American Journal of Medical Genetics.
2011;155A(6):1225–1235.
Haddock G, Davis CF, Raine P A M. Gastroschisis in the decade of prenatal
diagnosis. European Journal of Paediatric Surgery. 1996;6:18–24.
Jensen A. Nursing care and surgical correction of neonatal myelomeningocele.
Infant. 2012;8(5):142–146.
Lee SL, Beter TD, Kim SS, et al. Initial nonoperative management and delayed
closure for the treatment of giant omphaloceles. Journal of Pediatric Surgery.
2006;41(11):1846–1849.
Manna F, Pensiero S, Clarich G, et al. Cleft lip and palate: current status from the
literature and our experience. Journal of Craniofacial Surgery. 2009;20(5):1383–
1387.
McGuirk CK, Westgate MN, Holmes LB. Limb deficiencies in newborn infants.
Pediatrics. 2001;108(4):E64.
Medical Research Council Vitamin Study Research Group. Prevention of neural
tube defects: results of the Medical Research Council Vitamin Study. Lancet.
1991;338:131–137.
Pedersen RN, Calzolari E, Husby S, et al. Oesophageal atresia: prevalence,
prenatal diagnosis and associated anomalies in 23 European regions. Archives
of Disease in Childhood. 2012;97(3):227–232.
Salam MA. Posterior urethral valves: outcome of antenatal intervention.
International Journal of Urology. 2006;13(10):1317–1322.
Saleem SN, Said AH, Abdel-Raouf M, et al. MRI in the evaluation of fetuses
referred for sonographically suspected neural tube defects: impact on
diagnosis and management decisions. Neuroradiology. 2009;51(11):761–772.
Schlatter M, Norris K, Uitvlugt N, et al. Improved outcomes in the treatment of
gastroschisis using a preformed silo and delayed repair approach. Journal of
Pediatric Surgery. 2003;38(3):459–464.
Further reading
Jones KL. Smith's recognizable patterns of human malformation. 6th edn.
Saunders/Elsevier: Philadelphia; 2006.
This book provides a comprehensive and systematic approach to dysmorphic syndromes..
Useful websites
Antenatal Results and Choices (ARC). www.arc-uk.org.
This website provides non-directive support and advice to parents throughout the
antenatal testing process and when a malformation has been diagnosed.
Association for Spina Bifida and Hydrocephalus (ASBAH). www.asbah.org.
Children's Heart Federation. www.chfed.org.uk.
Cleft Lip and Palate Association (CLAPA). www.clapa.com.
Contact a Family. www.cafamily.org.uk.
This website provides information and support for families with disabled children..
Cystic Fibrosis Trust (CF). www.cftrust.org.uk.
Down's Syndrome Association. www.downs-syndrome.org.uk.
Genetic Alliance UK. www.geneticalliance.org.uk.
This is a national alliance of organizations which support children and families affected
by genetic disorders..
On-line Mendelian Inheritance in Man (OMIM). www.ncbi.nlm.nih.gov/omim.
Detailed information about clinical features and genetics of inherited diseases.
Reach: The Association for Children with Upper Limb Deficiencies.
www.reach.org.uk.
Scottish Down's Syndrome Association (SDSA). www.dsscotland.org.uk.
SOFT (Support Organization for Trisomy 13/18). www.soft.org.uk.
STEPS (National Association for Children with Lower Limb Deficiencies).
www.steps-charity.org.uk.
C H AP T E R 3 3
Significant problems in the newborn baby
Stephen P Wardle, Carole England
CHAPTER CONTENTS
Introduction 668
Initial examination and recognition of problems 668
The skin 668
The respiratory system 670
Central nervous system 671
The renal and genitourinary system 671
The gastrointestinal tract 672
Recognition of problems at the time of resuscitation, including neonatal
encephalopathy 672
Neonatal encephalopathy 672
Babies with less severe problems 674
Seizures and abnormal movements 674
Infection in the newborn 674
Umbilical cord 675
Bacterial infection in the newborn 675
Viral infections acquired before or during birth 676
Toxoplasmosis 677
Candida 678
Significant eye infections. 678
Respiratory problems 678
Initial management of babies presenting with respiratory distress 679
Possible causes of respiratory distress in the newborn 679
Congenital heart disease (CHD) 681
Management of a baby with an antenatal diagnosis of CHD 681
Care of a baby with a murmur 681
Jaundice 681
Bilirubin physiology 682
Physiological jaundice 682
Pathological jaundice 685
Late neonatal jaundice 687
Haematological problems 688
Bleeding 688
Possible causes of bleeding abnormalities 688
Metabolic problems 689
Glucose homeostasis 689
Hypoglycaemia 689
Hyperglycaemia 690
Electrolyte imbalances in the newborn 691
Sodium 691
Potassium 692
Calcium 692
Inborn errors of metabolism in the newborn 692
Phenylketonuria 693
Galactosaemia 694
Endocrine problems 694
Thyroid disorders 694
Adrenal disorders 695
Pituitary disorders 695
Parathyroid disorders 695
Effects on the newborn of maternal drug abuse/use during pregnancy 696
Signs of withdrawal 696
Treatment 696
Cocaine 697
Discharge and long-term effects 697
References 697
Further reading 701
Websites 701
A wide variety of conditions may present in the newborn baby that warrant
early referral to the neonatal multiprofessional team. The midwife needs to
be able to recognize and assess problems that distinguish healthy babies
from those that are ill/sick. Some problems will be life-threatening and will
require urgent assistance; others will be more subtle in their presentation,
but nevertheless remain important. Knowledge of the signs, characteristics
and features of the conditions presented will enable the midwife to make
well-informed and appropriate referrals, while also providing valuable
support for the parents before, during and after the neonatologist has
examined their baby.
The chapter aims to:
• assist the midwife in the assessment and identification of the sick newborn baby
• summarize possible problems that may be identified in a newborn baby and offer an
approach to dealing with them.
Introduction
The majority of newborn babies are born in good condition and require no
intervention after birth except to be dried with a warm towel and then to have skin-to-
skin contact with their mother (Chapter 29). Labour and birth may have been
straightforward but the baby may still need to be observed at this time to ensure a
healthy transition from uterine to postnatal life. A pproximately 5–10% of babies will
require admission to a neonatal unit. Many of these are preterm babies or those with
antenatally detected problems; however 6–9% of term babies will also require some
type of neonatal care (Tracy et al 2007). The length of time a mother spends in hospital
with her newborn baby has decreased significantly in recent years and many babies
may be born outside the hospital se ing, at home or in a midwifery-led unit. Context
may impact on early recognition and management of problems in the early newborn
period. The focus of this chapter is to aid the early detection of problems to enable the
midwife to distinguish the ill from the well baby and to decide when intervention is
required and what that initial action should be. The aim is not to give detailed
management about conditions that will clearly need the involvement of the neonatal
specialists, but to summarize those conditions that may first be recognized or come to
the attention of midwives and require their involvement.
Initial examination and recognition of problems
Most of the information the midwife requires for the assessment of a baby's wellbeing
comes from observation. The normal term baby will lie with their limbs partially
flexed and active, the skin colour should be centrally perfused, indicating adequate
oxygenation, and there should be no rashes or skin lesions. A fter the initial
observation there should follow a more systematic examination to ensure the newborn
baby is well (Chapter 28). The following areas should be examined carefully.
The skin
The skin of a neonate varies in its appearance and can often be the cause of
unnecessary anxiety in the mother, midwife and medical staff. I t is, however, often the
first sign that there may be an underlying problem in the baby. The presence of
meconium on the skin, which is usually seen in the nail beds and around the
umbilicus, in a baby with respiratory problems may indicate meconium aspiration as a
factor. More generally, the skin of all babies should be examined for pallor, plethora,
cyanosis, jaundice and skin rashes.
Pallor
A pale, mo led baby may be an indication of poor peripheral perfusion, however the
hands and feet are often blue soon after birth (acrocyanosis) and this does not indicate
an underlying problem. A lways examine the baby's face and chest when assessing
colour. The anaemic baby's appearance is usually pale pink, white or, in severe cases
where there is vascular collapse, grey. O ther presenting signs are tachycardia,
tachypnoea and poor capillary refill (CR) (press the skin briefly on the forehead or
chest and observe how long it takes for the colour to return; this should be less than 2
seconds). The most likely causes of anaemia immediately after birth are:
• a history in the baby of haemolytic disease of the newborn (HDN)
• twin-to-twin transfusions in utero (which can cause one baby to be anaemic and the
other polycythaemic)
• feto-maternal haemorrhage
• fetal haemorrhage from vasa praevia or bleeding from the umbilical cord.
Pallor can also be observed in babies who are hypothermic or hypoglycaemic.
Significant pallor can be associated with:
• anaemia and shock
• respiratory disorders
• cardiac anomalies
• sepsis.
Plethora
Babies who are very red in colour may be described as plethoric. Their colour may
indicate a high level of circulating red blood cells (polycythaemia). N ewborn babies
can become polycythaemic if they are recipients of:
• twin-to-twin transfusion in utero
• a large placental transfusion.
Contributing factors may include deferred clamping of the umbilical cord or
holding the baby below the level of the placenta, thereby allowing blood to flow into
the baby and giving a greater circulating blood volume (can occur in unassisted
births). Other babies at risk are:
• those that are small for their gestational age (SGA) as a means to increase oxygen
carrying capacity in the hypoxic situation (Chapter 30)
• infants of diabetic mothers (IDM) as a result of increased levels of growth hormone
and an overactive metabolism.
The diagnosis of polycythaemia is based upon levels of haemoglobin and
haematocrit (the relationship between red blood cells and plasma in the blood) and
how they compare with normal values, based on gestational age. S ome poor outcomes
have been associated with polycythaemia, however according to (Özek et al 2010) there
is no evidence that a particular level of haematocrit requires treatment nor that
treatment is of any benefit.
Cyanosis
Peripheral cyanosis of the hands and feet is common during the first 24 hours of life
and is of no significance. Central cyanosis should always be taken seriously. The
tongue and mucous membranes are the most reliable indicators of central colour in all
babies and if they appear blue this indicates low oxygen saturation levels in the blood,
usually of respiratory or cardiac origin. Episodic central cyanosis may be an indication
that the baby is having convulsions. Central cyanosis always demands urgent attention
(see later sections on respiratory problems and assessment of the cyanosed baby).
Other factors that affect the appearance of the skin
Preterm babies have thinner skin that is redder in appearance than that of term
infants. I n post-term babies, the skin is often dry and cracked. The skin is a good
indicator of the nutritional status of the baby. The S GA baby may look malnourished
and have folds of loose skin over the joints, owing to the lack or loss of subcutaneous
fat. This can predispose the baby to hypoglycaemia due to poor glycogen stores in the
liver and can also cause problems with hypothermia. I f the baby is dehydrated, the
skin looks dry and pale and is often cool to the touch. I f gently pinched, the skin will
be slow to retract. O ther signs of dehydration are tachycardia, pallor or mo led skin,
sunken eyes and anterior fontanelle. The best clinical indicator of dehydration is the
baby's reduced weight.
Skin rashes
S kin rashes are quite common in newborn babies but most are benign and self-
limiting. There are some rashes, however, which may indicate significant illness and
should not be ignored:
• Petechiae or purpura rash over the upper part of the body, particularly the face and
chest, may occur due to venous obstruction after normal or prolonged birth.
Petechiae can occur when there is a low platelet count (thrombocytopenia as
discussed later in the chapter) and this may present with a petechial rash over the
whole body with prolonged bleeding from puncture sites and/or the umbilicus and
bleeding into the intestinal system.
• Bruising can occur following breech extractions, forceps and ventouse-assisted
births. A sub-aponeurotic haemorrhage (Chapter 31) can cause a decrease in
circulating blood volume, which can result in anaemia and, if severe, hypotension.
• Vesicular rash is where small fluid-filled raised lumps occur on the skin associated
with some congenital viral infections, in particular herpes simplex or congenital
chicken pox (Varicella). These can be very serious infections in the newborn and should
always be carefully assessed. The midwife should enquire about a history of maternal
genital herpes infection although it can occur without any known history of infection.
Referral for neonatal medical assessment is essential and a diagnosis should be
confirmed before commencing treatment.
• Blistering rash is where areas of skin are raised and are fluid-filled. The surface of the
skin may also slough off, leaving red raw areas. This can occur in bacterial infections,
in particular Staphylococcus aureus, and in some rare but important skin diseases, e.g.
epidermolysis bullosa (EB), part of a group of inherited skin conditions some of
which are very serious and associated with significant morbidity and mortality. There
may be a family history. It presents as widespread tender erythema, followed by
blisters, which break leaving raw areas of skin or sometimes yellow-filled bullae. This
is particularly noticeable around the napkin area but can also cause umbilical sepsis,
breast abscesses, conjunctivitis and, in systemic infections, there may also be
involvement of the bones and joints. Babies with this condition are likely to be very
unwell and require admission to a neonatal intensive care unit (NICU). A blistering
skin rash should always be treated with broad spectrum intravenous (IV) antibiotics
that particularly cover S. aureus.
The respiratory system
Healthy babies should establish normal regular respiration within minutes of birth.
Many babies may display a slightly irregular breathing pa ern for a few minutes after
birth but should have regular respiration with a respiratory rate of 40–60 by
approximately 2 minutes. The baby's breathing pa ern will alter depending on his/her
level of activity but a respiratory rate consistently above 60 breaths per minute is
considered as tachypnoea.
Cardiorespiratory adaptations at birth
• Before birth the lungs are fluid-filled. At birth the newborn must clear this fluid in
order to breathe successfully. Some fluid is removed by physical means during
normal labour (Stephens et al 1998) but most is absorbed into the pulmonary
lymphatics and capillaries.
• The lungs inflate and remain inflated as a result of the presence of surfactant. In
some preterm babies, IDM and sick term babies, surfactant production may be
decreased, resulting in respiratory distress.
• Newborn babies are obligate nasal breathers. Obstruction to the nares (nostrils) can
therefore result in serious respiratory distress.
• The shape of the newborn thorax and the rib orientation tend to mean that the
expansion potential of the thorax is limited. The baby's soft and flexible ribs also
make the chest wall subject to collapse during increased respiratory efforts. To
compensate for this the baby tends to elevate lung volume at end expiration by a
rapid respiratory rate, intercostal activity and grunting.
Because of the factors described above the clinical signs of respiratory distress in the
newborn are different from other patient groups. The following features may be seen:
• Expiratory grunting is a characteristic noise and occurs due to partial closure of the
glottis during expiration. The baby is attempting to preserve some internal lung
pressure and prevent the airways from collapsing completely at the end of the breath.
• Intercostal recession uses the intercostal muscles more effectively, but as a result the
spaces between the ribs and the sternum are sucked in during each breath.
• Tachypnoea is an increased respiratory rate that occurs as the baby attempts to
compensate for an increased carbon dioxide concentration in the blood and
extracellular fluids. A normal respiratory rate in the newborn is 40–60 breaths per
minute.
• Nasal flaring is an attempt to minimize the effect of the airways resistance by
maximizing the diameter of the upper airways. The nares are seen to flare open with
each breath.
• Apnoea is an absence of breathing for more than 20 seconds and may occur as a
result of increasing respiratory fatigue in the term baby. The preterm baby may also
experience apnoea of prematurity due to immaturity of the respiratory centre and/or
obstructive apnoea from occluded airways.
A baby with significant signs of respiratory distress should be reviewed by the
neonatal team and should be admi ed to the N I CU for further investigation and
observation. O ccasionally in the first few minutes after birth, particularly following a
caesarean section, a baby may have mild respiratory abnormalities that se le quickly,
but babies with abnormal signs should always remain under observation as
deterioration can occur rapidly in some cases. O n initial assessment it may not be easy
to distinguish the cause of the respiratory distress and further evaluation, including a
chest X-ray, may be required (the initial assessment and treatment is described later in
the chapter).
The importance of body temperature control
A neutral thermal environment is defined as the ambient air temperature at which
oxygen consumption or heat production is minimal, with body temperature in the
normal range (Lissauer and Faranoff 2006). The normal body temperature range for
term babies is 36.5–37.3 °C. Merenstein and Gardner (2011) assert the importance of
the neutral thermal environment and how everyone caring for babies should
understand the need for maintenance of normal body temperature. Mothers are often
hot during labour and measures may be taken to produce a cooler environment for the
mother's comfort. I t is important to always consider this effect and maintain a suitable
environmental temperature for the newborn baby. I n addition to skin-to-skin contact,
this may require extra measures like use of a radiant heater or cot warmer, in some
circumstances. Environments that are outside the neutral thermal environment may
result in babies who are too cold or too warm, who will a empt to regulate their
temperature, and this can destabilize more vulnerable babies such as those of low
birth weight (preterm and S GA). A n abnormal temperature, either high or low, can be
an early sign of an underlying problem such as an infection, a respiratory or cardiac
problem, a metabolic abnormality or encephalopathy.
Hypothermia is defined as a core body temperature below 36 °C (J ain 2012). W hen
the body temperature is below this level the baby is at risk from cold stress. This can
cause complications such as increased oxygen consumption, lactic acid production,
apnoea and hypoglycaemia. I n preterm babies cold stress may also cause a decrease in
surfactant production, which is associated with increased mortality (Costeloe et al
2000; Confidential Enquiries into S tillbirths and D eaths in I nfancy [CES D I ] 2003
). The
hypothermic baby often looks pale or mottled and may be uninterested in feeding.
Hyperthermia is defined as a core temperature above 38.0 °C (J ain 2012). The usual
cause of hyperthermia is overheating of the environment, but it can also be an
important clinical sign of sepsis as the baby will attempt to regulate its temperature by
increasing his/her respiratory rate leading to an increased fluid loss by evaporation
through the airways. O ther problems caused by hyperthermia are hypernatraemia,
jaundice and apnoea.
Central nervous system
A ssessment of a baby's neurological status is usually carried out on a baby who is
awake but not crying. I mportant signs are the tone and quality of a baby's movements,
level of activity, posture and presence of normal newborn reflexes. A n abnormal
posture such as neck retraction, frog-like posture, hyperextension or hyperflexion of
the limbs, ji ery or abnormal involuntary movements and a high-pitched or weak cry,
could be indicative of neurological impairment and a need for investigation (Lawn and
Alton 2012).
Terminology that describes abnormal movement in babies is very variable and
includes fits, convulsions, seizures, twitching, jumpy and ji ery. I n contrast, a baby
with poor muscle tone is described as hypotonic or floppy. I t is often very difficult to
distinguish a seizure from ji eriness or irritability. The ji ery baby has tremors, rapid
movement of the extremities or fingers that are stopped when the limb is held or
flexed. J i eriness can be normal but is sometimes seen in babies who are affected by
drug withdrawal or in babies with hypoglycaemia (see section on seizures, p 674).
Hypotonia
Hypotonia describes the loss of muscle tension and tone. A s a result, the baby adopts
an abnormal posture that is noticeable on handling. I f hypotonia and a lack of
movement have been significant features before birth then limb contractures may also
be seen. Preterm babies below 30 weeks' gestation have a resting position that is
usually characterized as hypotonic. By 34 weeks their thighs and hips are flexed and
they lie in a frog-like position, usually with their arms extended. At 36–38 weeks'
gestation the resting position of a healthy newborn baby is one of total flexion with
immediate recoil. Hypotonia in a term baby is not normal and requires investigation.
It is also important to determine whether the hypotonia is associated with weakness or
normal power in the limbs, i.e. are there spontaneous movements? Can the baby make
normal movements against gravity? There are several causes of hypotonia in the
newborn.
Systemic causes
• maternal sedation or drugs (in particular some antidepressants)
• prematurity
• infection
• Down syndrome
• endocrine (e.g. hypothyroidism)
• metabolic problems (e.g. hypoglycaemia, hyponatraemia, inborn errors of
metabolism)
Central (brain) causes
• perinatal hypoxia-ischaemia or neonatal encephalopathy (see p 672 below)
• traumatic brain injury
• structural brain abnormality, e.g. holoprosencephaly
Peripheral nervous system causes
• neurological problems (e.g. spinal cord injuries sustained by difficult breech or
forceps assisted birth)
• neuromuscular disorders (e.g. spinal muscular atrophy, myasthenia gravis related to
maternal disease, myotonic dystrophy etc.)
The renal and genitourinary system
D ocumentation of the passage of urine after birth is important as it provides a record
that may help if later concerns arise. The genitourinary tract has the highest
percentage of anomalies, congenital or genetic, of all the organ systems. Prenatal
diagnosis is possible with ultrasound and aids the early assessment and intervention
that is essential if kidney damage is to be prevented. Urine that only dribbles out,
rather than being passed with a good stream, may be an indication of a problem with
posterior urethral valves. O ther renal problems may present as a failure to pass urine.
The healthy baby usually passes urine within 4–10 hours after birth. Urinalysis using
reagent strips will give information that may be helpful in diagnosis. Urinary
infections in the newborn period are uncommon. The signs of urinary tract infection
are often vague and can be mistaken for other problems. The baby typically presents
with lethargy, poor feeding, increasing jaundice and vomiting. Urine infections when
present are important, however, because renal scarring can result. Reduced urine
output is usually due to low fluid intake, often in breast-fed babies, but also consider:
• increased fluid loss due to hyperthermia, use of radiant heaters and phototherapy
units
• perinatal hypoxia-ischaemia
• congenital abnormalities
• infection.
The gastrointestinal tract
A ssess the baby's abdomen, looking for signs of distension, discoloration or
tenderness. Most babies should feed early and pass meconium within the first 8–12
hours of birth. Healthy babies should be able to feed within 30 minutes of birth.
Vomiting can be a sign of a problem but the midwife should distinguish between
posse ing, which occurs with winding and over-handling after feeding, and vomiting
due to overfeeding, infection or intestinal abnormalities. W hilst posse ing small
amounts of milk is common, babies with large vomits should be evaluated, as should
babies with blood in their vomit. Vomit containing green material can occasionally be
due to swallowed meconium but green bile is usually unmistakable.
Bile-stained vomiting
There should never be green bile in the vomit of a newborn baby and this always
requires prompt investigation. I t may indicate bowel obstruction and in the newborn
one of the possible causes is malrotation and volvulus, which could lead to bowel
damage and bowel loss if not promptly investigated. I f bile-stained vomiting is seen or
reported, check the baby carefully looking for abdominal distension or tenderness.
Check that the anus is patent. A n X-ray and contrast study is usually required to rule
out bowel obstruction and malrotation. O ther possible causes include infection, bowel
atresias, meconium ileus, anorectal malformations or necrotizing enterocolitis (NEC).
N EC is generally a problem in premature babies but may also occur in term babies,
particularly those who have risk factors such as perinatal hypoxia, polycythaemia and
hypothermia. I t is an acquired disease of the small and large intestine caused by
ischaemia of the intestinal mucosa. N EC may present with vomiting and this may be
bile-stained. The abdomen becomes distended, stools may be loose and may have
blood in them or the baby may not open its bowels. I n the early stages of N EC, the
baby can display non-specific signs of temperature instability, unstable glucose levels,
lethargy and poor peripheral circulation. A s the illness progresses, the baby may
become apnoeic and bradycardic and may need respiratory support.
Passage of meconium
A ccording to Metaj et al (2003), 97% of babies will pass meconium by 24 hours of age,
an event that should be documented. I f a baby has not passed meconium then
examine the abdomen to look for signs of distension or tenderness. Check that the
anus is patent. Possible causes of delayed passage of meconium include bowel atresia,
meconium ileus and imperforate anus. Hirschsprung's disease should be suspected in
term babies with failure to pass meconium in the first 48 hours after birth. Passage of
first meconium occurs later with earlier gestational age (Kumar and Dhanireddy 1995).
The normal term baby usually passes about eight stools a day. Breastfed babies'
stools are looser and more frequent than those of bo le-fed babies, and the colour
varies more and sometimes appears greenish. The baby who has a systemic infection
can often display signs of gastrointestinal problems, usually poor feeding and
vomiting. D iarrhoea may be a feature of this or may indicate a more serious
gastrointestinal disorder such as N EC. D iarrhoea caused by gastroenteritis is unusual
in the newborn although it may be seen after the first week. O utbreaks of viral
diarrhoea due to Rotavirus have been reported. Babies with this condition must be
isolated and scrupulous handwashing must be adhered to (I saacs and Moxon 1999).
Loose stools can also be a feature of babies receiving phototherapy.
Recognition of problems at the time of resuscitation,
including neonatal encephalopathy
A spects of resuscitation of the newborn are covered in Chapter 29, but problems that
might be encountered, or may present during or immediately after resuscitation, will
be covered here. I t is important to recognize promptly those babies who have adapted
poorly to extrauterine life and are in poor condition at birth because of hypoxia-
ischaemia, or have tolerated the birth process poorly as a result of pre-existing
problems.
Neonatal encephalopathy
N eonatal encephalopathy is a clinical syndrome of abnormal levels of consciousness,
tone, primitive reflexes, autonomic function and sometimes seizures in newborn
babies.
Which babies get encephalopathy?
The commonest cause is hypoxia-ischaemia, termed hypoxic ischaemic
encephalopathy (HI E), but it isimportant to remember that not all encephalopathy is
due to hypoxia-ischaemia.
Encephalopathy can be due to:
• cord obstruction (prolapse or compression)
• placental abruption
• breech
• shoulder dystocia etc.
I n addition, other causes such as metabolic, infective, malformation or trauma
should also be considered. The term neonatal HI E should be used only when there is
clear evidence of hypoxia and ischaemia. Globally, neonatal HI E is a very large
problem, with a high morbidity and mortality in developing countries (Vannucci 1990).
I n the United Kingdom (UK) and other developed countries the incidence varies
depending on the definition used but is approximately 0.5/1000 live births (Levene
et al 1986). N o specific treatment, other than general supportive treatment, has been
available for these babies but the advent of whole body cooling following the
publication of randomized controlled trials of this intervention in 2005–9, has
improved the outcome for some babies and has increased the need for prompt early
identification and treatment (S hankaran et al 2005; A zzopardi et al 2009; J acobs et al
2013). Midwives play a vital role in this new approach.
Features suggestive of hypoxia-ischaemia are detailed in Box 33.1.
Box 33.1
F e a t ure s sugge st ive of hypox ia - ischa e m ia
(A) Before birth:
– evidence of antenatal compromise
– decreased fetal movements
– abnormal fetal heart rate patterns
– low fetal pH
– meconium-stained amniotic fluid
(B) Poor condition at birth:
– low heart rate
– failure to establish normal respiration soon after birth (apnoea or
gasping respiration)
– acidotic cord pH
– cyanosis or pallor
(C) Abnormal neonatal neurology:
– decreased consciousness
– decreased tone
– poor suck and other primitive reflexes
Neonatal encephalopathy is often classified according to a grading system (modified
by S arnat and S arnat 1976; see Table 33.1). I n general, a neonatologist should be asked
to review any baby when:
• the heart rate remains <100 for more than 1 minute
• normal respiration is not established by 5 minutes of age
• the Apgar score is <5 at 5 minutes
• gasping respiration is seen
• cord pH <7.0.
Table 33.1
Grading criteria for neonatal encephalopathy
I n these babies whole body cooling may be considered. This treatment requires 72
hours of cooling of core body temperature to 33–34 oC. S everal studies have shown that
this treatment reduces the risk of cerebral palsy and increases the likelihood of
survival without significant disability by 50% ( S hankaran et al 2005; A zzopardi et al
2009; J acobs et al 2013). I f cooling is being considered, the neonatal team may
commence ‘passive’ cooling before a firm decision is made. This means active
warming of the baby is stopped and the baby's body temperature is allowed to fall
passively towards the levels required. This is only a temporary measure though while a
decision is being made, equipment is being prepared or transfer is being organized.
A ctive cooling requires the use of a cooling jacket or ma ress (see Fig. 33.1) to cool the
whole body, or sometimes a cap to cool the head. The treatment is started as soon as
possible after diagnosis (maximum within 6 hours) and then continued for 72 hours,
after which the baby is gradually warmed. A systematic review of 10 randomized
controlled trials (RCTs) (1320 babies in total) byJ acobs et al (2013) reported a lower
risk of death in cooled babies (whole body or head) in the first 18 months of life than
in babies treated by standard care. I n three of these studies with 18-month follow-up
(767 babies in total) the combined risk of death and severe disability was significantly
lower in cooled babies compared with those treated by standard care, and cooling
increased survival with normal neurological function compared with standard care at
18-month follow-up. I n summary therefore, using cooling decreases the risks of death
by more than 20% and increases the chance of survival without disability by 50%.
FIG. 33.1 Cooling jacket.
Babies with less severe problems
S ome babies with neonatal encephalopathy may not have clinically obvious signs
immediately and repeated assessment is necessary in babies who have risk factors
such as those listed above. I n some of these babies there will be poor feeding and low
tone for the first 24 hours after birth. These babies need careful observation and may
need additional feeding support but they are often well enough to remain with their
mother rather than being admi ed to the N I CU. Babies with this pa ern of
encephalopathy should improve after 24 hours and should not have any long-term
consequences of their encephalopathy. Babies with a mild encephalopathy like this
have not been shown to benefit from whole body cooling.
Seizures and abnormal movements
S eizures in the newborn period can be difficult to recognize; however, they are an
important indicator of potentially serious problems and their recognition is therefore
important. The most common cause is neonatal encephalopathy, most commonly HI E,
but readily treatable causes such as hypoglycaemia must not be missed. S eizures in
newborns differ from those in later life. They are often subtle and difficult to
differentiate from other normal behaviour. D ifferent types of seizures may be seen
and include tonic seizures (sustained posturing of the limbs or trunk or deviation of
the head), clonic (usually involves one limb or one side of the body jerking
rhythmically at 1–4 times per second) or myoclonic (rapid isolated jerking of muscles).
S ubtle seizures may include behaviours such as repetitive lip smacking, staring,
blinking or repetitive movements of the limbs such as cycling movements.
Causes of seizures
Seizures in the newborn almost always have an identifiable cause, e.g.
• HIE (49%)
• cerebral infarction (neonatal stroke) (12%)
• cerebral trauma (7%)
• infections (meningitis or encephalitis) (5%)
• metabolic abnormalities, including hypoglycaemia (3%)
• narcotic drug withdrawal (4%).
I t is important to distinguish seizures from ji eriness and neonatal sleep
myoclonus, both of which are benign. J i eriness is symmetrical rapid movements of
the hands and feet. I t is often stimulus-sensitive and may be initiated by sudden
movement or noise and there are no associated eye movements. Benign sleep
myoclonus involves bilateral or unilateral jerking during sleep. I t occurs during active
sleep, is not stimulus-sensitive and tends to be seen in upper limbs more than lower
limbs. I t is important to ensure that the newborn is not at risk from the seizure, so
ensure that the airway is clear and the baby is breathing. Ensure that readily treatable
causes are identified and treated. I n particular check the blood sugar to exclude
hypoglycaemia, and electrolytes to include calcium and sodium; also consider
infection. Hypocalcaemia can be a readily treatable cause of seizures in women with
vitamin D deficiency.
Infection in the newborn
I nfection in the newborn contributes significantly to morbidity and mortality and
possible infection is one of the commonest reasons for newborn babies becoming
unwell and requiring admission to a neonatal unit. N ewborn babies may acquire
infections antenatally (transplacental infection), during birth, or after birth.
Umbilical cord
Until its separation, the umbilical cord can be a focus for infection by bacteria that
colonize the skin of the newborn. The umbilical stump should be dry. I f peri-umbilical
redness occurs or a discharge is noted, infection should be considered and it may be
necessary to commence antibiotic therapy in order to prevent an ascending infection.
Babies are protected from infection by the passive transfer of antibodies from their
mother. The major advantage of this is that they receive passive immunity for those
infections they are most likely to come into contact with. The immune system is
functional at birth and newborn babies can also mount their own humeral (antibody)
response to new infections; however, preterm babies are particularly vulnerable to
infection as placental transfer of I gG mainly occurs after 32 weeks' gestation and their
own antibody response is immature.
Bacterial infection in the newborn
Early signs of infection may be subtle and difficult to distinguish from other
problems. The mother or midwife may simply feel the baby is ‘off colour’ or not right.
The physical signs that may be apparent are:
• Temperature instability. This may be a low temperature just as much as an increased
temperature. Always take seriously and carefully assess any normally grown baby
who is unable to maintain a temperature of 37 oC with a normal room temperature
and normal wrapping/clothing.
• Lethargy or poor feeding. In general, babies, particularly those who are
breastfeeding, will not get very large volumes of colostrum in the first 24 hours after
birth, however they should show an interest in feeding, be able to attach to the breast
and have a sucking reflex.
• Unexplained bradycardia (heart rate <100/min) or tachycardia (heart rate >180/bpm)
and any apnoea or episodes of cyanosis.
• Increased respiratory rate or signs of respiratory distress.
• Irritability, abnormal movements.
• Skin mottling, rashes, prolonged capillary refill time.
I f bacterial infection is suspected then antibiotics should be commenced and
investigations performed (often referred to by neonatologists as a ‘septic screen’).
A ntibiotics are generally given until blood and cerebrospinal fluid (CS F) cultures have
confirmed no growth of pathogenic organisms (usually 36–48 hours). The
investigations performed are usually:
• blood culture
• full blood cell count and blood film
• C-reactive protein measurement
• lumbar puncture for examination and culture of CSF.
Treatment of infection and management of babies with risk of
infection
The overall aim is to reduce the risk of septicaemia and life-threatening septic shock in
this vulnerable group. Bacterial infections are an important cause of neonatal
morbidity and mortality. The two commonest organisms in the newborn are group B
streptococcus (GBS ) andEscherichia (E. ) coli, which are both organisms the baby may
come into contact with via the maternal birth canal. Risk factors for early onset
neonatal infection include the following (O ddie and Embleton 2002; Ungerer et al
2004; Royal College of Obstetricians and Gynaecologists [RCOG] 2012):
• maternal intrapartum fever
• prolonged rupture of membranes greater than 18 hours
• prematurity less than 37 weeks
• maternal genital tract colonization with GBS
• previous baby with GBS disease.
These factors are therefore used in the UK to decide which babies should receive
antibiotics based on a risk-based approach. I n high-risk pregnancies, early onset
neonatal GBS infection can be reduced with antibiotics during labour (L aw et al 2005).
S imilarly, antibiotic use for preterm rupture of membranes is associated with reduced
neonatal morbidity (Kenyon et al 2010). Generally therefore risk factors should be
identified before labour so that, if possible, intrapartum antibiotics should be given at
least 4 hours prior to birth to obtain maximal antibiotic concentration in the amniotic
fluid (Pylipow et al 1994). There is, however, also some evidence that suggests 2 hours
may be adequate (de Cueto et al 1998). I n babies with more than one risk factor,
observation or treatment with antibiotics after birth can be considered.
The age of presentation of early onset GBS varies between studies. I n a prospective
UK study, when intrapartum antibiotics were not given, 50% of babies with early onset
GBS presented by 1 hour of age, 72% by 24 hours and 92% by 48 hours (O ddie and
Embleton 2002) . Bromberger et al (2000), in a retrospective study, found that 95% of
term babies with early onset GBS presented within the first 24 hours of life.
A dditionally, intrapartum antibiotics did not alter the constellation and timing of
onset of clinical signs of early onset GBS . Therefore if babies are well by 12 hours of
age they are unlikely to develop early onset disease.
Group B streptococcus (GBS) infection
I t is estimated that about one in 2000 babies born in the UK and I reland develop early
onset GBS infection. This means that every year in the UK (with 680 000 births a year)
around 340 babies will develop early onset GBS infection. GBS is recognized as the
most frequent cause of sepsis in the newborn (O ddie and Embleton 2002; Heath et al
2004). A survey by the Public Health Laboratory S ervice (PHLS ) GBS W orking Grou
during a 13-month period in 2000 and 2001 identified a total of 568 cases of invasive
GBS disease (early and late onset) in the UK and Republic of Ireland (Heath et al 2004).
This is equivalent to a total incidence of 0.72 per 1000 live births; the incidence for
early onset disease (n = 377) was 0.48 per 1000 live births and for late onset disease (n =
191) was 0.24 per 1000 live births. O verall mortality of the disease was 9.7% (n = 53):
10.6% (n = 38) early onset and 8% (n = 15) late onset.
O ne-third of the population carry GBS in the gut and over 20% of women have
vaginal colonization (Barcaite et al 2008). I n the United S tates of A merica (US A)
Australia and several European countries, screening of pregnant women is used with
treatment with antibiotics during labour, which is effective at reducing the incidence
of early onset GBS . This approach, however, has not been shown in trials to reduce the
risk of death or long-term harm from GBS ; its introduction in the UK has been hotly
debated but the introduction of screening has not been recommended (United
Kingdom N ational S creening Commi ee [UKN S C], 2012 ). The current UK
recommendations (RCO G 2012; UKN S C 2012 ) are therefore based on a risk factor
approach described above, whereby intrapartum antibiotic prophylaxis (I A P) is
offered to all women with recognized risk factors for early onset GBS disease.
Mathematical modelling in the US A suggests that this approach will result in
approximately 25% of women being offered I A P with a decrease in the incidence of
early onset GBS disease of 50.0–68.8% (R CO G 2012). UK data suggest that
approximately 16% of pregnancies will have one or more risk factors for early onset
GBS disease and approximately 60% of early onset GBS cases will have a risk factor
(Oddie and Embleton 2002; RCOG 2012).
Meningitis
N eonatal meningitis is an inflammation of the membranes covering the brain and
spinal column caused by such organisms as GBS ,E. coli, Listeria monocytogenes and,
less often, Candida and herpes. I n the UK, neonatal meningitis is most often caused by
GBS (L aw et al 2005). I n Australia and N ew Zealand, the incidence of GBS early onset
neonatal bacterial meningitis decreased significantly between 1993 and 2002, while the
incidence of E. coli meningitis remained the same (May et al 2005).
Very early signs are often non-specific, followed by those of meningeal irritation and
raised intracranial pressure such as crying, irritability, bulging anterior fontanelle,
increasing lethargy, tremors, twitching, severe vomiting, diminished muscle tone and
alterations in consciousness. Babies may also present with abnormal neurological
signs. Early diagnosis and treatment are critical to prevent collapse and death.
D iagnosis may be confirmed by examination of CS F. Very ill babies require intensive
care, intravenous fluids and antibiotic therapy. A lthough acute phase mortality has
declined in recent years, long-term neurological complications still occur in many
surviving babies. D e Louvois et al (2005) report that in one group aged 5 years, 23%
had a serious disability, with isolation of bacteria from CS F the best single predictor.
For such babies, long-term comprehensive developmental assessment is essential,
including audiometry and vision testing.
Viral infections acquired before or during birth
Rubella and varicella (chickenpox) can be major causes of fetal morbidity and
mortality, as can the protozoa toxoplasmosis. I nfections may be acquired through the
placenta, from amniotic fluid, or the birth canal. For management of sexually
transmissible and reproductive tract infections see Chapter 13. The acronym TO RCH
is often used for congenital infections:
• Toxoplasmosis
• Other (includes syphilis)
• Rubella
• Cytomegalovirus
• Hepatitis/HIV
All of these may cause significant illness in the newborn.
Rubella
For most immunocompetent children and adults (including pregnant women), the
rubella virus causes a mild, insignificant illness spread by droplet infection.
Congenital rubella syndrome (CRS ) in the newborn however remains a major cause of
developmental anomalies that include blindness and deafness (Banatvala and Brown
2004). Maternal rubella is now rare in many countries as a result of successful rubella
vaccination programmes (Robinson et al 2006). I n most industrialized countries the
measles, mumps and rubella (MMR) vaccine has significantly reduced the incidence of
rubella (W right and Polack 2006), although in recent years in the UK and some other
countries, vaccination rates have declined due to press scare stories that have resulted
in a lower uptake of the vaccine. I t is feared this may result in a rise in the incidence.
Countries without routine MMR programmes report rates similar to those of
industrialized countries before vaccination became available ( Banatvala and Brown
2004). Midwives need to emphasize the importance of avoiding contact with rubella
during pregnancy, as reinfection has been reported despite previous vaccination. A s
part of their extended public health role, midwives can encourage vaccination for
seronegative women before and after – but not during – pregnancy, and also discuss
the importance of vaccinating their child. Generally individuals will only be infected
with rubella once during their lifetime as they then develop an antibody response.
Primary rubella infection is most likely to cause problems if it is acquired in the first
12 weeks of pregnancy and in this situation maternal–fetal transmission rates are as
high as 85%. I ntrauterine infection is unlikely when the mother's rash appears before,
or within 11 days after the last menstrual period, and with proven infection later than
the 16th week, the risk of severe fetal sequelae is much lower (Enders et al 1988). First
trimester infection can result in spontaneous abortion and in surviving babies, a
number of serious and permanent consequences. These include cataracts,
sensorineural deafness, congenital heart defects, microcephaly, meningoencephalitis,
dermal erythropoiesis, thrombocytopenia and significant developmental delay
(Banatvala and Brown 2004; Bedford and Tookey 2006).
Diagnosis and treatment
Congenital rubella can be recognized when there has been a maternal history of
infection during pregnancy, or as a result of anomalies detected in the fetus or the
newborn. A ll women have screening for rubella titres at booking in the UK. Those
with negative titres cannot be offered immunization during pregnancy but can be
offered it after pregnancy. They should also avoid contact with anyone known to have
the illness during pregnancy. I f there is any contact then rubella titres should be
measured with increased surveillance of the fetus. Most women with first trimester
infection may request termination of pregnancy. Babies with CRS are highly infectious
and should be isolated from other babies and pregnant women (but not their own
mothers). Long-term follow-up is essential, as some problems may not become
apparent until the baby is older.
Varicella zoster
Varicella zoster virus (VZV) is a highly contagious virus of the herpes family that
causes varicella (chickenpox). Transmi ed by respiratory droplets and contact with
vesicle fluid, it has an incubation period of 10–20 days and is infectious for 48 hours
before the rash appears until vesicles crust over. A fter primary infection the virus
remains dormant in the sensory nerve root ganglia and with any recurrent infection
can result in herpes zoster (shingles). Primary infection during pregnancy can result in
serious adverse outcomes (Meyberg-Solomayer et al 2006).
Incidence and effects during pregnancy
Fetal effects vary with gestation at the time of maternal infection. D uring the first 20
weeks of pregnancy the baby has about a 2% risk of fetal varicella syndrome (FVS ).
S igns can include skin lesions and scarring, eye problems, such as chorioretinitis and
cataracts. S keletal anomalies include limb hypoplasia. S evere neurological problems
may include encephalitis, microcephaly and significant developmental delay. A bout
30% of babies born with skin lesions die in the first months of life. From 20 weeks'
gestation up to almost the time of birth, infection can result in milder forms of
neonatal varicella that do not result in negative sequelae for the neonate. The child
may have shingles during the first few years of life. Maternal infection after 36 weeks,
and particularly in the week before the birth (when cord blood VZV I gG is low) to 2
days after, can result in infection rates of up to 50%. A bout 25% of those infected will
develop neonatal clinical varicella. Most affected babies will develop a vesicular rash
and about 30% will die. O ther complications of neonatal varicella include pneumonia,
pyoderma and hepatitis.
Diagnosis and treatment
D iagnosis can be made if there has been a recent history of maternal chickenpox, and
polymerase chain reaction (PCR) to identify VZV in amniotic fluid. A ntenatal
ultrasound may confirm the effects of fetal varicella syndrome, e.g. limb contractures
and deformities, cerebral anomalies, borderline ventriculomegaly, intracerebral,
intrahepatic and myocardial calcifications, articular effusions and intrauterine growth
restriction (IUGR) (Degani 2006; Meyberg-Solomayer et al 2006).
Most pregnant women with chickenpox will need a great deal of information and
support. W omen infected during the first 20 weeks may request termination of
pregnancy. A lthough mother and baby should be isolated from others, they should
always be kept together. Varicella zoster immune globulin (VZI G) can be offered to
seronegative pregnant women who are exposed to chickenpox, within 72 hours of
contact, and always within 10 days. VZI G should also be offered to a baby whose
mother develops chickenpox between 7 days before and 28 days after the birth, or
whose siblings at home have chickenpox (if the mother is seronegative). A lthough no
clinical trials have shown that antiviral chemotherapy prevents fetal infection, the
antiviral drug acyclovir may reduce the mortality and risk of severe disease in some
groups, particularly if VZI G is not available. These include pregnant women with
severe complications, and newborns if they are unwell or have added risk factors such
as prematurity or corticosteroid therapy (S auerbrei & W u ler 2000; Hayakawa et al
2003).
Toxoplasmosis
Toxoplasmosis is caused by Toxoplasma gondii (T. gondii), a protozoan parasite
infecting up to a third of the world's population. I t is found in uncooked meat, cat and
dog faeces. Primary infection can be asymptomatic, or characterized by malaise,
lymphadenopathy and ocular disease. Primary infection during pregnancy can cause
severe damage to the fetus (Montoya and Liesenfeld 2004). Childhood-acquired
infection also causes half of toxoplasma ocular disease in UK and I rish children
(Gilbert et al 2006).
Incidence and effects during pregnancy
Risks for the infected fetus can include intrauterine death, low birth weight, enlarged
liver and spleen, jaundice, anaemia, intracranial calcifications, hydrocephalus,
retinochoroidal and macular lesions. I nfected neonates may be asymptomatic at birth,
but can develop retinal and neurological disease. Those with subclinical disease at
birth can develop seizures, cognitive and motor problems and reduced cognitive
function over time (Gilbert et al 2006; S chmidt et al 2006; S ystematic Review on
Congenital Toxoplasmosis [S YRO CO T] Group 2007 ). I n one group of 38 children with
confirmed toxoplasma infection, 58% had congenital infection. O f these, 9% were
stillborn while 32% of the live births had intracranial abnormalities and/or
developmental delay, and 45% had retinochoroiditis with no other abnormalities. O f
the 42% of children infected after birth, all had retinochoroiditis (Gilbert et al 2006).
The effectiveness of antenatal treatment in reducing the congenital transmission of
T. gondii is not proven. A meta-analysis of 1438 treated mothers (26 cohorts) also found
no evidence that antenatal treatment significantly reduced the risk of clinical signs
(S YRO CO T 2007 ). Babies with congenital toxoplasmosis are usually treated with
pyrimethamine, sulfadiazine and folinic acid for an extended period (Montoya and
Liesenfeld 2004; Schmidt et al 2006).
Prevention
Midwives have an essential role in prevention as health education can result in a 92%
reduction in pregnancy seroconversion. Breugelmans et al (2004) found the most
effective strategy was a leaflet explaining toxoplasmosis and how to avoid the
condition during pregnancy, with this information reinforced in antenatal classes. I n
the UK, N HS Choices (2013) website provides useful information, as well as the
Toxoplasmosis Trust for women, their families and healthcare professionals.
A ppropriate information includes advising women about washing kitchen surfaces
following contact with uncooked meats, stringent handwashing and avoiding cat and
dog faeces.
Candida
Candida is a Gram-positive yeast fungus with a number of strains (see Chapter 13).
Candida (C.) albicans is responsible for most fungal infections, including thrush in
babies. I nfection can affect the mouth (oral candidiasis), skin (cutaneous candidiasis)
particularly the nappy area and internal organs (systemic candidiasis). O ral
candidiasis is a common mild illness that may present as white patches on the baby's
gums, palate or tongue. I t can be acquired during birth or from caregivers' hands or
feeding equipment. Raw areas (removed by sucking) on the edge of the baby's tongue
can assist diagnosis. Risk factors for thrush include bo le use during the first 2 weeks,
the presence of siblings (Morrill et al 2005) and antibiotic exposure (D insmoor et al
2005). Breastfeeding women may also have infected breasts, with flaky or shiny skin of
the nipple/areola, sore, red nipples and persistent burning, itching or stabbing pain in
the breasts (Chapter 34). Risk factors for maternal thrush include bo le use in the first
2 weeks after the birth, pregnancy duration of >40 weeks (Morrill et al 2005), and
intrapartum antibiotic use (Dinsmoor et al 2005).
A ccurate diagnosis and treatment of thrush is important for continued
breastfeeding. Morrill et al (2005) found only 43% of women with thrush 2 weeks after
the birth were breastfeeding at 9 weeks, compared with 69% of women without.
Cutaneous candidiasis often co-exists with oral thrush and presents as a moist
papular or vesicular skin rash, usually in the region of the axillae, neck, perineum or
umbilicus. A lthough it is usually benign, recognition and treatment is important in
preventing problems (S molinski et al 2005). Management includes keeping the area
dry and applying topical nystatin. I n preterm babies the thin cutaneous barrier,
invasive procedures and immune system immaturity may contribute to the early onset
of systemic Candida infection. A ntifungal prophylaxis may be used to prevent systemic
Candida colonization. S ystemic candidiasis in a preterm baby is a serious problem and
requires a prolonged course of treatment with intravenous antifungal medication. I t is
associated with significant morbidity and mortality.
Significant eye infections
Eye infection caused by Chlamydia or Gonococcus will present with a red sore eye with a
large amount of purulent discharge, usually after the first week after birth.
O phthalmia neonatorum is defined in England as any purulent eye discharge within
21 days of birth, and in S cotland as eye inflammation within 21 days of birth
accompanied by a discharge. A swab must be taken for culture and sensitivity testing,
with immediate medical referral. I dentification of the organism responsible is
essential as chlamydial and gonococcal infections can cause conjunctival scarring,
corneal infiltration, blindness and systemic spread. Treatment includes local cleaning
and care of the eyes with normal saline, and appropriate drug therapy for the baby and
mother if required.
Respiratory problems
There are several important causes of respiratory distress in the newborn, which are
not always easy to distinguish. The commonest are infection, transient tachypnoea of
the newborn (TTN ) and surfactant-deficient lung disease ofprematurity. The la er
(also named hyaline membrane disease in the past) is confusingly called respiratory
distress syndrome (RD S ), but this is just one possible cause of respiratory distress in
newborn babies.
Initial management of babies presenting with respiratory
distress
Babies who are unwell should be assessed in a good light, ideally on a resuscitaire if
available so that oxygen and airway support can be given if necessary. I f a baby shows
any of the signs of respiratory distress after birth he/she should be closely observed.
I n general any baby who has a respiratory rate >80/min and central cyanosis should be
reviewed urgently. I n distinguishing the cause and importance of clinical signs, the
history of the pregnancy and birth are clearly important. Relevant factors are:
• gestation
• meconium in amniotic fluid
• mode of birth (caesarean section vs vaginal)
• high vaginal swabs during pregnancy
• antenatal scans.
Observe for:
• the respiratory rate, heart rate, work of breathing, colour
• the colour for cyanosis and skin perfusion, pallor, mottled or white
• the baby's level of activity and tone
• whether the baby has been able to feed – babies with significant respiratory distress
will not feed and should not be allowed to feed
• apnoea, and listen for heart rate. Proceed as for resuscitation at birth (see Chapter
29).
If the baby is breathing:
• position the airway with the head in a neutral position and if necessary use a jaw
thrust to help keep the airway patent
• avoid suction unless the baby clearly has fluid (blood/vomit) obstructing the upper
airway
• give air/oxygen via a face mask if the baby is initially cyanosed
• liaise with the neonatal medical team with regard to further intervention
• consider admission to a NICU for further investigations and intervention if a
significant respiratory distress persists.
Possible causes of respiratory distress in the newborn
Infection (particularly GBS)
A ll newborn babies presenting with features of respiratory distress should be treated
with I V antibiotics until infection is excluded as this may be the only presenting
feature and it can be very difficult to distinguish from other causes of respiratory
distress. A number of infectious disease processes present with signs of respiratory
distress in the newborn. A ll babies presenting with respiratory distress need to be
treated for infection until there is proof to the contrary.
Meconium aspiration syndrome
Meconium in the amniotic fluid is common and usually does not require treatment or
intervention if the baby is in good condition at birth and shows no signs of respiratory
distress. Meconium aspiration occurs because hypoxia-ischaemia causes the fetus to
pass meconium into the amniotic fluid. This meconium is generally unproblematic
unless the baby gasps or breathes in the meconium. Gasping respiration may also
occur as a result of hypoxia-ischaemia. Consequently, it is the baby showing signs of fetal
hypoxia which develops meconium aspiration syndrome. Greenough and Milner (2012)
report the incidence for meconium aspiration syndrome in one UK hospital as 0.2/1000
live births; however, this incidence is low and other countries, such as the US A , have
higher disease rates of 2–5/1000 (Greenough and Milner 2012). The initial respiratory
distress may be mild, moderate or severe with a gradual deterioration over the first
12–24 hours in moderate or severe cases. The baby may present with cyanosis,
increased work of breathing and a barrel-shaped chest. This chest appearance occurs
as a result of air trapping, leading to hyperexpansion of the lungs. The meconium can
become trapped in the airways and cause a ball-valve effect: air can enter the lung
during inhalation, the meconium then blocks the airway during expiration so that air
accumulates behind the blockage. This accumulation can then lead to the rupture of
the alveoli and cause the baby to develop a pneumothorax. W here the meconium has
contact with the lung tissue a chemical pneumonitis occurs and there is a risk of
super-added infection. Endogenous surfactant is also broken down in the presence of
meconium.
These babies may need intensive care and ventilation to prevent further
deterioration. Modalities such as nitric oxide (Finer and Barrington 2006) are of benefit
in reducing death or the need for extracorporeal membrane oxygenation (ECMO ) in
some babies. ECMO has been shown to increase survival by 50% (U K Collaborative
ECMO Trial Group 1996 ). A number of the most severely affected babies will have
signs of respiratory distress for some months, with ongoing residual respiratory
problems during early childhood.
Transient tachypnoea of the newborn (TTN)
The recorded incidence of TTN varies widely, partly as a result of the variety of
recording methods, differences in radiological interpretation and clear diagnostic
features. I t is frequently seen as a diagnosis of exclusion of other possible respiratory
causes. N evertheless, babies present with mild to moderate signs of respiratory
distress and usually require admission to the N I CU for further observation.
S upplemental oxygen may be required, however the condition gradually resolves
during the 24 hours following birth. The chest X-ray may show a streaky appearance
with fluid in the horizontal fissure of the right lung that confirms the diagnosis, but
sometimes it is only the clinical course that distinguishes between this, respiratory
distress syndrome (RD S ) and infection. The lungs are completely fluid-filled before
birth and most of this is squeezed out through chest compression, the rest is absorbed
via the lymphatic system. Babies born by elective caesarean section are at increased
risk because the thorax has not been squeezed while the baby descends into the
vagina. Being born this way appears to increase the risk of respiratory morbidity by
approximately six times. I n addition, birth at each week below 39 weeks approximately
doubles the risk (Morrison et al 1995). A lthough these babies tend to require initial
care on a N I CU, their stay is usually of a short duration with the provision of oxygen
and observation.
Respiratory distress syndrome (RDS)
RD S is generally a condition that affects preterm babies, however it can also occur in
those born at term as other disorders like maternal diabetes can also inhibit surfactant
production. A pproximately 50% of babies born before 30 weeks' gestation develop
RD S while 1% of all newborn babies may develop the condition (G reenough and
Milner 2012). S urfactant is made up of phospholipids and proteins and is produced by
the type I I pneumocytes to reduce the surface tension within the alveoli, preventing
their collapse at the end of exhalation. Collapsed alveoli require much greater
pressures and exertion to re-inflate them compared to partially collapsed alveoli. The
introduction of surfactant therapy into neonatal care during the 1980s and 1990s,
combined with much wider use of antenatal steroids in the 1990s, significantly
decreased the mortality and morbidity previously seen in RDS.
I n preterm babies with RD S the clinical picture is of a baby with progressive
respiratory distress developing over the first hours. The X-ray typically has a
homogenous ground-glass appearance (indicating poorly aerated alveoli) with air
bronchograms (black air-filled bronchi seen against white airless alveoli), although
this may be less obvious if the baby has already received exogenous surfactant. Babies
with RD S experience increasing respiratory distress and work of breathing. I t may take
48–72 hours to reach the peak of the disease without the administration of exogenous
surfactant. Resolution of the associated inflammation and the hyaline membrane
formation may take up to 7 days in the unsupported baby. I n extremely preterm
babies surfactant is often given on the labour suite at birth, although alternative
approaches using continuous positive airways pressure (CPA P) can also be used
(Morley et al 2008; S UPPO RT 2010 ). Exogenous surfactant can be given as ‘rescue
treatment’ if the baby develops significant early signs.
Pneumothorax
Pneumothoraces may occur spontaneously in 1% of the newborn population either
during or after birth; however, only one-tenth will be seen (S teele et al 1971). A
pneumothorax at birth may be caused by the large pressures generated by the baby's
first breaths, which may be in the range of 40–80 cmH2O . This can lead to alveoli
distension and rupture that allows air to leak to a number of sites, most notably the
potential space between the lung pleura. Babies receiving any assisted ventilation have
an increased susceptibility to a pneumothorax. This could be due to either
maldistribution of the ventilated gas in the lungs, high ventilation se ings or baby-
ventilator breathing interactions. S pontaneous pneumothorax can occur in otherwise
healthy term babies. They may present with signs of respiratory distress on the
postnatal ward. A lthough it is difficult to diagnose a pneumothorax in the absence of a
chest X-ray, there may be reduced breath sounds on the affected side, displaced heart
sounds and a distorted chest/diaphragm movement. A baby with a suspected
pneumothorax will need closer observation and may need intervention with a chest
drain, although many spontaneously breathing term babies can be managed without a
chest drain as long as they are closely observed. Most pneumothoraces will resolve
spontaneously.
Congenital diaphragmatic hernia (CDH)
CD H has an incidence of 3.5/1000 live births. I t is an important condition because
despite improvements in neonatal care reported, mortality rates remain high (Wright
et al 2010). Most babies with a diaphragmatic hernia have a prenatal diagnosis, usually
made at the 20th week anomaly scan; in some babies, however, the diagnosis is not
made until after birth. I n babies where there is a prenatal diagnosis most
neonatologists manage these babies with immediate intubation, insertion of a large
bore nasogastric (N G) tube to decompress the stomach and bowel and early
sedation/muscle relaxation. This allows optimal ventilation as early as possible to try
to allow the underdeveloped lungs to expand and to try to prevent significant
problems with persistent pulmonary hypertension and continual right-to-left shunting
of blood through the foramen ovale and ductus arteriosus. I ntensive care is difficult in
these babies and the priorities are to maintain good ventilation and perfusion to avoid
hypoxia. A surgical repair of the diaphragm will usually be performed at 2–7 days after
birth. I n all babies presenting with respiratory distress a chest X-ray is important to
look for the cause, and one of the possibilities that can be recognized is a CD H. Babies
with this condition typically have unilateral chest movement, heart sounds and an
apex beat on the right side (in the case of left-sided CD H, which is more common) and
a scaphoid abdomen. Babies with a postnatal diagnosis of CD H have a much be er
prognosis, with greater expected survival rates (van den Hout et al 2010).
Upper airway obstruction and stridor
Upper airway obstruction in the newborn is uncommon but is characterized by noisy
breathing on inspiration, different to grunting, which is an expiratory noise. The
importance is that obstruction to the upper airway significantly increases the work of
breathing for a newborn, and in the short term, in the most severe cases, this could
lead to respiratory arrest. Babies with stridor therefore always need neonatal medical
assessment. I t is important to assess the degree of respiratory distress and assess
whether the baby is managing to breathe comfortably despite the stridor. There are
many possible causes, the commonest being laryngomalacia, which tends not to cause
significant respiratory distress but the work of breathing may increase when the baby
is placed on his/her back. External compression of the trachea is a serious condition, so
any baby with stridor must always be carefully assessed by a neonatologist.
Congenital heart disease (CHD)
CHD (moderate or severe) occurs in 6/1000 live births but only 25% show signs in the
neonatal period (Fyler 1980). Early diagnosis is extremely important for some
conditions and it is vital that newborn babies are examined carefully to look for signs
of CHD (seeChapter 28). There are a number of ways that CHD may present in the
newborn period and these give some clues as to the underlying anatomical diagnosis:
• prenatal diagnosis on antenatal scan
• associated with a syndrome or other congenital problems, e.g. Down syndrome
• asymptomatic murmur
• cyanosis
• sudden collapse
• heart failure.
Management of a baby with an antenatal diagnosis of
CHD
I n a baby where an antenatal diagnosis of CHD has been made, early intervention may
be required depending on the type of lesion. Usually an antenatal plan of postnatal
care will have been made and should be available to those providing postnatal care.
For some types of serious congenital malformations (transposition of the great
arteries, pulmonary atresia [with or without VS D ], Fallot's tetralogy, coarctation of the
aorta, hypoplastic left heart syndrome) these will involve giving a prostaglandin
infusion to maintain patency of the ductus arteriosus. W herever the baby is born,
immediate stabilization and transfer to a cardiology centre will be required. S ome
types of CHD do not need intervention, but the baby will need follow-up with a
cardiologist.
Care of a baby with a murmur
Babies who are detected to have an asymptomatic heart murmur on their newborn
check (see Chapter 28) should be carefully evaluated by having a careful examination
to look for other signs of cardiac disease. O xygen saturation measurement using a
pulse oximeter shows normal values >96%. Be aware that babies with a saturation of 85%
often do not look cyanosed on visual inspection, so measuring the saturation of oxygen on
haemoglobin is an effective way of assessing the baby's respiratory and cardiac status
and represents good practice. Measuring pre- and post-ductal saturations can be
useful alongside measuring the blood pressure in all four limbs to look for signs of
coarctation of the aorta (lower pressures in lower limbs). A ll babies with a cardiac
murmur should be evaluated by a neonatologist and local guidelines are usually in
place for appropriate cardiac referral.
Jaundice
J aundice is one of the most common conditions needing medical a ention in newborn
babies. J aundice refers to the yellow coloration of the skin and the sclera caused by a
raised level of bilirubin in the circulation (hyperbilirubinaemia). A pproximately 60%
of term and 80% of preterm babies develop jaundice in the first week after birth, and
about 10% of exclusively breastfed babies are still jaundiced at one month of age. I n
most babies early jaundice is harmless. However, a few babies will develop very high
levels of bilirubin, which can be harmful if not treated. Clinical recognition and
assessment of jaundice can be difficult, particularly in babies with dark skin tones.
O nce jaundice is recognized, there is uncertainty about when to treat, and there is
widespread variation in the use of phototherapy and exchange transfusion. In the UK a
national guideline produced by the N ational I nstitute for Health and Clinical
Excellence (NICE 2010) has tried to standardize monitoring and treatment and similar
guidelines exist in other countries (American Academy of Paediatrics [AAP] 2004).
Bilirubin physiology
I n order to understand when jaundice is important and why the fat soluble,
unconjugated bilirubin concentration might be raised, it is important to understand
its metabolism. Bilirubin is produced as one of the breakdown products of
haemoglobin (Fig. 33.2A ,B). A geing, immature or malformed red cells are removed
from the circulation and broken down in the reticuloendothelial system (liver, spleen
and macrophages). Haemoglobin from these cells is broken down into the byproducts
of haem, globin and iron. Haem is converted to biliverdin and then to unconjugated
bilirubin. Globin is broken down into amino acids, which are used by the body to
make proteins. I ron is stored in the body or used for new red blood cells. The
unconjugated bilirubin is then transported to the liver. O nce in the liver,
unconjugated bilirubin is detached from albumin, combined with glucose and
glucuronic acid and conjugation occurs using the enzyme uridine diphosphoglucuronyl
transferase (UD P-GT). The conjugated bilirubin is now water-soluble and available for
excretion. Conjugated bilirubin is excreted via the biliary system into the small
intestine where normal bacteria change the conjugated bilirubin into urobilinogen.
This is then oxidized into orange-coloured urobilin. Most is excreted in the faeces, with
a small amount excreted in urine (Ahlfors and Wennberg 2004; Kaplan et al 2005).
FIG. 33.2 Bilirubin pathway. (A) Physiological change in bilirubin concentration after birth. (B)
Production and circulation of bilirubin.
Physiological jaundice
A ll newborn babies have a rise in unconjugated bilirubin during the first few days
after birth. This occurs for several reasons:
• The turnover of haemoglobin is high in the fetus and newborn but before birth the
bilirubin from the fetus is removed via the placenta.
• At birth, as the more efficient lungs increase oxygen levels, there is haemolysis of
excessive RBCs that are now not needed.
• At birth the newborn liver enzymes systems may be immature and not as effective.
A s a result of these factors there is a rise in serum unconjugated bilirubin in healthy
babies during the first few days after birth and this physiological jaundice follows a
characteristic pa ern (see Fig. 33.3). Typically, babies on the first day after birth will
not appear jaundiced but most babies will look yellow by day 3–4. A s unconjugated
bilirubin levels rise, the serum albumin becomes saturated and then any excesses
spills over into the blood plasma. Unconjugated bilirubin is fat-soluble and will
deposit in subcutaneous fat, which makes the skin look yellow. O nce these sites are
saturated, the brain is the next target, particularly the basal ganglia. High levels of
unconjugated bilirubin can potentially be a serious problem because it can cross the
blood–brain barrier and be deposited in the basal ganglia in the brain. This can cause
a bilirubin encephalopathy and in the longer term can result in cerebral palsy and
learning difficulties. The cerebral palsy is typically an athetoid type due to the site of
the damage in the brain. Kernicterus is the pathological (post mortem) finding of
bilirubin encephalopathy. W hilst bilirubin encepalopathy is a serious complication it
is rare because of the decrease in incidence of Rhesus haemolytic disease since the
introduction of anti-D prophylaxis (Chapter 11) and the use of other interventions to
control high unconjugated bilirubin levels in babies. I n recent years, however, there
have been concerns that the incidence is increasing again (Manning et al 2007) and
midwives can play a pivotal role in trying to prevent this devastating complication.
FIG. 33.3 Bilirubin chart.
Causes of concern in physiological jaundice
There are several situations where a midwife should be concerned about jaundice in
the newborn:
• Jaundice in the first 24 hours after birth.
• History of antibodies (which may cause RBC haemolysis) identified on the maternal
antibody screen.
• Any baby who is visibly jaundiced. The serum bilirubin (SBR) level should be
checked as the visual assessment of jaundice is not sufficiently accurate (NICE 2010).
• Any baby who remains jaundiced beyond 14 days of age.
Early physiological jaundice (within first 5 days after birth)
Possible causes include:
• physiological jaundice
• haemolysis (Rhesus isoimmunization, ABO incompatibility, other blood group
antigen problems)
• infection
• bruising
• polycythaemia
• dehydration (unlikely in the first 48 hours but must be considered in babies
presenting between 2–7 days after birth, particularly those who are breast fed).
This is not an exhaustive list but these are the causes that midwives will encounter
on a daily basis. A s a general rule, haemolysis must always be considered when a baby
is jaundiced in the first 24 hours after birth.
Assessment and diagnosis of physiological jaundice
Two initial important questions are:
• Is the jaundice physiological due to the normal process of breakdown of bilirubin or
the presence of another pathological process?
• Is the baby at risk of bilirubin encephalopathy?
Individual risk factors
The initial assessment of a baby should include identifying risk factors for jaundice.
These include any disease or disorder that increases bilirubin production, or alters the
transport or excretion of bilirubin. For example:
• birth trauma or evident bruising (increased production of unconjugated bilirubin)
• family history of significant haemolytic disease or jaundiced siblings
• maternal antibodies at booking
• evidence of infection
• prematurity
• timing of jaundice, for example, within the first 24 hours (suggesting haemolysis).
Jaundice at 3–6 days of age could be related to dehydration, particularly in a breast-
fed baby. Always take a feeding history and check the baby's weight when presenting
at this age to check hydration status. Even with significant weight loss, exclude other
causes too.
Physical assessment includes observation of the extent of changes in skin and scleral
colour, skin bruising or cephalhaematoma (Chapter 31) and other clinical signs such
as lethargy and decreased eagerness to feed with accompanying dehydration. Consider
signs of infection (temperature, vomiting, irritability or high-pitched cry). A lso
observe for dark urine and light stools, which could indicate intrahepatic or
extrahepatic obstructive disease.
Laboratory investigations will always include S BR. I f the bilirubin level is high then
the following investigations should also be carried out:
• direct Coomb's test (DCT) to detect presence of maternal antibodies on baby's red
blood cells
• blood groups (baby and mother) and Rh type for possible incompatibility
• haemoglobin concentration to assess anaemia/polycythaemia
• conjugated bilirubin if there are any factors to suggest conjugated
hyperbilirubinaemia.
Management of physiological jaundice
I f maternal antibodies were present on the booking screen, the neonatal team should
be informed and regular S BR concentrations should be checked. These babies may
need early phototherapy. I n the case of Rh-D antibodies and some other blood group
antigens with a high likelihood of causing haemolysis, other interventions such as the
use of immunoglobulin or exchange transfusion are likely to be needed, so many of
these babies may need admission to a N I CU. Plo ing the S BR concentration on a char
is always useful to see how the level compares with phototherapy intervention and/or
exchange transfusion interventions. A n example of a bilirubin chart is shown in Fig.
33.3. The trend or change in bilirubin can also be assessed from the chart as a guide to
whether the level is rising too quickly or is following a normal physiological pa ern.
Treatment strategies for physiological jaundice include phototherapy,
immunoglobulin therapy and occasionally exchange transfusion.
Phototherapy
The use of light therapy was first discovered by the observation in the 1950s at
Rochford Hospital, Essex, that babies cared for in sunlight became less jaundiced, as
was described by D obbs and Cremer (1975). I t works because ultraviolent blue light
(wavelength 420–448 nm) catalyses the conversion of transbilirubin into the water-
soluble cis-bilirubin isomer. This can then be excreted via the kidneys. I ts use is based
on S BR levels and the individual condition of each baby and standardized charts are
used to guide treatment (N I CE 2010). Commercially available phototherapy systems
include those delivering light via fluorescent bulbs, halogen quar lamps, light-
emi ing diodes and fibreoptic ma resses ( S tokowski 2006). Conventional
phototherapy systems use high intensity light from conventional white and/or blue,
blue–green and turquoise fluorescent phototherapy lamps. Fibreoptic light systems
use a woven fibreoptic pad that delivers high intensity light with no ultraviolet or
infrared irradiation. They can be used as bilibeds in especially adapted cots or fi ed
around the chest and abdomen of the baby. These systems may be more comfortable
for babies and allow easier accessibility and handling for parents.
Phototherapy is a very safe and effective treatment. S ide-effects are mild but can
include hyperthermia because of increased fluid loss and dehydration, damage to the
retina from the high intensity light, lethargy or irritability, decreased eagerness to
feed, loose stools, skin rashes and skin burns and alterations in a baby's state and
neurobehavioural organization. Phototherapy may be intermi ent or continuous (Lau
and Fung 1984) with mild/moderate jaundice and has been described as being
delivered at home (Walls et al 2004), although babies need to be carefully selected for
this approach and it is not suitable for all. Babies receiving phototherapy should be
nursed naked in an incubator or cot with lid, a minimum of 40 cm from the light. I n
addition phototherapy equipment should be routinely checked for safety. The baby's
temperature should be measured and recorded at least 4-hourly, more frequently if
unstable, and the baby should be turned regularly to maximize exposed areas of skin.
For overhead fluorescent therapy the baby's eyes should be shielded using Posey eye
shields. I f eye shields are used, these should not be applied too tightly to avoid
constriction to the scalp and excessive pressure over eyes and they should be removed
regularly and the baby's eyes inspected for signs of infection. A pplication of topical
creams or lotions should be avoided as there is a risk of burns and blistering.
Particular a ention should be paid to careful cleaning and drying of the skin,
especially if the stools are loose. The baby should be assessed regularly for signs of
dehydration using as a measure urine output or frequency of wet nappies. Consider
not nursing babies on a white sheet because of reflective glare. Parents should be
informed of the need for phototherapy and normal parental consent obtained and
contact encouraged for routine care. The baby may not always have to receive
continuous phototherapy and the phototherapy unit can be removed/switched off
during cares and feeds (for up to 30 minutes in every 3 hour period is acceptable while
on single phototherapy). However, if the baby is requiring multiple phototherapy this
should not be interrupted.
Stopping phototherapy
The S BR should be measured at least every 6–12 hours whilst phototherapy continues.
I t should be monitored more frequently when the rate of rise is rapid. Phototherapy
may be safely discontinued when the bilirubin is 50 µmol/l below the threshold.
Repeat S BR measurement is necessary 12–18 hours after ceasing phototherapy to
check for rebound hyperbilirubinaemia.
Immunoglobulin
I nfusion of a set volume of pooled human immunoglobulin is an effective treatment
which may help to prevent the need for an exchange transfusion (Go stein and Cooke
2003). I t is used with isoimmune haemolysis and may help to mop up excessive
antibodies, preventing a rapid rise in bilirubin. I t may help to prevent exchange
transfusions but may slightly increase the risk of needing a later top-up transfusion
but these are safer and less invasive.
Exchange transfusion
I f the bilirubin level cannot be controlled with phototherapy and good hydration and
the level exceeds recommended limits (N I CE 2010) an exchange transfusion is
performed to prevent the bilirubin level reaching levels known to be linked to
bilirubin encephalopathy. Exchange transfusion carries significant risks and should
always be carried out in a neonatal intensive care unit (refer to individual hospital
guideline) with experienced operators. Complications can result from the procedure
and from blood products. Babies with other medical problems are more likely to have
severe complications, such as hypocalcaemia and thrombocytopenia. I t involves
transfusing a large volume of blood to the baby (double the baby's blood volume or
160 ml/kg) whilst removing blood from the baby, usually via an umbilical venous
catheter. This process removes excess bilirubin and, if the cause is isoimmunization,
antibodies that may be causing the RBC haemolysis. With haemolytic disease of the
newborn sensitized erythrocytes are replaced with blood that is compatible with both
the mother's and the baby's serum.
Pathological jaundice
Haemolytic jaundice
A s described above, jaundice within the first 24 hours after birth is assumed to be due
to haemolysis until proven otherwise. Haemolysis is increased haemoglobin
destruction in the fetus or newborn and has several causes, the most important being
blood group incompatibility. This can occur due to various antibodies, but the most
important is caused by Rhesus (Rh-D ) isoimmunization/incompatibility. This occurs if
blood cells from a Rhesus-positive baby enter a Rhesus-negative mother's
bloodstream. Her blood treats the D antigen on positive blood cells as a foreign
substance and produces antibodies. These antibodies can then cross the placenta and
destroy fetal red blood cells (see Figs 33.4–33.9).
FIG. 33.4 Normal placenta with no communication between maternal and fetal
blood.
FIG. 33.5 Fetal cells enter maternal circulation through ‘break’ in ‘placental
barrier’, e.g. at placental separation.
FIG. 33.6 Maternal production of Rhesus antibodies following introduction of
Rhesus-positive blood.
FIG. 33.7 In a subsequent pregnancy maternal Rhesus antibodies cross the
placenta, resulting in haemolytic disease of the newborn.
FIG. 33.8 Anti-D immunoglobulin administered within 72 hours of birth or other
sensitizing event.
FIG. 33.9 Anti-D immunoglobulin has destroyed fetal Rhesus-positive red cells
and prevented isoimmunization.
FIGS 33.4–33.9 Isoimmunization and its prevention.
W hile other causes of increased haemolysis are important, this condition is
emphasized because of the midwife's critical role in the injection of anti-D
immunoglobulin (anti-D I g). Without this anti-D prophylaxis, Rh-D isoimmunization
can cause severe haemolytic disease of the newborn (HD N ) with significant mortality
and morbidity (N I CE 2010). With the effectiveness of anti-D prophylaxis, antibodies
against other blood groups are now more common than anti-D (e.g. anti-A , anti-B and
anti-Kell). A lthough few antibodies to blood group antigens other than those in the Rh
system cause such severe haemolytic disease of the newborn, some report mortality
and morbidity with antibodies other than anti-D . These include anti-E haemolytic
disease of the fetus or newborn (J oy et al 2005), and anti-Kell (van D ongen et al 2005).
A BO incompatibility can also occur and is the most frequent cause of mild to
moderate haemolysis in neonates.
Rh-D isoimmunization
Rh-D isoimmunization is commonest among Caucasians, about 15% of whom are Rh-
negative, compared with 3–5% of A frican and about 1% of A sian populations (Bianchi
et al 2005). Before the introduction of anti-D I g in 1969, Rh-D isoimmunization was a
major cause of perinatal mortality and morbidity. I n England and Wales, about 500
cases of Rh-D haemolytic disease of the fetus and newborn still occur each year,
resulting in 25–30 deaths and 15 children with major permanent developmental
problems (NICE 2010).
Causes of Rh-D isoimmunization
The placenta usually acts as a barrier to fetal blood entering the maternal circulation
(Fig. 33.4). However, during pregnancy or birth, fetomaternal haemorrhage (FMH) can
occur, when small amounts of fetal Rh-positive blood can cross the placenta and enter
the Rh-negative mother's blood (Fig. 33.5). The woman's immune system produces
anti-D antibodies (Fig. 33.6). I n subsequent pregnancies these maternal antibodies can
cross the placenta and destroy the red cells of any Rh-positive fetus (Fig. 33.7). Rh-D
isoimmunization can result from any procedure or incident where positive blood leaks
across the placenta, or from any other transfusion of Rh-positive blood (e.g. blood or
platelet transfusion or drug use). Haemolytic disease of the fetus and newborn caused
by Rh-D isoimmunization can occur during the first pregnancy. However, in most
cases sensitization during the first pregnancy or birth leads to extensive destruction of
fetal red blood cells during subsequent pregnancies (Finning et al 2004; Bianchi et al
2005; Geifman-Holtzman et al 2006; NICE 2010).
Prevention of Rh-D isoimmunization
Most cases of Rh-D isoimmunization can be prevented by injecting anti-D I g within 72
hours of birth or any other sensitizing event (Fig. 33.8). A nti-D I g is a human plasma-
based product that is used to prevent women producing anti-D antibodies. A nti-D I g
is of value to women with non-sensitized Rh-negative blood who have a baby with Rh-
positive blood type (Fig. 33.9). I t is not used when anti-D antibodies are already present in
maternal blood. A s well, anti-D I g does not protect against the development of other
antibodies that cause haemolytic disease of the newborn.
Routine prophylaxis
I n the UK since 2002 (and some other countries), routine antenatal anti-D prophylaxis
at 28 and 34 weeks' gestation is recommended for all non-sensitized Rh-negative
women (N I CE 2008). With postnatal anti-D I g prophylaxis, about 1.5% of Rh-negative
women still develop anti-D antibodies following a first Rh-positive pregnancy. A meta-
analysis (A llaby et al 1999) and Cochrane Review (Crowther et al 2013) suggest the
antenatal sensitization rate is further reduced by routine antenatal prophylaxis.
A ntenatal prophylaxis should always be given following possible sensitization events
such as spontaneous miscarriage before 12 weeks, any threatened, complete,
incomplete or missed abortion after 12 weeks of pregnancy, termination of pregnancy
by surgical or medical methods regardless of gestational age, fetal death in utero or
stillbirth, ectopic pregnancy or amniocentesis, cordocentesis, chorionic villus
sampling, fetal blood sampling or other invasive intrauterine procedure such as shunt
insertion. I n addition, postnatal prophylaxis should be given. A systematic review of
six eligible trials of more than 10 000 women found when given within 72 hours of
birth (and other antenatal sensitizing events), anti-D I g lowered the incidence of Rh
isoimmunization 6 months after birth and in a subsequent pregnancy, regardless of
the ABO status of the mother and baby (Crowther and Middleton 1997).
Management of Rh-D isoimmunization
D estruction of fetal RBCs results in fetal anaemia and less oxygen reaches fetal tissue,
and oedema and congestive cardiac failure can develop. Lesser degrees of red cell
destruction may result in fetal anaemia only, while extensive haemolysis can cause
hydrops fetalis and fetal death. Mortality rates are higher for those with hydrops
fetalis (van Kamp et al 2005). Early referral to specialist care for women with Rh-D
antibodies detected at booking is essential. W hile early specialist care influences fetal
outcome (Ghi et al 2004; Craparo et al 2005; van Kamp et al 2005), ongoing midwifery
information and support are also important. Treatment aims to reduce the effects of
haemolysis. I ntensive fetal monitoring is usually required, and often a high level of
intervention throughout the pregnancy. Monitoring and treatment can include the
principles outlined in Box 33.2.
Box 33.2
K e y principle s in t he m a na ge m e nt a nd t re a t m e nt of
isoim m uniz a t ion
• In early pregnancy maternal blood is grouped for Rh type, and women
who are Rh-negative are screened for antibodies (indirect Coombs' test).
A positive test indicates the presence of antibodies, or sensitization.
• Maternal blood is re-tested frequently to monitor any increase in antibody
titres. Even with low anti-D levels, sudden and unexpected rises in serum
anti-D levels can result in hydrops fetalis.
• Red blood cells obtained by chorionic villus sampling can be Rh-
phenotyped as early as 9–11 weeks' gestation.
• If antibody titres remain stable, ongoing monitoring is continued.
• If antibody titres increase, Doppler ultrasonography of the middle
cerebral artery peak systolic velocity is used for non-invasive diagnosis of
fetal anaemia. This procedure is as sensitive as amniocentesis in
predicting anaemia and bilirubin breakdown products, has less associated
risk and can safely replace invasive testing in the management of
isoimmunized pregnancies (Joy et al 2005; Mari et al 2005; van Dongen
et al 2005; Oepkes et al 2006).
• Intravenous immunoglobulin (IVIG) blocks fetal red cell destruction,
reducing maternal antibody levels, and may be used to maintain the fetus
until intrauterine fetal transfusion can be performed (see below).
• Intrauterine intravascular transfusion can be used to treat fetal anaemia
until the fetus is capable of survival outside the uterus (Craparo et al 2005;
van Kamp et al 2005).
• Detailed fetal neuroimaging using multiplanar sonography and/or
magnetic resonance imaging may be used to assess brain anatomy in
fetuses with severe anaemia (Ghi et al 2004).
• The ongoing severity of the haemolysis and the condition of the fetus will
influence the duration of the pregnancy. In general, a gestational age
greater than 34 weeks is aimed for to minimize the complications of
prematurity.
Postnatal treatment of isoimmunization
Management aims to monitor the S BR level so that early intervention can be made if
the level is high or increasing rapidly to try to prevent levels reaching those that might
be harmful. The following factors are worthy of consideration:
• Using phototherapy from birth helps to prevent a rapid rise in some babies.
• Regular SBR measurements from birth every 4 hours.
• A low haemoglobin concentration at birth may indicate the need for early
intervention with an exchange transfusion.
• If the SBR level is increasing too rapidly or is too high then intervention is required.
Treatment depends upon the baby's condition. Careful monitoring but less
aggressive management may be adequate, with mild to moderate haemolytic anaemia
and hyperbilirubinaemia. S everely affected babies often require early admission to the
N I CU. Babies with hydrops fetalis are pale, have oedema and ascites. I n some cases
phototherapy alone can be effective and is very useful to help to prevent the need for
exchange transfusion, which carries many more risks. D espite this, exchange
transfusion is often required, and later packed cell transfusion may be needed to
increase haemoglobin levels as babies are at risk of ongoing haemolytic anaemia and
this may occur up to 6–8 weeks of age. Treatment with I VI G can be effective at
blocking ongoing haemolysis, with shorter duration of phototherapy and fewer
exchange transfusions although this may also increase the likelihood of a later ‘top-up’
blood transfusion (Gottstein and Cooke 2003).
ABO isoimmunization
A BO isoimmunization usually occurs when the mother is blood group O and the baby
is group A , or sometimes group B. I ndividuals with type O blood develop antibodies
throughout life from exposure to antigens in food, Gram-negative bacteria or blood
transfusion and by the first pregnancy may already have high serum anti-A and anti-B
antibody titres. S ome women produce I gG antibodies that can cross the placenta and
a ack to fetal red cells and destroy them (see effects of isoimmunization in the
discussion below referring to Rhesus disease). A BO incompatibility is also thought to
protect the fetus from Rh incompatibility as the mother's anti-A and anti-B antibodies
destroy any fetal cells that leak into the maternal circulation. A lthough first and
subsequent babies are at risk, destruction is usually much less severe than with Rh
incompatibility. I n most cases haemolysis is fairly mild but can be more severe. A BO
isoimmunization can, rarely, cause severe fetal anaemia and hydrops fetalis.
A ntibodies are not often detected in pregnancy and it is usually a diagnosis made in
a baby with an unexpectedly high S BR level. Postnatal management depends on the
severity of haemolysis and, as with isoimmunization, aims to prevent bilirubin levels
that may be harmful. The diagnosis is usually made after birth in an unexpectedly
jaundiced baby. The direct Coombs' test is positive and the maternal and baby's blood
groups are consistent with A BO incompatibility (i.e. maternal group O and baby A or
B or A B). A s with other causes of haemolysis, if babies require phototherapy it is
usually commenced at a lower serum bilirubin level (140–165 µmol/l or 8–10 mg/dl). I n
rare cases, babies with high S BR levels require exchange transfusion. I VI G
administration to newborns with significant hyperbilirubinaemia due to A BO
haemolytic disease (with a positive direct Coombs' test) has reduced the need for
exchange transfusion (Miqdad et al 2004).
Late neonatal jaundice
This is generally defined as a bilirubin concentration that remains raised beyond 14
days of age. There are a number of causes and investigation is important because,
whilst uncommon, some of the causes are conditions that have significant long-term
implications if not treated and treatments are available which are effective if used
early enough.
Causes of late neonatal jaundice
A ny disease or disorder that increases bilirubin production or alters transport or
metabolism of bilirubin is superimposed upon normal physiological jaundice. I t is
best to divide the causes into those conditions that cause a raised unconjugated
bilirubin (fat soluble) and those that cause a raised conjugated bilirubin (water
soluble).
Late neonatal (>14 days) unconjugated hyperbilirubinaemia
I ncreased red cell destruction or haemolysis causes raised S BR levels and blood
type/group incompatibility, including Rhesus (Rh-D ) and A BO incompatibility, anti-E
and anti-Kell. O ther factors include sepsis, particularly urinary tract infection,
hypothyroidism and galactosaemia. N on-immune haemolysis features spherocytosis
(fragile red cell membranes) and enzyme deficiencies. Glucose-6-phosphate
dehydrogenase (G6PD ) is an enzyme that maintains the integrity of the cell membrane
of RBCs and deficiency results in increased haemolysis. G6PD deficiency is an X-linked
genetic disorder carried by females that can affect male babies of A frican, A sian and
Mediterranean descent.
Late neonatal (>14 days) conjugated hyperbilirubinaemia
A lways consider this when there are pale stools and dark urine. I mportant causes can
include:
• biliary atresia
• dehydration, starvation, hypoxia and sepsis (oxygen and glucose are required for
conjugation)
• TORCH infections (toxoplasmosis, others, rubella, cytomegalovirus, herpes)
• other viral infections (e.g. neonatal viral hepatitis)
• other bacterial infections, particularly those caused by E. coli
• metabolic and endocrine disorders that alter uridine diphosphoglucuronyl
transferase (UDPGT) enzyme activity (e.g. Crigler–Najjar disease and Gilbert's
syndrome)
• other metabolic disorders such as hypothyroidism and galactosaemia.
Haematological problems
Bleeding
Bleeding is generally rare in the newborn, however there are a small number of
significant conditions that can result in bleeding of which the midwife should be
aware. Blood from the gastrointestinal tract (vomiting or passed per rectum as
malaena) is sometimes seen and the commonest cause is swallowed maternal blood.
This is supported if there is a clear history of maternal bleeding and bloodstained
amniotic fluid. The baby should be carefully evaluated and the possibility of bleeding
from the gastrointestinal tract considered. This could occur if there was a clo ing or
platelet abnormality, or occasionally with some serious gastrointestinal disorders such
as NEC.
Possible causes of bleeding abnormalities
Vitamin K-deficient bleeding (VKDB)
Early VKDB, occurring in the first 48 hours, is rare and usually occurs to babies born to
mothers who have received medications that interfere with vitamin K metabolism.
These include the anticonvulsants phenytoin, barbiturates or carbamazepine, the
antitubercular drugs rifampicin or isoniazid and the vitamin K antagonists warfarin
and phenprocoumarin. I t is prevented by giving vitamin K to the mother (except those
that require ongoing anticoagulation) in the last weeks of pregnancy and ensuring a
dose of intramuscular (I M) vitamin K is given to the baby. Vitamin K is given to all
newborn babies by virtue of their mother's consent, usually as an I M injection to
prevent VKD B. I f there is unexplained bruising or bleeding it is important to check
that vitamin K has been given as some mothers will decline from giving consent.
Classic VKD B occurs in the first week of life, often in sick babies or those slow to
establish feeds. Gastrointestinal bleeding is common and may be severe, epistaxis or
unexplained bruising or oozing from the umbilical cord are common features.
Bleeding into the brain is uncommon. I t is prevented by ensuring that an early first
dose of vitamin K is given by any route.
Late VKD B occurs from the first week up to 6 months, usually between 4 and 12
weeks. This form is more commonly associated with intracranial bleeds (30–50%) than
classic VKD B, and this can be fatal or leave permanent disability. I t is almost
completely confined to fully breast-fed babies. A bout half will have an underlying
liver disease or other malabsorptive state. Late VKD B can be optimally prevented by
1 mg vitamin K I M at birth or significantly reduced by repeated doses of oral vitamin
K.
Thrombocytopenia
A low platelet count may present with bleeding or a petechial rash. It may be due to:
• maternal idiopathic thrombocytopenic purpura (ITP), where autoimmune maternal
antibodies destroy maternal and fetal platelets
• isoimmune thrombocytopenia, where maternal antiplatelet antibodies destroy fetal
platelets of a different group
• congenital infections, both viral and bacterial
• drugs, administered to mother or baby
• severe Rhesus haemolytic disease.
Haemophilia and other inherited problems
Haemophilia A is an X-linked recessive disorder, which therefore affects only boys.
Females may be carriers. The diagnosis is often known or suspected antenatally
because of a family history. I n these cases investigation should occur after birth and
I M injections and invasive procedures should be avoided. The diagnosis can be made
by checking a clo ing profile and should always be considered in a male baby who has
unexpected bleeding.
Metabolic problems
Many metabolic abnormalities can occur in the newborn, particularly in preterm or
IUGR babies. By far the most common problem is hypoglycaemia.
Glucose homeostasis
The fetus has a constant supply of glucose via the placenta. Following birth, this
supply of nutrients ceases and there is a fall in glucose concentration (S rinivasan et al
1986). At the same time, however, endocrine changes (decrease in insulin and a surge
of catecholamines and release of glucagon) result in an increase in glycogenolysis
(breakdown of glycogen stores to provide glucose), gluconeogenesis (glucose
production from the liver), ketogenesis (producing ketones, an alternative fuel) and
lipolysis (release of fa y acids from adipose) bringing about an increase in glucose
and other metabolic fuel. Problems arise in the newborn when there is either a lack of
glycogen stores to mobilize (preterm and I UGR babies) or excessive insulin
production (infants of diabetic mothers) or when the babies are sick and have a poor
supply of energy and increased requirements.
Low glucose concentrations are a potential problem in the newborn because if there
is a lack of fuel or nutrients available for the brain, cerebral dysfunction and
potentially brain injury may occur. The problem for those caring for newborn babies is
not only to identify those who are at risk and treat them appropriately, but also to
avoid excessive treatment and investigation in babies where intervention is not
required.
Hypoglycaemia
The definition of hypoglycaemia is controversial and many different definitions can be
found in the literature (Koh et al 1988b). The problem is that defining a specific level
of blood glucose is unhelpful because a baby's ability to compensate and use
alternative fuels may be as important as the specific glucose concentration.
Pragmatically, however, a specific level is helpful for management purposes. The
consensus appears to favour a cut-off value in the newborn of 2.6 mmol/l although the
evidence for the use of this level is not strong. This figure comes mainly from two
studies (Koh et al 1988a; Lucas et al 1988) . Koh et al (1988a) demonstrated abnormal
sensory-evoked brain stem potentials in a small number of term babies. This did not
occur in any infants where the blood glucose was above 2.6 mmol/l, whether or not
signs were present (Koh et al 1988a). I n addition, and perhaps more importantly, in a
retrospective study of preterm infants the neurological outcome was less favourable if
the blood glucose concentration had been <2.6 mmol/l on ≥5 days during the neonatal
period (Lucas et al 1988). These studies suggest that levels of blood glucose
concentration above 2.6 mmol/l are likely to be safe but they do not take into account
the baby's ability to compensate for low glucose concentrations. Lower values may be
safe in some babies.
Signs of hypoglycaemia
A baby who has signs of hypoglycaemia has a glucose concentration that is too low and this
should be treated whatever the exact glucose level. The signs of hypoglycaemia are
lethargy, poor feeding, seizures and decreased consciousness level. J i eriness is
commonly ascribed to hypoglycaemia but is a common feature in the newborn and
alone should not be used as an indication for measuring blood glucose concentration.
Healthy term babies
I t is likely that healthy term babies are able to tolerate low blood glucose
concentrations using compensatory mechanisms and use alternative fuels such as
ketone bodies, lactate or fa y acids (Hawdon et al 1992). These babies may have blood
glucose concentrations as low as 2.0 mmol/l without any ill-effects because, if
responding normally, they are likely to have increased ketone body concentrations so
that fuel is available for the brain (Hawdon et al 1992). Term babies who are breastfed
are particularly likely to have low blood glucose concentrations, probably because of
the low energy content of breastmilk in the first few postnatal days. However, these
babies have higher ketone body concentrations to compensate (Hawdon et al 1992)
and they are unlikely, therefore, to suffer any ill-effects. Unfortunately, however,
routine measurements of ketone body concentrations are not readily available and
when glucose measurements are made in these babies it becomes difficult for
practitioners to resist giving treatment that may involve supplementary formula
feeding or even I V dextrose at the expense of breastfeeding. This should obviously be
avoided unless there are other clinical indications for intervention. Because of their
ability to counter-regulate, clinically well, appropriately grown, full-term babies who
are feeding do not require monitoring of their glucose concentration. D oing so would
result in many babies being inappropriately treated.
Babies at risk of neurological sequelae of hypoglycaemia
Babies where monitoring and treatment should be considered are those in whom
counter-regulation may be impaired. Preterm babies (<37 completed weeks) and I UGR
babies (<3rd centile for gestation) have lower glycogen stores and cannot therefore
mobilize glucose as rapidly during the immediate postnatal period. I n addition they
also have immature hormone and enzyme responses and are less likely to be enterally
fed at an early stage. I nfants of diabetic mothers (I D M) frequently have low blood
glucose concentrations because of an excess of insulin production. This is produced by
the fetal pancreatic gland as a result of stimulation by increased maternal glucose
concentrations. This excess of insulin also acts as a growth factor and brings about
excessive fat and glycogen deposition. This is why these infants have a characteristic
appearance and are relatively macrosomic (Fig. 33.10; note macrosomic appearance
with increased adiposity). A study by the Confidential Enquiry into Maternal and
Child Health (CEMA CH 2005 ) demonstrated that practice across the UK varies with
regard to the management of I D M and many babies appear to be inappropriately
admi ed to N I CU. This should be avoided where possible but it requires the ability to
monitor these babies on routine postnatal wards. I n sick babies following perinatal
hypoxia-ischaemia or sepsis there may also be low substrate stores compounded by
feeding difficulties that add to the problem. Also consider babies with inborn errors of
metabolism (discussed later in this chapter).
FIG. 33.10 Macrosomic infant.
Diagnosis, prevention and management of hypoglycaemia
Term babies who are admi ed to the postnatal ward and are feeding should not have
blood glucose measured unless they are symptomatic. I n particular, breastfeeding
information and intervention should not be based on blood glucose concentrations.
Prevention is important in at-risk babies and they should therefore have:
• adequate temperature control – keep warm
• early breastfeeding within 1 hour of birth (100 ml/kg per day if formula feeding)
• frequent feeding (≤3 hourly)
• a blood glucose check immediately before the second feed and then 4–6 hourly
thereafter.
There is no advantage in checking the blood glucose concentration earlier than this
providing there are no clinical signs as it is likely to be low and the appropriate
treatment at this stage is to feed the baby. I f there are signs of hypoglycaemia, the
glucose should be checked and treatment given immediately. Breastfed babies are
particularly difficult to manage in this situation as it is important to avoid
supplemental feeding with formula to promote successful breastfeeding but the risks
associated with significant hypoglycaemia in at risk-babies outweigh this advantage. I f
the blood glucose concentration is <2.6 mmol/l then a feed should be given at an
increased volume and decreased frequency (2 hourly or even hourly). This may require
supplementary feeding with colostrum or formula milk for those who are being
breastfed and the use of a nasogastric tube should always be considered.
I f the blood glucose concentration remains low despite these measures and there is
an adequate feed volume intake, then I V treatment with dextrose is required. I t is
important in this situation that enteral feeding is continued as colostrum/milk
contains much more energy than 10% dextrose and promotes ketone body production
and metabolic adaptation. I f the blood glucose concentration is >2.6 mmol/l before the
second and third feed then glucose monitoring can be discontinued but feeding
should continue at 3-hourly intervals. I n babies where enteral feeding is
contraindicated for some reason, I V 10% dextrose at least 60 ml/kg on the first day
should commence.
Hyperglycaemia
Hyperglycaemia is much less of a clinical problem than hypoglycaemia and occurs
predominantly in preterm and severely affected I UGR babies. I t is also seen in term
babies in response to stress, especially following perinatal hypoxia-ischaemia, surgery
or drugs (especially corticosteroids). I n general no treatment is required. I n preterm
babies it is usually a transient phenomenon related to the immature autoregulation or
inability to deal with excessive glucose intakes. I n general, treatment is not required
unless there is significant loss of glucose in the urine that may cause an osmotic
diuresis. I f treatment is required the rate of glucose infusion can be decreased, but
there may be some advantages in this situation of giving an I V insulin infusion. This
allows glucose input to continue and sufficient calories to continue to be given and
may result in better weight gain (Collins et al 1991).
Electrolyte imbalances in the newborn
I n the first few days after birth all babies lose weight due to a loss of extracellular
fluid. This diuresis and loss of weight is associated with cardiopulmonary adaptation;
it occurs rapidly in healthy babies but may be delayed in those with RD S . A s
extracellular fluid is lost there is a net loss of both water and sodium over these first
few days after birth, although the baby's serum sodium should remain within the
normal range. The healthy baby should lose up to 10% of its birth weight. This weight
loss is physiological and should be expected.
Sodium
S odium is normally excreted via the kidney, controlled by the renin–angiotensin
system. This control mechanism is functional in the preterm baby but loss of sodium
may occur in these babies because of renal tubule unresponsiveness. Term breastmilk
has relatively li le sodium (<1 mmol/kg per day), showing that the healthy newborn
can preserve sodium via the kidney in order to maintain growth. N ormal sodium
requirements are 1–2 mmol/kg per day in term babies and 3–4 mmol/kg per day in
preterm babies. Changes in serum sodium reflect changes in sodium and water
balance. I n order to assess changes in sodium concentration it is important to know a
baby's weight as hypernatraemia in the presence of a loss of weight suggests
dehydration whereas when there is weight gain it is due to fluid and sodium overload.
Hyponatraemia in the presence of weight gain represents fluid overload whereas a
reduced sodium with inappropriate weight loss represents sodium depletion. The
normal serum sodium concentration is 133–146 mmol/l (Ayling and Bowron 2012).
Hyponatraemia
Hyponatraemia is due either to fluid overload or sodium depletion. The la er may be
due to inadequate intake or excessive losses.
Fluid overload
I n the first few days after birth this is the commonest cause of a low sodium
concentration. I t is commonly seen in babies receiving I V fluids or in babies with
oliguric renal failure or those on medication, e.g. indomethacin given to preterm
babies. A ppropriate treatment is to limit the fluid intake whilst maintaining normal
sodium intake with appropriate intravenous fluids.
Sodium depletion
The causes include renal loss in preterm babies, which is treated by increasing sodium
intake to compensate for the losses. S ome preterm babies may require a very large
daily intake of I V sodium with their I V fluids when losses are high. A lso consider loss
of sodium into the bowel due to ileus (intestinal obstruction, sepsis or prematurity) or
severe vomiting. D iuretics can affect the loss and occasionally adrenocortical failure.
This is rare but may be due to congenital adrenal hyperplasia or hypoplasia, or adrenal
haemorrhage in a sick baby.
Hypernatraemia
I ncreased sodium concentration is almost always due to water depletion and loss of
extracellular fluid but can also rarely be due to an excessive sodium intake. These
causes can again be easily differentiated, by weighing the baby to assess the change
since birth.
Water depletion
This is rare in term babies but does occur occasionally in babies with an inadequate
intake of breastmilk. It is more common in preterm babies. The causes include:
• transepidermal water loss in preterm babies – this occurs particularly in babies <28
weeks' gestation and can be prevented by adequate environmental humidity and
regular weighing to gauge fluid loss to predict fluid requirements
• excessive urine output in preterm babies during recovery from RDS
• high rates of fluid loss during vomiting, diarrhoea or bowel obstruction
• inadequate lactation.
Water depletion is perhaps the most important cause of hypernatraemia. The
incidence has been estimated as 2.5/10 000 live births and it typically occurs in term
babies of breastfeeding primiparous mothers (O ddie et al 2001). I t can be associated
with significant morbidity and even mortality (Edmondson et al 1997), however, it can
be prevented with sufficient assistance and supervision of feeding. Babies typically
present at 5–9 days of age with lethargy and poor feeding. They have lost >15% of their
birthweight and are usually significantly jaundiced. The serum sodium concentration
can be between 150 and 200 mmol/l.
I n general, many babies are not weighed during this period. Mothers who are
breastfeeding can be discouraged by the fact that their baby has lost weight despite a
good technique and this can serve to undermine breastfeeding no ma er how
carefully the physiology of the phenomenon is explained. A dditionally (particularly in
primiparous mothers) lactogenesis is only just starting at between 48 and 72 hours.
Thus the volume of milk transferred to the baby is still rising sharply between 72 and
96 hours of age. However, weighing babies during this period can be very useful when
a baby is unwell or if there are concerns about intake and fluid and electrolyte balance.
I t has been suggested that routine weighing of babies may be useful to prevent
dehydration and hypernatraemia in breastfed babies with referral to hospital if weight
loss exceeds 10% (van D ommelen et al 2007). The baby's fluid deficit can be calculated
from the loss in weight and this is then replaced by gradual rehydration over 24–48
hours. Feeding can continue but I V treatment is often required with normal saline and
dextrose. A ssistance with lactation can then be given to continue to promote
breastfeeding.
Excessive sodium intake
I n general this is rare in term babies, although it may be seen in sick preterm babies
due to excessive bicarbonate and other sodium-containing fluids. Causes are:
• incorrect fluid prescription
• excessive administration of sodium bicarbonate
• incorrectly formulated powdered feeds
• Münchausen's syndrome by proxy – intentional administration of salt to a baby.
Potassium
Potassium is the major intracellular cation. A low serum concentration therefore
implies significant potassium depletion. A bnormalities in serum potassium
concentration are important because they can cause significant arrhythmias.
Potassium concentrations can be severely affected by measurement technique, and
any haemolysis of the blood sample, especially from capillary sampling, is likely to
lead to a falsely high value.
Hyperkalaemia
Causes include:
• acidosis
• acute renal failure
• congenital adrenal hyperplasia.
Treatment is to remove all potassium supplements from I V fluids, and to consider
giving calcium resonium rectally, calcium gluconate I V, sodium bicarbonate to
increase pH and I V glucose and insulin. I n general these measures will be required
only where there is a serum potassium that is very high (>8 mmol/l) and/or evidence of
an abnormal electrocardiogram (ECG) or arrhythmia.
Hypokalaemia
Causes include:
• inadequate intake of potassium
• bowel losses (vomiting or diarrhoea)
• diuretic therapy
• hyperaldosteronism.
Hypokalaemia is treated by adding potassium to I V infusion fluids or orally. The
normal daily requirement of potassium is 2 mmol/kg per day.
Calcium
Calcium metabolism is closely linked to phosphate metabolism and these are very
important minerals in relation to bone development. This is of particular importance
in preterm infants as they need much higher concentrations of phosphate and
calcium. These are given as I V supplements, by supplementing breastmilk with
fortifier (Lucas et al 1996) or by giving specific preterm milk formula rather than term
formula. High serum calcium concentrations are unusual but there are rare but
important causes of low serum calcium. The normal serum concentration is 2.2–
2.7 mmol/l but this must be interpreted with the serum albumin concentration as
serum calcium is bound to albumin therefore a low albumin concentration will lead to
a falsely low serum value. Calcium concentrations fall within 18–24 hours of birth as
the baby's supply of placental calcium ceases but accretion into bone continues. I n the
past, hypocalcaemia during the first week after birth used to be caused by giving
unmodified cow's milk. This has a high phosphate concentration and a relatively low
calcium concentration that depressed the serum calcium concentration and caused
seizures. This is now rare with modern formula feeds.
Hypocalcaemia can cause seizures, tremors, ji eriness, lethargy, poor feeding and
vomiting. S evere signs can be treated by I V replacement of calcium. Longer-term
management depends on the cause. Hypocalcaemia can be caused by:
• prematurity
• significant hypoxia-ischaemia
• renal failure
• hypoparathyroidism including DiGeorge syndrome (see later)
• maternal diabetes mellitus.
Inborn errors of metabolism in the newborn
I nborn errors of metabolism (I EM) are rare inherited disorders occurring in
approximately 1 in 5000 births. They result mainly from enzyme deficiencies in
metabolic pathways leading to an accumulation of substrate, leading to toxicity. In
utero, the placenta provides an effective dialysis system for most disorders, removing
toxic metabolites. Most affected babies are therefore initially born in good condition
with normal birth weight. A high index of suspicion is needed when evaluating an
acutely sick neonate, as many disorders are treatable and early diagnosis and
treatment can reduce morbidity. I t has been estimated that 20% of babies presenting
with sepsis in the absence of risk factors have an inborn error of metabolism.
The mode of inheritance is usually autosomal recessive, therefore family history is
crucial and the following information should be sought:
• any affected siblings
• previous stillbirth/neonatal death
• parental consanguinity
• features associated with feeding, fasting or a surgical procedure
• improvement when feeds are stopped and relapse on restarting.
A clinical examination often reveals li le specific evidence and the baby can appear
healthy. The features in Box 33.3 may be seen in isolation with many diagnoses,
however multiple features indicate that an underlying I EM should be seriously
considered
Box 33.3
C linica l fe a t ure s a ssocia t e d wit h m a ny dia gnose s – a
com bina t ion of t he se fe a t ure s could be indica t ive of
an I E M
• Septicaemia
• Hypoglycaemia
• Metabolic acidosis
• Convulsions
• Coma
• Cataracts
• Cardiomegaly
• Jaundice/liver disease
• Severe hypotonia
• Unusual body odour
• Dysmorphic features
• Abnormal hair
• Hydrops fetalis
• Diarrhoea
The following laboratory tests are a basic first step in the investigation process:
• full blood count
• septic screen
• creatinine, urea and electrolytes (including chloride)
• liver enzymes
• blood gas
• blood glucose and lactate concentration
• urine reducing substances (sugar)
• urine ketones (dipstick)
• plasma ammonia concentration
• coagulation tests.
Many other investigations may be necessary and useful, but in general,
investigations need to be discussed with a consultant biochemist or paediatrician with
an interest in metabolic disorders. Principles of emergency management are to reduce
any abnormal load on affected pathways by removing toxic metabolites and
stimulating residual enzyme activity. Hypoglycaemia is corrected, adequate ventilatory
support and hydration are maintained, convulsions are treated and significant
metabolic acidosis is treated with I V sodium bicarbonate, and electrolyte
abnormalities are corrected. I n general, antibiotics are frequently given as infection
may have precipitated metabolic decompensation and occasionally dialysis may also
be required (Wraith and Walker 1996).
Phenylketonuria
Phenylketonuria (PKU) is important, first because it is a treatable cause of brain injury
and second because it is possible to successfully screen for it during the first week of
life in order to identify affected individuals and treat them appropriately to produce a
favourable outcome.
PKU is an autosomal recessive disorder of protein metabolism that has an incidence
of approximately 1 in 10 000 in the UK. Babies with PKU are born in good condition
but begin to be affected by their condition during the first few weeks/months after
birth. Untreated it leads to severe learning difficulties/disability (I Q <30). However, if
it is identified early (within the first 3 weeks), it can be treated by a diet specifically
restricted in phenylalanine. The common type is caused by the absence of or reduction
in an enzyme called phenylalanine hydroxylase which, in the liver, converts the
essential amino acid phenylalanine to another essential amino acid, tyrosine. The toxic
accumulation of phenylalanine and the deprivation of tyrosine leads to brain damage.
PKU is particularly suitable for mass screening because there is a simple widely
available diagnostic test and because treatment is effective. Midwives collect the blood
sample for PKU screening in the UK between days 5 and 8 after birth with the
knowledge that the baby has been taking milk feeds. The level of phenylalanine is
analysed and babies with increased levels need to be prescribed a low phenylalanine
diet and have further assessment to determine whether they are affected by the
‘classic’ type of the disease or other variants. I f it is treated early, the prognosis for
PKU is good and normal intelligence can result. A ffected people will have to stay on a
low phenylalanine diet for life and women who wish to conceive need to pre-
conceptionally have their diet reviewed to prevent congenital abnormalities like
microcephaly in their developing fetus. This is because fetal brain injury may result
from exposure to high concentrations of phenylalanine and its metabolites in the
mother.
Galactosaemia
Galactosaemia is a disorder of carbohydrate metabolism that is autosomal recessive in
inheritance and has an incidence of 1 in 60 000. I t is caused by an absence or severe
deficiency of the enzyme galactose-1-phosphate uridyltransferase (often referred to as
Gal-I -P UT). This enzyme is important for converting galactose to glucose and since
milk's main sugar lactose is a disaccharide containing glucose and galactose, babies
with this condition rapidly become affected when fed either human breastmilk or
cow's milk formulae. The metabolite that builds up and is harmful is galactose-1-
phosphate.
The clinical signs of the disorder are those of liver failure and renal impairment.
A ffected babies tend to present with vomiting, hypoglycaemia, jaundice, bleeding,
acidosis, failure to gain weight and hypotonia during the first few days after birth.
A nother important clinical feature is congenital cataract. A ffected babies may also
present with septicaemia (particularly E. coli) due to damage to intestinal mucosa by
high levels of galactose in the bowel. Galactosaemia is an important differential
diagnosis to consider when dealing with a baby with unresponsive hypoglycaemia and
prolonged or severe jaundice. Babies with galactosaemia will have galactose but not
glucose in their urine. The diagnosis therefore can be made by looking for urine-
reducing substances (galactose) using a Clinitest, whereas a urine test for glucose will
be negative. Confirmation of the diagnosis is by assay of the enzyme level (Gal-I -P UT)
within red blood cells.
Treatment is with a lactose-free milk formula, commenced as soon as the diagnosis
is suspected. This results in a rapid correction of the abnormalities. However, cataracts
and mild brain injury have occurred even when galactosaemic babies have been fed
lactose-free milk from birth. S creening for this disorder is possible but many babies
will have presented before the screening test is available and there is li le evidence to
suggest that diagnosis at or soon after birth gives a be er long-term outlook than
diagnosis by rapid screening of the deteriorating sick baby.
Endocrine problems
Endocrine problems in the newborn are relatively rare but may be serious, even life-
threatening, but are nearly always treatable so identification and diagnosis is
important. D isorders of blood glucose homeostasis have already been described so
this section will concentrate on other endocrine abnormalities that may present in the
newborn.
Thyroid disorders
The thyroid gland produces hormones that have an effect on the metabolic rate in
most tissues. They are also essential for normal neurological development. Thyroid
stimulating hormone (TS H) is produced by the anterior pituitary gland and this
stimulates production of T3 and T4 by the thyroid gland with a feedback mechanism
to the anterior pituitary.
Hypothyroidism
The incidence of hypothyroidism in the newborn is 1 in 3500. There are several
possible causes for hypothyroidism in the newborn, including abnormalities in gland
formation (thyroid dysgenesis), defects in hormone synthesis (dyshormonogenesis)
and rarely secondary pituitary causes. The la er causes a decrease or lack of TS H,
whereas primary (thyroid) causes result in very high TS H values. The presentation is,
however, the same, although this has implications for screening. Babies with
hypothyroidism tend to be large, post term and have a large posterior fontanelle. They
have coarse features and often have an umbilical hernia. These features are often
missed, which is why screening for this disorder is so important. Untreated babies
develop impaired motor development with growth failure, a low I Q , impaired hearing
and language problems. With treatment the physical signs of hypothyroidism do not
appear but the intellectual and neurological prognosis is poor unless treatment is
started within the first few weeks of life and this should always occur when affected
babies are detected by screening. S creening for hypothyroidism involves measuring
thyroid stimulating hormone (TS H) on a blood spot taken at 5–8 days of age. This
method detects almost all cases, however it cannot detect cases caused by secondary
(pituitary) hypothyroidism that will have a low TS H. This condition is, however, much
less common, with an incidence of 1 in 60 000 to 1 in 100 000 (Fisher et al 1979).
Hyperthyroidism
Graves' disease is an autoimmune disorder that causes hyperthyroidism. N eonatal
hyperthyroidism occurs relatively rarely but is possible when the mother has or has
had Graves' disease. I t occurs not because of neonatal autoantibodies but as a result of
the transfer of maternal thyroid stimulating immunoglobulins. These are
autoantibodies that are produced and act in the same way as TSH. This can occur when
a mother has active, inactive or treated Graves' disease (Teng et al 1980).
Thyrotoxicosis in the fetus can lead to preterm labour, low birth weight, stillbirth and
fetal death, but only a small percentage of babies of mothers with Graves' disease
show signs of thyrotoxicosis. I n the baby the signs are irritability, ji eriness,
tachycardia, prominent eyes, sweating, excessive appetite and weight loss. These may
be present immediately after birth or presentation may be delayed for as long as 4–6
weeks (S kuza et al 1996). The baby therefore needs to be observed for this period and
treatment will be required with anti-thyroid medication if any signs appear.
Adrenal disorders
The adrenal glands are vital for the normal function of many systems within the body.
They are divided into a medulla and a cortex. The medulla produces catecholamines,
which help to maintain blood pressure and are produced at times of stress.
A bnormalities of function of the adrenal medulla are not described in the newborn.
The adrenal cortex produces three groups of hormones – glucocorticoids,
mineralocorticoids and sex hormones – that have distinct functions. Glucocorticoids
regulate the general metabolism of carbohydrates, proteins and fats on a long-term
basis. They have a particular role in modifying the metabolism in times of stress.
Mineralocorticoids regulate sodium, potassium and water balance. The sex hormones
are responsible for normal development of the genitalia and reproductive organs.
A bnormalities in function of the glands represent the functions of these different
groups of hormones.
Adrenocortical insufficiency
This is caused by congenital hypoplasia, adrenal haemorrhage, enzyme defects or can
be secondary to pituitary problems. I t generally presents with the signs of
hypoglycaemia, vomiting, poor feeding and weight gain with prolonged jaundice. The
baby may have hyponatraemia, hypoglycaemia, hyperkalaemia and acidosis.
Treatment is by I V therapy with glucose and electrolytes followed by replacement of
corticosteroid and mineralocorticoid hormones.
Adrenocortical hyperfunction
This may occur in the form of congenital adrenal hyperplasia (CA H). This is the name
given to a group of inherited disorders that are due to deficiency of enzymes
responsible for hormone production within the adrenal gland. The most common
enzyme deficiency results in an excess of androgenic hormones but a deficiency of
glucocorticoid and mineralocorticoids often also occurs. These disorders can cause
abnormalities in the formation of the genitalia leading to ambiguous genitalia
(virilization of females or inadequate virilization of males) (see Fig. 33.11) and features
of adrenal insufficiency (vomiting, diarrhoea, vascular collapse, hypoglycaemia,
hyponatraemia, hyperkalaemia). The classification of disorders of sexual
differentiation has been revised in recent years. For more information see the
consensus statement by Hughes et al (2006).
FIG. 33.11 Female infant with ambiguous genitalia due to congenital adrenal hyperplasia.
I t is important to make a prompt diagnosis. The genetic sex must be determined
(chromosome analysis) and it is important not to assign a sex until the diagnosis has
been established (see Chapter 28). The biochemical diagnosis is made by analysing
urine and plasma for steroid hormone metabolites. Treatment is as for adrenocortical
insufficiency by replacement of glucocorticoid and mineralocorticoid hormones.
Virilized girls may also require surgical intervention to correct the genital
abnormalities.
Pituitary disorders
Pituitary insufficiency is rare in the newborn. I t may occur in association with other
abnormalities, particularly midline developmental defects. Presentation is with signs
of glucocorticoid deficiency (hypoglycaemia), prolonged jaundice or signs of
hypothyroidism. Growth hormone deficiency generally causes hypoglycaemia but no
other signs in the newborn. W hen it is recognized, treatment is with replacement of
the missing hormones.
Parathyroid disorders
The parathyroid glands are responsible for control of calcium metabolism but
abnormalities of the parathyroid glands are rare causes of hypocalcaemia and
hypercalcaemia in the newborn. W hen hypoparathyroidism does occur it may be
familial or may occur in association with deletions of chromosome 22 (22q11 deletion
or DiGeorge syndrome). The signs associated with hypocalcaemia are detailed above.
Effects on the newborn of maternal drug abuse/use
during pregnancy
The incidence of drug use within the UK population has a large geographical variation.
A s a result the incidence of drug withdrawal amongst babies also has a markedly
varying incidence. I nner city areas are more likely to be affected but even within cities
large variation is seen in the incidence of problems.
O piates and other drugs cross the placenta and the fetus during pregnancy is likely
to be exposed to the same peaks and troughs of drug exposure as the mother.
Withdrawal may be manifested before birth. The increased incidence of fetal distress
may be related in part to drug withdrawal during labour but the effects of drugs and
withdrawal on the fetus and newborn are related to the timing of drug doses. Babies
born to mothers who have used illicit drugs during pregnancy are at risk of withdrawal
effects. Other problems that are more common in these pregnancies are:
• obstetric complications of pregnancy including placental abruption, IUGR, signs of
fetal compromise during labour, stillbirth
• poor attendance for antenatal care
• non-disclosure of information regarding drugs taken during pregnancy
• risk of infectious disease (hepatitis B and C, and HIV)
• social problems such as poor housing, chaotic lifestyle, care of other children
• poor attendance for neonatal follow-up.
A endance for antenatal care and supervision during pregnancy may be improved
by midwifery support and community liaison. I t is important to identify these women
during pregnancy in order to try to prevent some of the above problems and offer
appropriate support. I dentification during pregnancy also allows screening for
infectious diseases and this is particularly important for hepatitis B and HI V where
treatments are available to decrease the chance of the newborn being affected.
Signs of withdrawal
Many drugs have been reported to cause problems of withdrawal in the newborn. The
most common seen in the UK are opiates in the form of heroin and methadone but
barbiturates, benzodiazepines, cocaine and amphetamines are also frequently seen.
Multidrug use is common and usually leads to prolonged difficult withdrawal. Each
drug has a different half-life and this leads to different pa erns of withdrawal
behaviour. I n general methadone produces effects for longer periods than heroin
(Herzlinger et al 1977) but benzodiazepines may also contribute to this (S u on and
Hinderliter 1990).
The signs most frequently seen are ji eriness, irritability and constant high-pitched
crying. Babies often fail to se le between feeds and are hyperactive. W hen feeds are
offered they often feed voraciously although some have a poor suck. Vomiting is
common. D iarrhoea and an irritant nappy rash are also often seen. S neezing and
yawning are also seen alongside episodes of high temperature in the absence of
infection. In rare circumstances babies may also have seizures.
S everal scoring systems have been developed to help to guide when to give
pharmacological treatment (Finnegan et al 1975). These scoring systems aim to make
the assessment more objective, however most of the features and their severity are
difficult to quantify. Babies assessed for signs of drug withdrawal by a scoring system
are less likely to be inappropriately treated and may have a shorter hospital stay. I t is
important not to over-treat them with drugs as the long-term effects are not clear and
the treatment may then be difficult to withdraw. A lso treatment in many maternity
hospitals means admi ing the baby to the N I CU therefore possibly separating mother
and baby. O n the other hand babies who are withdrawing appear to be in discomfort,
which arguably warrants management, but the long-term effects of withdrawal are
also unclear. From experience the most useful feature is whether the baby se les and
sleeps between feeding. I f the baby does, then pharmacological treatment may be
unnecessary.
Treatment
Treatment can be divided into general care given to these babies and pharmacological
treatment. I t is important, if at all possible, to keep mother and baby together.
Bonding with and care of these babies by their mother should be positively
encouraged. The mother is likely to be feeling upset and guilty because of the baby's
appearance/behaviour and the co-existing social problems involved with these families
makes for a challenging time for all involved. Breastfeeding can be encouraged as long
as there is no evidence of HI V or ongoing drug use (heroin and cocaine) that precludes
this. S ome recommend limiting this to mothers who are taking methadone on a dose
that is less than 20 mg/day (Commi ee on D rugs, A merican A cademy of Pediatrics
1989). A quiet environment with reduced light and noise is helpful in keeping stimuli
to a minimum. S waddling is useful and feeds may need to be given frequently. These
babies will often take large volumes of milk, which is acceptable as long as vomiting is
not a problem. Rocking or cradling are also useful interventions.
Pharmacological treatment
S everal different treatments have been recommended in the past. Previously, the four
drugs recommended for use were paregoric (a mixture of alcohol and opiate),
phenobarbitone, diazepam and chlorpromazine (Commi ee on D rugs, A merican
A cademy of Pediatrics 1998). A number of randomized trials have been performed
a empting to assess the use of various drugs in the treatment of neonatal abstinence
syndrome (N A S ) (T heis et al 1997). I t seems logical to treat opiate withdrawal with
opiates and now the two most commonly used treatments are oral methadone and oral
morphine. These appear to control withdrawal seizures much more effectively (Lawn
and A lton 2012). They can be given in increasing doses if necessary until the features
are controlled and then the dose gradually reduced. A possible dosing regimen for
oral morphine is shown below:
• initially 0.04 mg/kg morphine sulphate oral 4-hourly
• then 0.03 mg/kg morphine sulphate oral 4-hourly
• then 0.02 mg/kg morphine sulphate oral 4-hourly
• then 0.01 mg/kg morphine sulphate oral 4-hourly.
The dose is reduced every 24 hours if the baby is feeding well and se ling be er
between feeds. I f the feeding and se ling does not improve or profuse watery stools
and excessive vomiting continue, other treatment needs to be considered. O ther
medication may sometimes be useful, e.g. clonazepam for benzodiazepine use or
chloral hydrate as a general sedative.
Cocaine
Cocaine deserves special mention because its effects on the newborn are different. It is
a larger problem in the US A than in the UK but the incidence of its use during
pregnancy is unknown. I t is only present in maternal urine for 24 hours after exposure
therefore detection is difficult ( Zuckerman et al 1989). I t can produce significant
withdrawal signs although these are often less severe and less troublesome than with
other drugs, but it is associated with many other harmful effects on the fetus (Fulroth
et al 1989). These include significant fetal I UGR, brain injury due to haemorrhage or
infarction (Hadeed and S iegel 1989), abnormalities of brain development, limb
reduction defects and atresias of the gastrointestinal system. Correlation between
cocaine exposure, small head size and developmental scores has been reported
(Chasnoff et al 1992).
Discharge and long-term effects
D ischarge must be planned with the involvement of other support agencies. This may
include a planning meeting involving all agencies concerned with the care of the
mother and baby. A lthough it seems intuitive that exposure to drugs in utero would
cause neurodevelopmental impairment, this is not borne out by carefully controlled
studies (Lifschi et al 1985). This implies that impairment in intellectual outcome in
these children relates to other adverse prenatal and postnatal factors. Babies born to
these mothers are smaller and have smaller head circumferences (Kandall et al 1976).
However, it is difficult to be certain about the exact causes of any long-term harmful
effects because so many factors are involved, all of which are interlinked. These
include:
• the effects of the drugs themselves on the developing fetus
• the use of other harmful substances by mothers who use drugs (e.g. cigarettes and
alcohol)
• the effect of pregnancy complications
• the effect of the withdrawal syndrome on the developing neonate
• the effect of treatment to prevent withdrawal behaviours
• the effect of the home environment of the chaotic drug-user for the developing child
• genetic effects
• reporting bias means that negative associations with drug-taking are more likely to
be reported (Koren et al 1989).
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Further reading
Wylie L. Newborn screening and immunization. Lumsden H, Holmes D. Care of
the newborn by ten teachers. Hodder Arnold: London; 2010:51–64.
This chapter provides further information on all conditions that are screened by blood
spot at present, to include medium-chain acyl CoA dehydrogenase deficiency
(MCADD), cystic fibrosis and sickle cell disease..
Websites
GBS Support. www.gbss.org.uk.
National Society for Phenylketonuria. www.nspku.org.
C H AP T E R 3 4
Infant feeding
Sally Inch
CHAPTER CONTENTS
Introduction 704
The breast and breastmilk 704
Anatomy and physiology of the breast 704
Lactogenesis 705
Milk production and the mother 706
Properties and components of breastmilk 707
Management of breastfeeding 710
Exclusive breastfeeding for the first 6 months of life 710
Antenatal preparation 711
The first feed 711
The next feed 711
Effective positioning for the mother 711
Effective positioning for the baby 712
Attaching the baby to the breast 712
The role of the midwife 715
Feeding behaviour 716
Expressing breastmilk 718
Care of the breasts 719
Breast problems 719
Difficulties with breastfeeding 720
Feeding difficulties due to the baby 721
Contraindications to breastfeeding 723
Cessation of lactation 723
Complementary and supplementary feeds 724
Human milk banking 725
Choosing breast or formula milk 725
Feeding with formula milk 726
Types of formula milk 726
Choosing a breastmilk substitute 727
Preparation of an artificial feed 727
Feeding the baby with the bottle 728
Healthy Start (and the Welfare Food Scheme) 729
Midwives and the International Code of Marketing of Breastmilk Substitutes 729
The Baby Friendly Hospital Initiative 729
References 730
Further reading 736
Useful websites and contact details 736
Midwives have a key role in supporting mothers to breastfeed successfully.
It is strongly in the interest of both individual mothers and the community as
a whole that those who chose to breastfeed are enabled to do so for as long
as they want. The reasons women give for discontinuation are consistent
over time and internationally: they think they do not have enough milk,
breastfeeding is painful and they have problems getting the baby to feed.
Preventing these distressing problems requires a multifaceted approach
that has to start with effective, practical and evidence-based training of all
those who offer help and support to breastfeeding mothers, especially in
the first week of their baby's life.
For those mothers who cannot, or choose not to breastfeed, the midwife
has an equally important role in ensuring that the baby is fed safely and
appropriately.
The chapter aims to:
• explain the structure and function of the female breast
• describe the properties and components of breastmilk
• emphasize the role of the midwife in ensuring breastfeeding success for both mother
and baby
• discuss the role of breastmilk expression and human milk banking
• describe the different causes of difficulty with breastfeeding
• discuss the use of formula feeding and the various products available
• outline the requirements and recommendations of the International Code of Marketing
of Breastmilk Substitutes and the Baby Friendly Hospital Initiative
Author's note: I n this chapter, where the masculine pronoun has been used to refer to
a baby this is simply to avoid the cumbersome ‘he or she’ and to more clearly
distinguish the baby from the mother.
Introduction
Introduction
Breastfeeding for the first 6 months of life is the ideal start for babies. Breastfeeding
improves infant and maternal health and cognitive development in both developed
and developing countries, and it is the single most important preventive approach for
saving children's lives (Renfrew and Hall 2008). Low breastfeeding rates in the United
Kingdom (UK) have led to a progressive increase in the incidence of illness that has a
significant cost to the N ational Health S ervice (N HS ). Recent calculations from a mere
handful of illnesses (where breastfeeding is thought to have a protective effect and
enough data existed to determine total cost of care expected for each episode of a
particular disease) revealed potential annual savings to the N HS from a moderate
increase in breastfeeding rates of about £40 million per year (Renfrew et al 2012). The
true cost savings are likely to be much higher (UNICEF–UK 2012a).
The problems that deter women from breastfeeding can mostly be prevented
(Renfrew and Hall 2008). This requires a multi-faceted approach, with implementation
of the UNICEF–UK Baby Friendly Initiative at its core (NICE 2008).
The breast and breastmilk
Anatomy and physiology of the breast (Fig. 34.1)
The breasts are compound secreting glands, composed of varying proportions of fat,
glandular and connective tissue, and arranged in lobes. Each lobe is divided into
lobules consisting of alveoli and ducts.
FIG. 34.1 (A) Anatomy of the breast (reproduced with permission of Liz Ellis). (B) Cross-section
of the breast.
Because of the intimate and congruous connection between fat and glandular tissue
within the breast (Nickell and Skelton 2005), the relative proportion of fat to glandular
tissue is difficult to calculate non-invasively. However, analysis of 21 non-lactating
breasts (surgically removed for carcinoma in situ) (Vandeweyer and Hertens 2002)
revealed that the percentage weight of fat per breast varied from 3.6 to 37.6.
Mammographic studies of non-lactating breasts have reported breast glandularity
decreasing with age (Jamal et al 2004).
I nvestigations carried out on 25 sections of central breast tissue removed during
breast reduction operations performed on women with an average body mass index
(BMI ) of 28, found a mean of 61% fat (C ruz-Korchin et al 2002). O n average, the
women's central breast area contained only 7% glandular tissue and 29% connective
tissue. This finding, that larger breasts contain relatively more fat, is supported by an
observational study of 136 patients with an average BMI of 32, undergoing breast
reduction surgery (Nickell and Skelton 2005).
Research on the volumes of 20 complete duct systems (lobes) in an autopsied breast,
found considerable variation in the proportion of breast tissue serviced by each duct.
The largest lobe drained 23% of breast volume, 50% of the breast was drained by three
ducts and 75% by the largest six. Conversely, eight small duct systems together
accounted for only 1.6% of breast volume (Going and Moffat 2004).
Ultrasound investigations of the lactating breasts of 21 subjects (Ramsay et al 2005)
identified nine or so milk ducts per breast (range being 4–18), fewer than previously
believed but commensurate with the investigations conducted by Love and Barsky
(2004). Taneri et al (2006) examined 226 mastectomy specimens and found the mean
number of ducts in the nipple duct bundle was 17.5. This is significantly higher than
the number reported to open on the nipple surface. They reflected that this
discrepancy could be due to duct branching within the nipple or the presence of some
ducts that do not reach the nipple surface.
Taken together, the intimate and inseparable relationship between fat and glandular
tissue, the uneven distribution of milk glands and the high variability in the number
of milk ducts, have implications for those women who require breast surgery. This is
especially the case with women who have breast reduction surgery, as the loss of only
a few ducts may inadvertently compromise a woman's future ability to breastfeed (see
below).
T h e alveoli contain milk-producing acini cells, surrounded by myoepithelial cells,
which contract and propel the milk out (Fig. 34.2). S mall lactiferous ducts, carrying
milk from the alveoli, unite to form larger ducts. S everal large ducts (lactiferous
tubules) conveying milk from one or more lobes emerge on the surface of the nipple.
Myoepithelial cells are oriented longitudinally along the ducts and, under the
influence of oxytocin, these smooth muscle cells contract and the tubule becomes
shorter and wider (W oolridge 1986; Ramsay et al 2004). The tubule distends during
active milk flow, while the myoepithelial cells are maintained in a state of contraction
by circulating oxytocin for about 2–3 minutes. The fuller the breast when let-down
occurs, the greater the degree of ductal distension (Ramsay et al 2004).
FIG. 34.2 Alveoli surrounded by myoepithelial cells, which propel the milk out of the lobule.
The human nipple, in common with other mammalian nipples, is covered with
epithelium and contains cylindrically arranged smooth muscle and elastic fibres.
W hen this contracts and the nipple becomes erect, a tight sphincter is formed at the
end of the teat (Cross 1977) to prevent unwanted loss of milk from the mammary
gland when it is not being suckled.
S urrounding the nipple is an area of pigmented skin called the areola, which
contains Montgomery's glands. These produce a sebum-like substance, which acts as a
lubricant during pregnancy and throughout breastfeeding. Breasts, nipples and
areolae vary considerably in size from one woman to another.
The breast is supplied with blood from the internal and external mammary arteries
and branches from the intercostal arteries. The veins are arranged in a circular fashion
around the nipple. Lymph drains freely from the two breasts into lymph nodes in the
axillae and the mediastinum.
D uring pregnancy, oestrogens and progesterone induce alveolar and ductal growth,
and stimulate the secretion of colostrum. O ther hormones (such as growth hormone,
prolactin, epidermal growth factor, fibroblast growth factor, human placental lactogen,
parathyroid hormone-related protein and insulin-like growth factor) are involved,
governing a complex sequence of events that prepares the breast for lactation (Neville
et al 2002).
Lactogenesis
O nce the alveolar epithelial cells have developed into lactocytes, around mid
pregnancy (Lactogenesis I ), they are able to produce small quantities of secretion:
colostrum. A lthough some women may produce as much as 30 ml per day in late
pregnancy (Cox et al 1999), the production of milk is held in abeyance until after 30–40
hours following the birth, when levels of placental hormones have fallen sufficiently to
allow the already high levels of prolactin to initiate milk production (Lactogenesis I I ).
Continued production of prolactin is caused by touch, as the baby feeds at the breast,
with concentrations highest during night feeds. Prolactin is involved in the
suppression of ovulation, and some women may remain anovular until lactation
ceases, although for others the effect is not so prolonged (Kennedy et al 1989; Ramos
et al 1996) (see Chapter 27).
Maternal nutritional intake and nutritional status are known to affect birth outcome,
and the fetus in utero. The mother's diet during pregnancy may also programme the
fetus, affecting health in adult life (Hall Moran 2012), but the effects of maternal
nutrition on the development of the mammary gland in pregnancy are less well
known. Evidence from rats (Kim and Parks 2004) suggests that undernutrition may
actually enhance cell growth and milk production. Torgersen et al (2010) found no
differences in the risk of cessation of exclusive breastfeeding in mothers with and
without eating disorders. O vernutrition (obesity), however, has been shown to
adversely affect lactogenesis II (Rasmussen 2007).
I f breastfeeding (or expressing) is delayed for a few days, lactation can still be
initiated because prolactin levels remain high, even in the absence of breast use, for at
least the first week (Kochenour 1980). However, the establishment of lactation is more
secure if breastfeeding or expressing begins as soon after birth as possible.
Prolactin seems to be much more important to the initiation of lactation than to its
continuation. A s lactation progresses, the prolactin response to suckling diminishes
and milk removal becomes the driving force behind milk production. This is known to
be due to the presence in secreted milk of a whey protein that is able to inhibit the
synthesis of milk constituents (Prentice et al 1989; Daly 1993; Wilde et al 1995).
The protein collects in the breast as the milk accumulates, exerting negative
feedback control on the continued production of milk. Removal of this autocrine
inhibitory factor (sometimes referred to as Feedback I nhibitor of Lactation: FIL) by
extracting the milk, allows milk production to accelerate.
Because this mechanism acts locally within the breast, each breast can function
independently of the other. It is also the reason that milk production slows as the baby
is gradually weaned from the breast. I f necessary, it can be increased again if the baby
is put back to the breast more often, perhaps because of illness.
Milk is synthesized continuously into the alveolar lumen, where it is stored until
milk removal from the breast is initiated. O nly when oxytocin is released, and the
myoepithelial cells contract, is milk made available to the suckling baby. Milk release
is under neuroendocrine control. Tactile stimulation of the breast also stimulates the
oxytocin, causing contraction of the myoepithelial cells. This process is known as the
let-down or milk-ejection reflex and makes the milk available to the baby. This occurs in
discrete pulses throughout the feed and may trigger bursts of active feeding.
I n the early days of lactation, this reflex is unconditioned. Later, as it becomes a
conditioned reflex, the mother may find her breasts responding to the baby's cry or
other circumstances associated with the baby or feeding. I n one small study,
psychological stress (mental arithmetic or noise) was found to reduce the frequency of
the oxytocin pulses without affecting the amplitude of the pulse. N either was there
any effect on either prolactin levels or the amount of milk the baby received (Ueda
et al 1994).
Milk production and the mother
The human mother manages the process of lactation in an entirely different way from
her non-primate counterpart. Much of the mis-information to which women are
subjected derives from extrapolation from veterinary and dairy science (Woolridge
1995). A dequate milk production is largely independent of the mother's nutritional
status and BMI (Prentice et al 1994).
D ietary surveys in developed countries have consistently found calorie intake to be
less than the recommended amount (W hitehead et al 1981; Bu e et al 1984).
Controlled trials conducted in developing countries have demonstrated that giving
extra food to mothers, even those who were poorly nourished, did not increase the rate
of growth of their babies (Prentice et al 1980, 1983). I t has been suggested that
metabolic efficiency is enhanced in lactating women, thus enabling them to conserve
energy and subsidize the cost of their milk production (Illingworth et al 1986).
The lactational performance of the human female is compromised when
undernutrition is sufficiently severe, but it appears that this occurs only in famine or
near-famine conditions. A s milk production appears to drive appetite, rather than the
reverse, hunger effectively regulates the calorie intake of a breastfeeding woman, and
the practice of encouraging breastfeeding mothers to eat excessively should be
abandoned. S imilarly, if healthy breastfeeding women wish to undertake strenuous
exercise from 6–8 weeks after birth, or to lose weight (500–1000 g/week), they can be
assured that neither the quality nor the quantity of their milk will be affected (Dewey
et al 1994; D usdieker et al 1994). Exclusive breastfeeding combined with low fat diet
and exercise will result in more effective weight loss than diet and exercise alone
(Hammer et al 1996; Dewey 1998).
Milk production is similarly unaffected by fluctuations in the woman's fluid intake.
I t has been repeatedly demonstrated that neither a significant decrease (D earlove and
Dearlove 1981) nor a significant increase (Morse et al 1992) in maternal fluid intake has
any effect on milk production or the baby's weight.
Properties and components of breastmilk
Human milk varies in its composition:
• with the time of day (e.g. fat content is lowest in the morning and highest in the
afternoon)
• with the stage of lactation (e.g. the fat and protein content of colostrum is higher
than in mature milk)
• in response to maternal nutrition (e.g. although the total amount of fat is not
influenced by diet, the type of fat that appears in the milk will be influenced by what
the mother eats)
• because of individual variations.
The most dramatic change in the composition of milk occurs during the course of a
feed (Hall 1979). At the beginning of the feed the baby receives a high volume of
relatively low fat milk (the foremilk). A s the feed progresses, the volume of milk
decreases but the proportion of fat in the milk increases, sometimes to as much as five
times the initial value (the hindmilk) (J ackson et al 1987). The baby's ability to obtain
this fat-rich milk is not determined by the length of time he spent sucking at the
breast, but by the quality of the a achment to the breast. The baby needs to be well
a ached so that the tongue can be used to maximum effect, stripping the milk from
the breast, rather than relying solely on the mother's milk ejection reflex. A poorly
a ached baby may have difficulty in obtaining enough fat to meet their needs,
resorting to very frequent feeds to obtain sufficient calories from low-fat feeds. A well-
attached baby may, however, obtain all he requires in a very short time.
The length of the feed, provided that the baby is well a ached, is thus determined
by the rate of milk transfer from mother to baby. I f milk transfer occurs at a high rate,
feeds will be relatively short; if it occurs slowly, feeds will be longer (W oolridge et al
1982) (Fig. 34.3). Milk transfer seems to be more efficient (and thus feeds are shorter)
in a second lactation than in a first (Ingram et al 2001).
FIG. 34.3 Pattern of milk intake at a feed for 20 6-day-old babies. From Woolridge et al 1982, with
permission.
Fats and fatty acids
For the human baby, with its unique and rapidly growing brain, fat, not proteín, in
human milk has particular significance. S ome 98% of the lipid in human milk is in the
form of triglycerides: three fa y acids linked to a single molecule of glycerol. More
than 100 fa y acids have so far been identified, about 46% being saturated fat and 54%
unsaturated fat. O ver the past decade, there has been an explosion of interest in the
unsaturated fa y acid content of human milk, particularly in the long chain
polyunsaturated variety (LC-PUFA s), because of their role in brain growth and
myelination (Fernstrom 1999). Two of them, arachidonic acid (A A) and
docosahexanoic acid (D HA) appear to play an important role in the development of
the retina and visual cortex of the newborn. Fat also provides babies with >50% of their
calorific requirements (Picciano 2001). Fat is utilized very rapidly because the milk
itself contains the enzyme bile-salt-stimulated lipase, needed for fat digestion, but in a
form that becomes active only when it reaches the baby's intestine. Pancreatic lipase is
not plentiful in the newborn, so a baby who is not fed human milk is less able to
digest fat.
Cholesterol, a risk factor for coronary heart disease (CHD ) in adults, occurs in human
milk at higher levels than are currently present in infant formulae (Kamelska et al
2012). However, these high levels not only play an important role in brain growth and
development (S chol et al 2013), but also paradoxically lower the cholesterol
concentration in blood in later life (Owen et al 2008).
Carbohydrate
The carbohydrate component of human milk is provided chiefly by lactose, providing
the baby with about 40% of calorific requirements. Lactose is converted into galactose
and glucose by the action of the enzyme lactase in order to be more readily
metabolized and absorbed. These sugars provide energy to the rapidly growing brain.
Lactose enhances the absorption of calcium, promoting the growth of lactobacilli,
which increase intestinal acidity thus reducing the growth of pathogenic organisms in
the baby.
Protein
Human milk contains less protein than any other mammalian milk (A kre 1989a). This
accounts in part for its more transparent appearance. Human milk is whey-dominant,
which is mainly α-lactalbumin, and forms soft, flocculent curds when acidified in the
stomach.
A llergies occur less frequently in breastfed babies than in those fed with formula
milk. This may be because the infant's intestinal mucosa is permeable to proteins
before the age of 6–9 months and proteins in cow's milk can act as allergens. I n
particular, bovine β-lactoglobulin, which has no human milk protein counterpart, is
capable of producing antigenic responses in atopic infants (Bahna 1987; A dler and
Warner 1991).
O ccasionally a baby may react adversely to substances in their mother's milk that
come from her diet. However, this is rare and can usually be resolved by the mother
identifying and avoiding the foods that cause the adverse reaction so that she may
continue to breastfeed. A nother bovine whey protein, bovine serum albumin, has
been implicated as the trigger for the development of insulin-dependent diabetes
mellitus (Vaarala et al 1999; Paronen et al 2000).
Vitamins
A ll the vitamins required for good nutrition and health are supplied in breastmilk,
and although the actual amounts vary from mother to mother, none of the normal
variations poses any risk to the infant (Hopkinson 2007).
Fat-soluble vitamins
Vitamin A
Vitamin A is present in human milk as retinol, retinyl esters and beta carotene.
Colostrum contains twice the amount present in mature human milk, giving
colostrum its yellow colour. Bile-salt-stimulated lipase (present in human milk: see
Fa y acids, above) assists the hydrolysation of the retinyl esters and may account for
the rarity of vitamin A deficiency in breastfed babies in affluent societies ( Fredrikzon
et al 1978; Leaf 2007).
Vitamin D
Vitamin D plays an essential role in the metabolism of calcium and phosphorus in the
body, preventing osteomalacia in adults and rickets in children. I t is not strictly a
vitamin, but a hormone triggered by ultraviolet light. The principal unfortified dietary
source of vitamin D is fish liver oils, with bu er, eggs and cheese contributing much
smaller amounts. I n the UK, only margarine fortification with 2800–3520 I U/kg of
vitamin D is compulsory. I n other countries, vitamin D fortification of various other
foods is either compulsory or permitted.
Vitamin D is the name given to two fat-soluble compounds: calciferol (vitamin D2)
and cholecalciferol (vitamin D3). A plentiful supply of 7-dehydrocholesterol, the precursor
of vitamin D3, exists in human skin, and needs only to be activated by sufficient
ultraviolet light (<30 min of summer sunlight a day) to become fully potent.
For light-skinned babies, exposure to sunlight for 30 minutes per week wearing only
a nappy, or 2 hours per week fully clothed but without a hat, keeps vitamin D
requirements within the lower limits of the normal range (S pecker et al 1985).
However, latitude and strength of the sunlight is important. I n S candinavia, photo-
conversion of 7-dehydrocholesterol has been found to occur only between March and
O ctober, with a maximum in J une and J uly (M oan et al 2008). I n the UK, reseachers in
A berdeen found that sunlight exposure in summer and spring provided 80% of the
baby's total annual intake of vitamin D (Macdonald et al 2011). Those living in regions
where exposure to the sun is low have always been at risk for vitamin D deficiency
(Garza and Rasmussen 2000).
I n order to ensure adequate stores in the baby's liver at birth, pregnant women
would need to maintain own their vitamin D levels at a high enough level to supply
sufficient amounts via the placenta, as the concentration of vitamin D in human milk
is low. However, social mobility, cultural considerations and concerns over skin cancer
from sunlight have increased the risk of vitamin D deficiency by reducing the skin's
exposure to sunlight. I n the UK this is of particular concern in women and infants of
Asian and Afro-Caribbean ethnic origin (Gregory et al 2000; Leaf 2007).
Maternal vitamin D deficiency during pregnancy has been implicated as a risk factor
for diabetes, ischaemic heart disease and tuberculosis. I n addition to the previously
known paediatric problems of hypocalcaemic convulsions, dental enamel hypoplasia,
infantile rickets and congenital cataracts in early life, vitamin D deficiency has been
shown to affect neonatal head and linear growth and may adversely affect the
developing fetal brain (Shaw and Pal 2002).
T he N ational I nstitute for Health and Clinical Excellence (N I CE) (2008)published
specific recommendations to guide health professionals in advising women about the
benefits of taking a vitamin D supplement of 10 µg per day during pregnancy and
while breastfeeding. S uch advice is also supported by the D epartment of Health (D H)
(2009). I n addition, healthy breastfed babies should receive a vitamin D supplement
from 6 months of age as part of a multivitamin supplement. Unless a baby who is
being fed on formula milk is considered to be at risk, they would not routinely require
any vitamin D supplementation as this will already be contained within the formula
milk.
Vitamin E
A lthough vitamin E is present in human milk, its role is uncertain. I t appears to
prevent the oxidization of polyunsaturated fatty acids and may prevent certain types of
anaemia to which preterm infants are susceptible.
Vitamin K
Vitamin K is the generic name for a group of structurally similar, fat-soluble vitamins.
The two naturally occurring forms of this vitamin are vitamin K1 (phytonadione)
found in green leafy vegetables, and K2 (menaquinone), which is synthesized by gut
flora. I t has been suggested that, by 2 weeks of age, the breastfed baby's gut flora
should be synthesizing adequate amounts of vitamin K2 (Akre 1989b).
Vitamin K is essential for the synthesis of blood-clo ing factors I I , VI I , I X and X. I
is present in human milk and absorbed efficiently. Because it is fat-soluble, it is
present in greater concentrations in colostrum and in the high-fat hindmilk (Kries et al
1987). The increased volume of milk as lactation progresses means that the baby
obtains twice as much vitamin K from mature milk than from colostrum (Canfield et al
1991) . Greer (1997) found that marked increases in breastmilk concentrations of
vitamin K, with corresponding increases in babies' blood levels, can be obtained by
giving mothers oral vitamin K, although this subsequently received little attention.
Vitamin K deficiency bleeding (VKD B), formerly called haemorrhagic disease of the
newborn, is a coagulation disturbance in newborns due to vitamin K deficiency. The
incidence of classic VKD B, occurring between 1 and 7 days of life, ranges from 0.25 to
1.7 cases per 100 births (Willacy 2010). However, those instances where VKD B occurs
in the first 24 hours of life are largely confined to the babies of mothers who were
taking medications such as isoniazid, rifampicin, anticoagulants and anticonvulsant
agents in pregnancy. Late VKD B occurs between 2 weeks and 12 weeks of life and
occurs predominantly in exclusively breastfed babies as vitamin K is added to infant
formula milks, but may also occur in any baby who is unable to absorb the fat-soluble
vitamin K (see Chapter 31).
There has been much debate over which babies are at risk of VKD B, and if
supplements should be given after birth and how these should be given. Pucke and
Offringa (2000) found that a single intramuscular (I M) dose (1 mg) was more effective
than a single oral dose at achieving appropriate plasma vitamin K levels at 2 weeks
and 1 month, but achieved lower plasma vitamin K levels than a 3-dose oral schedule
at 2 weeks and at 2 months. I t was recommended by N I CE (2006a) that all babies
should be offered intramuscular vitamin K within the first 24 hours of birth. However,
where parents declined to give consent to the injection, they should be offered an oral
form of the vitamin, with the further explanation that this would need to be given
several times in the first few weeks to be effective.
I n the two years following the issuing of this guidance, Busfield et al (2013) found
that all (236) of the consultant maternity units they surveyed were offering vitamin K
routinely at birth. In 72% of units it was offered intramuscularly, 20% offered parents a
choice and the remaining 8% offered an oral, multidose regime. They identified 11
babies as suffering from VKD B after birth, of these, six had received no prophylaxis
(five because the parents withheld consent) and two had received incomplete oral
prophylaxis. The remaining three developed VKDB despite intramuscular prophylaxis.
Water-soluble vitamins
Unless the mother's diet is seriously deficient, breastmilk will contain adequate levels
of the water-soluble vitamins, B and C. S ince they are fairly widely distributed in foods
(vitamin C in most fruit and vegetables), a diet significantly deficient in one vitamin
will be deficient in others as well. Thus, an improved diet will be more beneficial than
artificial supplements. Water-soluble vitamins are actively transported across the
placenta throughout pregancy.
Vitamin B complex
Vitamin B complex consists of eight water-soluble vitamins: thiamine (B1), riboflavin
(B2), niacin (B3), panthotenic acid (B5), pyridoxine (B6), biotin (B7), folic acid (B9) and
cyanocobalamin (B12). All play an important role in metabolism in the body.
Vitamin C
Vitamin C (L-ascorbic acid) is an antioxidant that helps protect cells from free radical
damage. I t is necessary to form collagen, and thus plays a role in growth and repair of
bone, skin and connective tissue. I t also assists the body to absorb iron. With some
vitamins, e.g. vitamin C and thiamine, a plateau may be reached where increased
maternal intake has no further impact on breastmilk
Minerals and trace elements
Iron
Healthy term babies are usually born with a high haemoglobin level (16–22 g/dl),
which decreases rapidly after birth. The iron recovered from haemoglobin breakdown
is re-utilized. Babies also have ample iron stores, sufficient for at least 4–6 months.
A lthough the amounts of iron are less than those found in formula milks, the
bioavailability of iron in breastmilk is very much higher: 70% of the iron in breastmilk
is absorbed, against 10% from formula milk (Saarinen and Siimes 1979). The difference
is due to a complex series of interactions taking place within the gut. Babies receiving
fresh cow's milk or formula may become anaemic because the cow's milk protein,
especially if unmodified, can irritate the lining of the stomach and intestine, leading to
loss of blood into the stools (Ziegler 2011).
Zinc
A deficiency of this essential trace mineral may result in the baby's failure to thrive
and development of typical skin lesions. A lthough there is more zinc present in
formula milk than in human milk, the bioavailability is greater in human milk.
Breastfed babies maintain high plasma zinc values compared with formula-fed babies,
even when the concentration of zinc is three times that of human milk (Sandstrom
et al 1983; Khaghani et al 2010) as zinc is actively transported from the maternal
circulation to the mammary gland (Krebs 1999). Preterm babies may need zinc
supplements.
Calcium
Calcium is more efficiently absorbed from human milk than from breastmilk
substitutes because of the higher calcium : phosphorus ratio of human milk. Formula
milks based on cow's milk inevitably have higher phosphorus content than human
milk.
Other minerals
Human milk has significantly lower levels of calcium, phosphorus, sodium and
potassium than formula milk. Copper, cobalt and selenium, however, are present at
higher levels. The higher bioavailability of these minerals and trace elements ensures
that the baby's needs are met while also imposing a lower solute load on the neonatal
kidney than do breastmilk substitutes.
Anti-infective factors
Leucocytes
D uring the first 10 days following birth, there are more white cells/ml in breastmilk
than there are in blood. Macrophages and neutrophils are among the most common
leucocytes in human milk and they surround and destroy harmful bacteria by their
phagocytic activity.
Immunoglobulins
Five types of immunoglobulin have been identified in human milk: I gA , I gG, I gE, I gM
and I gD . O f these the most important is I gA , which appears to be synthesized and
stored in the breast. A lthough some I gA is absorbed by the baby, the majority is not.
I nstead, it coats the intestinal epithelium and protects the mucosal surfaces against
entry of pathogenic bacteria and enteroviruses. I t affords protection against Escherichia
coli, salmonellae, shigellae, streptococci, staphylococci, pneumococci, poliovirus and
the rotaviruses.
The mother's body is also able to monitor and respond to potential pathogens in her
infant's environment from moment to moment via an elegant system known as GA LT
and BA LT (gut-associated lymphoid tissue and bronchus-associated lymphoid tissue) or the
broncho-mammary and entero-mammary circulation. Pathogens that enter the
mother's respiratory or gastrointestinal tract stimulate pre-commi ed lymphocytes in
the bronchial submucosa or in the Peyer's patches of the small intestine. The activated
Beta cells migrate via the blood to the mammary (and salivary) glands where they
become transformed into plasma cells that start secreting large quantities of the
appropriate neutralizing antibody into the milk.
Lysozyme
Lysozyme kills bacteria by disrupting their cell walls. The concentration of lysosyme
increases with prolonged lactation (Hamosh 1998; Montagne et al 2001).
Lactoferrin
Lactoferrin binds to enteric iron, thus preventing potentially pathogenic E. coli from
obtaining the iron they need for survival. I t also has antiviral activity against human
immunodeficeincy virus (HI V), cytomegalovirus (CMV) and herpes simplex virus
(HSV), by interfering with virus absorption or penetration (Liu and Newberg 2013).
Bifidus factor
Bifidus factor in human milk promotes the growth of Gram-positive bacilli in the gut
flora, particularly Lactobacillus bifidus, which discourages the multiplication of
pathogens. Babies fed on cow's-milk-based formulae, however, have more potentially
pathogenic bacilli present in the flora of their gut.
Hormones and growth factors
Epidermal growth factor and insulin-like growth factor stimulate the baby's digestive
tract to mature more quickly and strengthen the barrier properties of the
gastrointestinal epithelium. O nce the initially leaky membrane lining the gut matures,
it is less likely to allow the passage of large molecules, and becomes less vulnerable to
micro-organisms. The timing of the first feed has a significant effect on gut
permeability, which decreases markedly if the first feed takes place soon after birth.
Management of breastfeeding
Exclusive breastfeeding for the first 6 months of life
Human milk is species-specific. I n 2003, the Global S trategy for I nfant and Young
Child Feeding called for all mothers to have access to skilled support to initiate and
sustain exclusive breastfeeding for 6 months and ensure the timely introduction of
adequate and safe complementary foods with continued breastfeeding up to 2 years or
beyond (W orld Health O rganization [W HO ]/UN I CEF 2003 ). This was echoed in the
same year by the Department of Health and is still current policy (DH 2011).
I t has been known for some time that exclusively breastfed babies who consume
enough breastmilk to satisfy their energy needs will easily meet their fluid
requirements, even in hot dry climates (S achdev et al 1991; A shraf et al 1993). Extra
water does nothing to speed the resolution of physiological jaundice, should it occur
(Carvahlo et al 1981; N icoll et al 1982). The only consistent effect of giving additional
fluids to breastfed infants is to reduce the time for which they are breastfed (Fenstein
et al 1986; White et al 1992).
Antenatal preparation
Breasts and nipples are altered by pregnancy (Chapter 9). I ncreased sebum secretion
obviates the need for cream to lubricate the nipple. W omen who have inverted and
non-protractile (flat) nipples often find that they improve spontaneously during
pregnancy (Hy en and Baird 1958). I f not, help given with a aching the baby to the
breast after birth often results in successful breastfeeding. N either the wearing of
W oolwich shells nor Hoffmann's exercises are of any value (Main Trial Collaborative
Group 1994) and should not be recommended, nor should any other unevaluated
commercially available device. Education of the mother is likely to be more effective
than any physical exercises.
The first feed
The mother should have her baby with her immediately after birth. Early and extended
skin contact ensures the cues that indicate that the baby is ready to feed will not be
missed. Early feeding contributes to the success of breastfeeding, but the time of the
first feed should, to a large extent, depend on the needs of the baby. S ome may
demonstrate a desire to feed almost as soon as they are born; others show no interest
until they are an hour or so old (Widström et al 1987; Righard and A lade 1990). Babies
of mothers who have received narcotics in labour may be sleepy and thus require
additional support to breastfeed so they do not lose an excess of weight in the first
week (Dewey et al 2003).
The first feed should be supervised by the midwife. I f it proceeds without pain and
the baby is allowed to end the feed spontaneously, both mother and baby will have
been helped to begin the learning process necessary for effective breastfeeding in a
happy and positive way.
The next feed
All mothers should be offered help with the next feed, within approximately 6 hours of
birth or earlier if desired. O nce the baby is feeding satisfactorily the mother should be
told about the cause and prevention of sore nipples, being advised to seek help if any
problems arise. S he should also be informed about the changes that will take place in
her breasts during the following few days. Helping mothers to understand that
breastfeeding is a learned, not an instinctive, skill enables them to be patient with
themselves and their babies during this time (Royal College of Midwives [RCM] 2002 ).
Mothers who receive the right help and education at the start will require less support
and remedial intervention later.
Effective positioning for the mother
A comfortable position is a prerequisite of comfortable breastfeeding. A woman who
has recently given birth, especially one new to breastfeeding, may need some help
with this.
A fter a caesarean section, or where the perineum is very painful, lying on her side
may be the only position a woman can tolerate in the first few days after birth, as
shown in Fig. 34.4. I t is likely that she will need assistance in placing the baby at the
breast in this position, because she has only one free hand. W hen feeding from the
lower breast it may be helpful to raise her body slightly by tucking the end of a pillow
under her ribs. O nce the woman can do this unaided, she may find this a comfortable
and convenient position for night feeds, enabling her to get more sleep.
FIG. 34.4 Mother lying on her side. Reproduced with kind permission from the Health Education Board for
Scotland.
I f the woman shares her bed with her baby in hospital, the hospital's guidelines on
bed-sharing should be followed. A ll mothers, whether they intend to bed-share at
home or not, should receive guidance on the subject from the midwife (N I CE 2013).
Guidance on this complex and sometimes emotive issue is available for both parents
and health professionals (UNICEF 2011a; UNICEF 2011b).
A lternatively, the mother may prefer to sit up to feed her baby, as in Fig. 34.5. I n the
early days following the birth, it is particularly important that the mother's back is
upright at a right-angle to her lap. This is not possible if she is si ing in bed with her
legs stretched out in front of her, or si ing in a chair with a deep backward-sloping
seat and a sloping back. Both lying on her side and si ing correctly in a chair with her
back and feet supported enhance the shape of the breast and allow ample room in
which to manoeuvre the baby.
FIG. 34.5 Mother feeding sitting up. Reproduced with kind permission from the Health Education Board for
Scotland.
Effective positioning for the baby
The baby's body should be turned towards the mother's body (Fig. 34.6) so that the
baby is coming up to her breast at the same angle as her breast is coming down to the
baby.
FIG. 34.6 Baby turned towards the mother's body. From an original drawing by Hilary English.
The more the mother's breast points down, the more the baby needs to be on his
back (Fig. 34.7). The advice to have the baby tummy to tummy may be mistakenly taken
to imply that the baby should always be lying on his side. However, taking account of
the angle of the dangle might be more useful.
FIG. 34.7 Baby's body in relation to the mother's body, depending on the angle of the
breast. From an original drawing by Hilary English.
I f the baby's nose is opposite his mother's nipple, being brought to the breast with
the neck slightly extended, the baby's mouth will be in the correct relationship to the
nipple (Fig. 34.8).
FIG. 34.8 The baby's mouth opposite the nipple, the neck slightly extended. From an original
drawing by Jenny Inch.
Attaching the baby to the breast
The baby should be supported across the shoulders, so that slight extension of the
neck can be maintained. The baby's head may be supported by the extended fingers of
the mother's supporting hand (Fig. 34.9) or on the mother's forearm (Fig. 34.10). I t may
be helpful to wrap the baby in a small sheet (Vancouver wrap), as shown in Fig. 34.11,
so that his hands are by his side.
FIG. 34.9 Mother supporting the baby's head with her fingers. Reproduced with kind permission from
the Health Education Board for Scotland.
FIG. 34.10 The baby's head is supported by the mother's forearm. Reproduced with kind permission
from the Health Education Board for Scotland.
FIG. 34.11 The Vancouver wrap to keep the baby's hands by his side.
Healthy term babies are equipped with a number of primitive reflexes that enable
them to obtain the nourishment they require. At birth, all reflexes are of brainstem
origin, with minimal cortical control. A s the baby matures, higher, cortical pathways
develop and the reflexes disappear sequentially: rooting at about 4 months of age and
tongue protrusion by about 6 months of age (Bagnall 2005).
I f the newborn baby's mouth is moved gently against the mother's nipple, the baby
will open his mouth wide, as shown in Fig. 34.12. A s the baby drops his lower jaw and
darts his tongue down and forward, he should be moved quickly to the breast. The
intention of the mother should be to aim the baby's bo om lip as far away from the
base of the nipple as is possible. This allows the baby to draw breast tissue as well as
the nipple into his mouth with his tongue. I f correctly a ached, the baby will have
formed a teat from the breast and the nipple (Fig. 34.13) (Woolridge 1986, 2011).
FIG. 34.12 A wide gape. Photo courtesy of the Health Education Board for Scotland and Mark-it TV
www.markittelevision.com.
FIG. 34.13 The baby has formed a ‘teat’ from the breast and the nipple, which causes the nipple
to extend back as far as the junction of the hard and soft palates. The lactiferous ducts are within
the baby's mouth. A generous portion of areola is covered by the bottom lip. Reproduced from
Woolridge 1986, with permission.
The nipple should extend almost as far as the junction of the hard and soft palate.
Contact with the hard palate triggers the sucking reflex. The baby's lower jaw moves
up and down, following the action of the tongue. A lthough the mother may be startled
by the physical sensation, she should not experience pain. I f the baby is well a ached,
minimal suction is required to hold the teat within the oral cavity. The tongue can then
apply rhythmical cycles of compression and relaxation so that milk is removed from
the ducts. This view of the main mechanism a baby uses to remove milk from the
breast has been recently challenged (Geddes et al 2008), but even more recently
confirmed by further ultrasound studies (Monaci and W oolridge 2011). A lthough the
tongue is used from time to time to generate increased suction pressure aiding milk
removal, this is superimposed on the peristaltic action and does not occur in isolation
(Woolridge 2011).
The baby feeds from the breast rather than from the nipple, and the mother should
guide her baby towards her breast without distorting its shape. The baby's neck
should be slightly extended and the chin in contact with the breast. I f the baby
approaches the breast as illustrated in Fig. 34.8, a generous portion of areola will be
taken in by the lower jaw, but it is positively unhelpful to urge the mother to try to get
the whole of the areola in the baby's mouth (see Fig. 34.14).
FIG. 34.14 The baby's lower jaw takes in a generous amount of the areola. Photo courtesy of the
Health Education Board for Scotland and Mark-it TV www.markittelevision.com.
The role of the midwife
The midwife's role during the first few feeds is twofold. First, she must ensure that the
baby is adequately fed at the breast. S econdly her role is to support the mother in
developing the necessary practical positioning and a achment skills so that she is able
to feed her baby independently. W hilst the baby is reflexly equipped for
breastfeeding, mothers are not. For all primate mothers breastfeeding is a
learned/socially acquired skill. A common pitfall is the assumption that breastfeeding
is instinctive for the mother. A ll new mothers, but particularly those who have never
experienced breastfeeding before, require encouragement and reassurance (emotional
support), advice and guidance on the fundamentals of effective a achment so that
feeding is pain free (practical support), and factual information about breastfeeding
(informational support) in small, manageable quantities. S ome mothers will need
more help and support than others.
Many mothers who have had babies before require as much support with
breastfeeding as those who have given birth to their first baby. Reasons for this
include:
• Previous unsuccessful breastfeeding.
• Breastfeeding may have gone well last time by chance rather than knowledge.
• The new baby may behave very differently, or have different needs, from the
mother's previous baby/babies.
• The mother may have recently fed (or still be feeding) a toddler and has forgotten
quite how much help a new baby requires to breastfeed.
• Their previous baby may have been born at a time when underpinning information
now known to be outdated was thought to be correct.
Hands-on help from the midwife
W here possible, breastfeeding support from the midwife should always be hands off,
but pragmatically, it may be necessary for the midwife to help the mother a ach the
baby to the breast for the first few feeds. I n this case, the midwife should think of her
own comfort, as well as that of the mother and the baby. The midwife will put less
strain on her own back if she kneels on a foam mat beside the mother, rather than
bending over her (see Fig. 34.15).
FIG. 34.15 The midwife is kneeling by the mother to assist her with attaching the baby to the
breast. Reproduced with kind permission of Nancy Durrel-McKenna.
The midwife should also consider which hand guides the baby most skilfully. For
example, a right-handed midwife helping a mother who is lying on her left side will
a ach the baby to the left breast with her right hand. I nstead of asking the mother to
turn on her right side so that she can feed from the right breast, the midwife could
raise the baby on a pillow and a ach him to the right breast, again using her right
hand. A lternatively, if the mother is si ing up, she could consider placing the baby
under the mother's arm on the right side, so that she can again use her right hand.
O nce a baby has fed efficiently he is more likely to do so again and from this point
the mother can begin to learn how to feed her baby independently. I f the midwife
needs to give hands-on help to the mother, she should also explain what she is doing,
and the reason, so that the mother learns from the encounter. The importance of
observing babies as they go to the breast and feed cannot be overemphasized. The
midwife cannot be confident the baby has a ached correctly and feeds effectively if
she does not see it happen.
Feeding behaviour
A breastfeeding baby typically performs one of three activities (Monaci and W oolridge
2011):
1. Doing nothing.
2. Stimulating the mother's nipple, without swallowing milk (non-nutritive
sucking/simply sucking).
3. Sucking and swallowing milk (nutritive sucking/swallowing).
A fter an initial burst of nipple stimulation that is short frequent sucking, two sucks
per second, the baby begins swallowing – slow, deep, one suck per second (nutritive)
sucking – and feeds vigorously with few pauses (Bosma et al 1990). A s the feed
progresses, pausing occurs more frequently and lasts longer. Pausing is an integral
part of the baby's feeding rhythm and should not be interrupted. The midwife should
simply encourage the mother to allow the baby to pace the feed. The change in the
pattern generally relates to milk flow.
The foremilk is more generous in quantity but lower in fat than the hindmilk
delivered at the end, which is thus higher in calories (W oolridge and Fisher 1988). I f
the baby receives an excessive quantity of foremilk as a result of either poor
a achment or premature breast switching (see below), it may result in increased gut
fermentation causing colic, flatus and explosive stools (W oolridge and Fisher 1988;
Evans et al 1995). This is the commonest cause of colic in breastfed babies (see Fig.
34.16) and is resolved in this case by improving a achment. N either simeticone
preparations, which are often prescribed for this condition, nor commonly used
complementary medicines, have been shown to be of value (Metcalf et al 1994; Perry
et al 2011; Cohen and Albertini 2012).
FIG. 34.16 Causes of colic.
Finishing the first breast and finishing a feed
The baby will release the breast when he has had sufficient milk from it. His ability to
know this may be controlled either by the calories he has received or by the change in
the volume available. He should be offered the second breast after he has had the
opportunity to expel any wind, which he may take according to appetite.
The baby should not be deliberately removed from the breast before he releases it
spontaneously, unless the mother is experiencing pain, in which case the baby should
be rea ached, if still willing to feed. Taking the baby off the first breast before he has
finished may cause two problems. First, the baby is deprived of the high calorie
hindmilk; second, if adequate milk removal has not taken place, milk stasis may occur
ultimately leading to the mother developing mastitis or experiencing reduced milk
production, or both. Provided that the baby starts each feed on alternate sides, both
breasts should be used equally. I f a baby does not release the breast or will not se le
after a feed, the most likely reason is that he has not been correctly a ached to the
breast and was therefore unable to remove the milk efficiently.
Other reasons for babies withdrawing from the breast are:
• incorrect attachment
• the milk flow is very fast and the baby needs to let go and pause
• the baby has swallowed air with the generous flow of milk that occurs at the
beginning of a feed and requires an opportunity to expel wind.
There is no justification for imposing either one breast per feed or alternatively both
breasts per feed as a feeding regimen.
Timing and frequency of feeds
A healthy term baby knows be er than anyone else how often and for how long he
needs to be fed. This is now being described as responsive feeding, superseding the
terms baby-led feeding and demand feeding (UN I CEF–UK 2012b ). The baby who
remains close to his mother can signal his need to feed so that the feed can begin
while he is still calm. W hen the baby wakes up he will start to move about, beginning
with movement of the head and mouth, including licking his lips. Finally the baby
finds something to suck, which is usually his fingers. I f the mother misses these
feeding cues the baby may then start to cry. Crying is a sign of distress, which is a late
sign of hunger, and as a result, the baby will need to be calmed before he can feed
effectively.
I t is not unusual in the first day or so for the baby to feed infrequently, and have 6–8
hour gaps between effective feeds, each of which may be quite long (I nch and Garforth
1989; Waldenström and S wensen 1991). This is normal, providing the mother with the
opportunity to sleep if she needs to. A s milk volume increases, the feeds tend to
become more frequent and a li le shorter. I t is unusual for a baby to feed less often
than six times in 24 hours from the 3rd day and most babies are taking at least six
feeds every 24 hours by the time they are one week old. Babies who feed infrequently
may be consuming less milk than they need, or they may be unwell, or both, whereas
babies who feed frequently (10–12 feeds in 24 hours after they are a week old) may be
poorly a ached to the breast. The feeding technique and the baby's weight should be
monitored. However, individual mother–baby pairs develop their own unique pa ern
of feeding and, providing the baby is thriving and the mother is happy, there is no
need to change it.
Volume of the feed
Well-grown term babies are born with good glycogen reserves and high levels of
antidiuretic hormone (A D H). Consequently babies do not need large volumes of milk
or colostrum before they become available physiologically. I n the first 24 hours, the
baby takes an average of 7 ml per feed and by the second 24 hours, this has increased
to 14 ml per feed (RCM 2002; S antoro et al 2010). N o precise information is available
on the actual volume of breastmilk an individual baby requires in order to grow
satisfactorily. Previous recommendations (150 ml/kg) were based on the requirements
of formula fed babies, and these can therefore be used only as a guideline (D avies et al
1972).
Weight loss and weight gain
Most newborn babies lose some weight during their first week of life. There is a
general expectation that the baby will regain their birthweight by 10–14 days. There is
less agreement about how great a weight loss is normal or acceptable. A lthough the
figure of 10% is often cited as the upper limit of normal, there is li le evidence to
support a figure as high as this. D ata from nine studies conducted between 1986 and
1999 suggest a normal range of 3–7%; and normative data on 435 breastfed babies born
in a S co ish Baby Friendly Hospital, reported median maximum weight loss of 6.6%
(Macdonald et al 2003).
Monitoring milk transfer
A noticeable change in the baby's sucking/swallowing pa ern is the most consistent
sign of milk transfer. S oft but audible swallows may also be heard at the beginning of
the feed. Most mothers are aware that their breast feels softer after the baby has fed
well. A well-fed baby will release the breast spontaneously, appear satisfied and
remain content.
O ver the first four days of life, the baby's stools change from black meconium to the
characteristic yellow stool, typical of a baby fed on breastmilk. A stool that is still
changing at 96 hours of life could indicate that further a ention needs to be paid to the
way the mother is feeding her baby. S imilarly, urine output should increase from one
or more wet nappies per day in the first two days of life, to three or more over the next
two days. From the end of the first week onwards, the baby's urine output should have
increased such that there are around six or more wet nappies evident.
A n assessment of milk transfer should be made at each postnatal contact. This
should ideally be done daily for the first week, to reduce the risk of babies losing an
unacceptable amount of weight. A n assessment tool, suitable for use by face-to-face or
telephone contact, has been developed by UN I CEF–UK for this purposeUNICEF–UK
(
2010a).
D ifficulty with a achment is the commonest reason for babies failing to obtain
enough milk. I f the baby is difficult to a ach, because he is sleepy or because the
breast tissue is inelastic, the same principles should apply in this situation as when
the baby and mother are separated by illness or prematurity: namely, to support the
mother in hand expression to encourage the establishment of lactation. I f this is not
accomplished, the mother's lactation will be in arrears of her baby's requirements by
the time he is in need of larger volumes around the 3rd/4th day.
I f the mother is still not able to feed effectively by the end of the first week, it is
important that she expresses her milk, using either her hands or an effective breast
pump, so that her lactation is maintained and her baby is fed. O ngoing help from the
midwife to improve breastfeeding is essential.
Expressing breastmilk
A lthough all women who choose to breastfeed their babies should know how to hand
express milk, routine expression of the breasts should not be part of the normal
management of lactation, even for mothers who have given birth by caesarean section
(Chapman et al 2001). Provided no limitation is placed on either feed frequency or
duration, and the baby is a ached effectively, the volume of milk produced will be in
accordance with the requirements of the baby. This should prevent the occurrence of
problems such as breast engorgement requiring removal of milk by hand/pump.
Expression is appropriate in the following situations, if:
• there is concern about the interval between feeds in the early perinatal period
(expressed colostrum should always be given in preference to formula milk to healthy
term babies)
• there are difficulties in attaching the baby to the breast
• the baby is separated from the mother, due to prematurity or illness
• there is concern about the baby's rate of growth, or the mother's milk supply
(expressing to top up with the mother's own milk may be necessary in the short term
while the cause of the problem is resolved)
• the mother needs to be separated from her baby for periods (occasionally or
regularly), as the baby gets older.
Manual expression of milk
Manual expression has several advantages over mechanical pumping and should be
taught to all mothers. I t is usually the most efficient method of obtaining colostrum.
Some mothers will find hand expressing superior to any breast pump.
Expressing with a breast pump
If it is possible and practical, the mother should be able to experiment with a variety of
breast pumps to discover what will suit her best (Auerbach and Walker 1994) as not all
pumps work well for every woman.
Manually operated pumps
Most manually operated pumps are not efficient enough to allow initiation of full
lactation but they can be useful when expressing is required once lactation is
established. I t is helpful for midwives to explain to mothers that these pumps function
most efficiently if the vacuum phase is considerably longer than the release phase.
Electrically controlled pumps
S ome electrically controlled pumps provide a regular vacuum and release cycle, with
variability in the strength of the suction and others also vary the frequency of the
cycle. D ouble pumping is possible with most models, and this has repeatedly been
shown to be of benefit, either reducing the time for which the mother needs to use the
pump at each session to obtain the available milk (Groh-Wargo et al 1995; Hill et al
1999), or increasing the volume of milk obtained for term babies (Auerbach 1990) and
preterm babies (Jones et al 2001).
How much and how often?
Mothers of preterm babies who begin expressing milk by a pump as soon as possible
after birth and use the pump a minimum of six times per 24 hours, are more likely to
sustain lactation at adequate levels than those who delay expressing or express less
frequently. In a Baby Friendly hospital the mother will be advised to express her milk at
least 8 times in 24 hours, including once at night. The earlier the mother is able to
express good volumes of milk in a 24 hours period, the be er the outlook for
sustaining adequate milk production for her baby. Breast massage (J ones et al 2001)
a n d kangaroo care (see Fig. 30.6, p 626): holding the baby in skin to skin contact
between the mother's breasts (Hill et al 1999) have also been positively associated with
enhanced milk production.
N o time limit should be set for the length of each expressing session. The mother
should be guided by the milk flow, not the clock. Expressing should continue until
milk flow slows, followed by a short break, and each breast should be expressed twice,
either separately (sequential pumping) or together (double pumping). W hen milk flow
slows for the second time, the session should end. Frequent expressing sessions are
more likely to have the desired effect than lengthy, infrequent sessions.
I nadequate milk volume, followed by declining production, is a common problem
for mothers who are expressing their milk for their preterm baby. I n order to prevent
this from happening, the midwife should discuss with the mother the value of early
initiation of expressing, the appropriate use and correct size of equipment and the
importance of the frequency of expression, rather than trying to rescue failing lactation
pharmacologically. I t may also be helpful to show the mother how to express hands
free, using an expressing brassiere to hold the breast shields securely in place. For
examples of hands-free expressing please go to
http://www.phdinparenting.com/blog/2010/9/13/hands-free-pumping-options-for-
breastfeeding-moms.html.
Storage of breastmilk
NICE (2008) advises that expressed milk can be stored for up to:
• 5 days in the main part of a fridge, at 4 °C or lower
• 2 weeks in the freezer compartment of a refrigerator
• 6 months in a domestic freezer, at −18 °C or lower.
Care of the breasts
D aily washing is all that is necessary for breast hygiene. Brassieres may be worn in
order to provide comfortable support and are useful if the breasts leak and breast
pads (or breast shells) are used.
Breast problems
Sore and damaged nipples
The cause is almost always trauma from the baby's mouth and tongue, which results
from incorrect a achment of the baby to the breast. Correcting this will provide
immediate relief from pain and allow rapid healing to take place. Epithelial growth
factor, contained in fresh human milk and saliva, may aid this process.
Resting the nipple enables healing to take place but makes the continuation of
lactation much more complicated because it is necessary to express the milk and to
use some other means of feeding it to the baby. N ipple shields should be used with
caution, and never before the mother has begun to lactate, as the baby is unlikely to
extract colostrum via a shield. They may make feeding less painful, but often they do
not. Their use does not enable the mother to learn how to feed her baby correctly, and
their longer-term use may result in reduced milk transfer from mother to baby. This in
turn may result in mastitis in the mother (reduced milk removal), slow weight gain or
prolonged feeds in the baby (reduced milk transfer), or both. I f mothers choose to use
them, they should be advised to seek help with learning to a ach the baby
comfortably without a nipple shield as soon as practicable (McKechnie and Eglash
2010).
Other causes of soreness
I nfection with Candida albicans (thrush) can occur, although it is not common during
the first week following the baby's birth. S udden development of pain after a period of
trouble-free feeding is suggestive of thrush. The nipple and areola are inflamed and
shiny, and pain typically persists throughout the feed. The baby may show signs of
oral or anal thrush. Both mother and baby should receive concurrent fungicidal
treatment, such as miconazole, and it may take several days for the pain in the nipple
to disappear.
Dermatitis
S ensitivity may develop to topical applications such as creams, ointments or sprays,
including those used to treat thrush.
Anatomical variations
Short nipples
S hort nipples should not cause problems as the baby is able to form a teat from both
the breast and nipple.
Long nipples
Long nipples can lead to poor feeding because although the baby is able to latch on to
the nipple, he is unable to draw any breast tissue into his mouth, due to the length of
the nipple.
Abnormally large nipples
I f the baby is small, his mouth may not be able to get beyond the nipple and onto the
breast. Lactation can be initiated by expressing, by hand or by pump, provided the
nipple fits into the breastshield. A s the baby grows and the breast and nipple become
more protractile, breastfeeding may become possible.
Inverted and flat nipples
I f the nipple is deeply inverted it may be necessary to initiate lactation by expressing
and delay a empting to a ach the baby to the breast until lactation is established and
the breasts have become soft and the breast tissue more elastic.
Difficulties with breastfeeding
Engorgement
This condition occurs around the 3rd or 4th day following the baby's birth. The breasts
become hard, often oedematous, painful and sometimes appear flushed. The mother
may be pyrexial. Engorgement is usually an indication that the baby is not keeping
pace with the stage of lactation. Engorgement may occur if feeds are delayed or
restricted or if the baby is unable to feed efficiently because he is not correctly
attached to the breast.
Management should be aimed at enabling the baby to feed well (Box 34.1). I n severe
cases the only solution will be the gentle use of a pump. This will reduce the tension in
the breast and will not cause excessive milk production. The mother's fluid intake
should not be restricted, as this has no effect on milk production.
Box 34.1
B a bie s who a re difficult t o a a ch
I nelastic breast tissue, overfull or engorged breasts or deeply inverted
nipples may present the baby with more of a challenge.
• If the breast is engorged, pushing away the oedema by gently
manipulating the tissue that lies under the areola may be all that is
required.
• Hand expression, or the use of a breast pump, may relieve fullness to the
point where the baby can draw in the inner tissue to create the necessary
teat from the breast.
• If attachment is still difficult, try asking the mother to lie on her side with
the short edge of a pillow under her ribs to raise the breast off the bed.
The midwife may need to assist the baby in attaching.
• If the midwife is unable to attach the baby to the breast, the mother
should be shown how to hand express and how to give her colostrum to
her baby.
• It may also be necessary to show the mother how to use a breast pump
(hand or electric). However, in the first 24–48 hours colostrum is usually
best expressed by hand.
W hen a achment is difficult, the priorities should be to ensure that the
baby is adequately fed on his mother's milk, and to work on making the
breast tissue more elastic (both of which can be facilitated by hand or
electrical expressing). A aching the baby to the breast directly can come
later.
Deep breast pain
I n most cases, deep breast pain responds to improvement in breastfeeding technique
and is likely to be due to raised intraductal pressure caused by inefficient milk
removal. A lthough it may occur during the feed, it typically occurs afterwards. This
distinguishes it from the sensation of the let-down reflex , which some mothers
experience as a fleeting pain. Very rarely, deep breast pain may be the result of ductal
thrush infection.
Mastitis
I n the majority of cases, mastitis, an inflammation of the breast, is the result of milk
stasis, not infection, although infection may supervene (Thomsen et al 1984). Typically,
one or more adjacent segments of breast tissue are inflamed through milk being
forced into the connective tissue of the breast, and appear as wedge-shaped areas of
redness and swelling. I f milk is forced back into the bloodstream, the woman's pulse
and temperature may rise and in some cases flu-like symptoms, including shivering
a acks or rigors, may occur. The presence or absence of systemic symptoms does not
help to distinguish infectious from non-infectious mastitis (WHO 2000).
Non-infective (acute intramammary) mastitis
N on-infective (acute intramammary) mastitis results from milk stasis and may occur
during the early days of breastfeeding as the result of unresolved engorgement or at
any time due to poor feeding technique when milk from one or more segments of the
breast is not being efficiently drained by the baby. I t occurs much more frequently in
the breast that is opposite the mother's dominant side for holding her baby (I nch and
Fisher 1995). Pressure from fingers or clothing has been blamed for causing the
condition, without any supporting evidence. I t is extremely important that
breastfeeding from the affected breast continues, otherwise milk stasis will increase
further, providing ideal conditions for pathogenic bacteria to replicate. A n infective
condition could then arise, leading to abscess formation if left untreated.
W here supervision is available from the midwife, 12–24 hours could elapse to
ascertain whether the mastitis can be resolved by helping the mother to improve her
feeding technique and encouraging her to allow the baby to complete the first breast
initially. I f supervision is not available or if there is no improvement during the 24
hours period, antibiotics such as cephalexin, flucloxacillin or erythromycin, should be
given prophylactically (WHO 2000; RCM 2002).
Infective mastitis
The main cause of superficial breast infection is damage to the epithelium, allowing
bacteria to enter the underlying tissues. The damage usually results from incorrect
a achment of the baby to the breast, which has caused trauma to the nipple. The
mother therefore requires urgent assistance to improve her feeding technique, as well
as appropriate antibiotics. Multiplication of bacteria may be enhanced by the use of
breast pads or shells. I n spite of antibiotic therapy, abscess formation may occur.
Infection may also enter the breast via the milk ducts if milk stasis remains unresolved
(WHO 2000).
Breast abscess
A fluctuant swelling develops in a previously inflamed area: namely a breast abscess.
Pus may be discharged from the nipple. S imple needle aspiration may be effective, or
incision and drainage may be necessary (D ixon 1988). I t may not be possible for the
baby to feed from the affected breast for a few days, however milk removal should
continue by expression with breastfeeding recommencing as soon as practicable as
this would reduce the chances of further abscess formation (W HO 2000). A sinus that
drains milk may form, but it is likely to heal in time.
Blocked ducts
Lumpy areas in the breast are not uncommon, due to distended glandular tissue. I f
such lumps become very firm and tender and sometimes flushed, they are often
described as blocked ducts. This description carries with it the image of a physical
obstruction within the lumen of the duct. However, this is very rarely the cause of the
symptoms. I t is much more likely that milk drainage has been somewhat uneven due
to less than optimal a achment and that secreted milk is trying to occupy more space
than is actually available, causing the alveoli to distend. Milk may subsequently be
forced out into the connective tissue of the breast where it causes inflammation. The
inflammatory process narrows the lumen of the duct by exerting pressure on it from
the outside as the tissue swells, resulting in mastitis or incipient mastitis. Consequently,
the solution is to improve milk drainage by improved a achment, with possibly milk
expression, and to treat the accompanying pain and inflammation. Massage, often
advocated to clear the imagined blockage, may make ma ers worse, as all it does is
force more milk into the surrounding tissue.
White spots/epithelial overgrowth
Very occasionally, a ductal opening in the tip of the nipple may become obstructed by
epithelial overgrowth. A white blister is evident on the surface of the nipple,
effectively causing a physical obstruction closing off the exit points from one or more
milk-producing sections of the breast. This may sometimes be resolved by the baby
feeding. A lternatively, after the baby has fed and the skin is softened, the blister may
be removed with a clean fingernail, a rough flannel, or a sterile needle. True blockages
of this sort tend to recur, but once the woman understands how to deal with them, the
progression to mastitis can be avoided.
Feeding difficulties due to the baby
Colic in the breastfed baby
Figure 34.16 represents diagrammatically the causes and effects of secondary lactose
intolerance – or ‘colic’ – in the breastfed baby.
A lthough not all abdominal discomfort is due to poor a achment, symptoms of
‘colic’ in a breastfed baby, such as abdominal discomfort, excessive flatus/wind,
explosive stools, light green stools, may often be explained in terms of the
foremilk/hindmilk mixture that the baby receives during the course of the feed/day.
I f the baby is not well a ached, he may not be able to access the fat-rich milk as the
feed volume diminishes. S ince it is the fat that provides most of the calories, as well as
slowing gastric emptying time, the poorly a ached baby will be hungry again sooner
than he would be if he had been well a ached. O nce again (unless the mother makes
changes to the attachment) the baby will receive another ‘low fat’ feed.
O ver 24 hours the baby will have consumed a much greater volume of milk than he
would have done if he had been be er a ached. Since the concentration of lactose in milk
is fairly constant, he will have also received much more lactose than otherwise. This
excess lactose in the gut may transitorily exceed the amount of the enzyme lactase
which the baby's intestinal brush border is able to generate. The baby thus exhibits
the signs of lactose intolerance/lactase deficiency. The accumulated undigested lactose
creates an osmotic gradient that draws water into the bowel. A dded to which the
bacteria in the baby's gut are provided with more substrate than usual, which they
eagerly a ack as an energy source, producing large quantities of gas in the process
(mostly carbon dioxide and methane). D istension of the gut by both fluid and gas
produces pain (cramping) and looser stools. These are often green in colour due to the
presence of bile that has not been re-absorbed. D epending on the extent of the lactase
deficiency and the quantity of lactose ingested, symptoms can range from mild
abdominal discomfort to severe dehydrating diarrhoea.
(A mong the pharmaceutical industry's responses has been the production of ‘over
the counter’ simethicone and lactase, which distraught mothers can buy. N ot only are
there no good quality trials demonstrating their effectiveness in breastfed babies,
there is a much simpler solution than trying to fix the symptoms – which is to address
the cause – and improve attachment.)
I f the baby who is not well a ached can consume sufficient milk in each 24-hour
period to get the calories he needs, he will grow. But he may have to feed very
frequently to achieve this. Frequent feeds may in turn increase his mother's milk
supply, giving rise to the frustrating scenario of a mother with an abundant supply, yet
a baby who is feeding ‘round the clock’. I f the baby simply cannot hold enough milk,
the situation above will be compounded by a baby who is also failing to grow well.
Cleft lip
Provided that the palate is intact, the presence of a cleft in the lip should not interfere
with breastfeeding because the vacuum that is necessary to enable the baby to a ach
to the breast is created between the tongue and the hard palate, not the breast and the
lips.
Cleft palate
Because of the cleft, the baby is unable to create a vacuum and form a teat out of the
breast and nipple. There is no reason why the mother should be discouraged from
pu ing the baby to the breast, for comfort, pleasure or food, provided that she is
aware of the above and appreciates that it is likely that she will need to give her baby
her expressed milk as well. A variety of measures are available to support feeding in
infants thus affected until surgery can take place (around 6 months of age) but li le to
suggest that many of these babies will successfully breastfeed (Reid 2004; Garcez and
Guigliani 2005).
Tongue tie (Ankyloglossia)
I f the baby cannot extend his tongue over his lower gum he is unlikely to be able to
draw the breast deeply into his mouth to feed effectively (J ohnson 2006). This may be
due to the tongue being short or because the frenulum, which is the whitish strip of
tissue a aching the tongue to the floor of the mouth, is too tight or not stretchy
enough. A s the baby tries to lifts his tongue, the tip may sometimes become heart-
shaped as the frenulum pulls on it.
I ncreasingly it is argued that more emphasis should be placed on tongue function
rather than simply its appearance as tongue movement is more complex than simply
the ability to protrude it beyond the gum ridge. Many practitioners maintain that
when a ention to a achment does not resolve a breastfeeding problem, a full
assessment should be carried out, observing any impairment of activities that require
a functional tongue (Hazelbaker 2010).
The N ational I nstitute for Health and Clinical Excellence recommended that the
surgical release of the frenulum (frenotomy) was safe, only taking a few seconds to
perform in a young baby (NICE 2005). The procedure is usually bloodless and painless
and its practice is further supported by evidence from clinical trials (D ollberg et al
2006; Hogan et al 2005) and ultrasound studies (Ramsay 2005; Geddes et al 2008).
Blocked nose
Babies normally breathe through their noses. O bstruction causes great difficulty with
feeding because they have to interrupt the process in order to breathe. Blockages
caused by mucus may be relieved with a twist of damp co on wool, or by instilling
drops of normal saline before a feed (Bollag et al 1984).
Down syndrome
Babies who have D own syndrome can be successfully breastfed, although extra help
and encouragement may be necessary initially (Chapter 32).
Prematurity
Preterm infants who have developed sucking and swallowing reflexes may successfully
breastfeed, which is considered to be less tiring than taking a feed by bo le (Meier
and Cranston-Anderson 1987). However, if the reflexes are not strongly developed, the
baby may tire before the feed is complete and complementary feeding by nasogastric
tube may be necessary.
Babies who are too immature to breastfeed may be able to cup-feed, as an
alternative to being tube-fed (Lang et al 1994). Less mature babies who are unable to
suck or swallow will be dependent on receiving nutrition via artificial methods such as
tube-feeding and intravenous alimentation.
Illness or surgery
I n general, babies recover quickly following illness or surgery, but if they have never
been to the breast, or if feeding has been interrupted for a long period, the mother will
require skilled help from the midwife to initiate or re-establish feeding.
Contraindications to breastfeeding
Breastfeeding may have to be suspended temporarily following the administration of
certain drugs, e.g. chloramphenicol, or following diagnostic techniques using
radiopharmaceuticals. Most regions have drug centres/hospital pharmacy information
services where advice may be sought about the safety of drugs for lactating women.
Carcinoma
I f the mother has carcinoma, the cytotoxic treatment she receives will make it
impossible to breastfeed without causing harm to the baby. However, if she wishes to,
she could express and discard her milk for the duration of the treatment and resume
breastfeeding later. I f she has had a mastectomy, she may feed successfully from the
other breast. The woman may also be able to breastfeed following a lumpectomy for
carcinoma, but it is advisable to seek advice from her surgeon.
Breast surgery
N either breast reduction nor augmentation is an inevitable contraindication to
breastfeeding, but much depends on the techniques used. W here possible, advice
should be sought from the surgeon. I f the nipple has been displaced, the duct system
may not be patent. N ickell and S kelton (2005) recommend that if surgery is proposed
for a woman who wishes to breastfeed in the future, it may be possible to alter the
surgery to preserve the ductal system. Ultimately, the only way to determine if the
breast will function effectively is to test it by encouraging the baby to go to the breast.
Breast injury
I njuries caused by scalding to the chest in childhood may cause such severe scarring
that breastfeeding is impossible. Burns or other accidents may also cause serious
damage.
One breast only
I t is perfectly possible to feed a baby effectively using just one breast. I f the mother
has only one functioning breast, she should be reassured that each breast works
independently of the other. I f the baby is offered only one breast, that breast will
make enough milk to feed that individual baby. There are documented cases of
women feeding two babies with just one breast (Nicolls 1997).
Human immunodeficiency virus (HIV) infection
Human immunodeficiency virus (HI V) may be transmi ed in breastmilk. I n
developed countries, where formula milk feeding is relatively safe, the mother may be
advised not to breastfeed if she is HI V-positive (C hapter 13). I n countries where
formula feeding is a significant cause of infant mortality, exclusive breastfeeding for
the first 6 months may be the safer option (Coutsoudis et al 1999; Coovadia et al 2007;
WHO et al 2010).
Cessation of lactation
Suppression of lactation
I f a mother chooses not to breastfeed, or if she has a late miscarriage or stillbirth,
lactation will still commence. The woman may experience discomfort for a day or two,
but if unstimulated the breasts will naturally cease to produce milk. Very rarely, severe
discomfort with engorgement occurs. Expressing small amounts of milk once or twice
can afford great relief without interfering with the rapid regression of the condition.
The mother will be more comfortable if her breasts are supported, but it is doubtful if
binding the breasts contributes anything towards suppression (Swift and Janke 2003).
There is no basis on which to advise the mother to restrict her fluid intake or to seek
a prescription for a diuretic, which will be equally ineffective (Hodge 1967) . These
measures merely add to the woman's discomfort by making her thirsty.
Pharmacological suppression of lactation with dopamine receptor agonists such as
bromocriptine and cabergoline is effective but is not recommended for routine use.
Bromocriptine and cabergoline are currently licensed in the UK, although
bromocriptine had its licence withdrawn in the United S tates of A merica (US A) some
time ago.
Discontinuation of breastfeeding
D iscontinuing lactation abruptly once breastfeeding has become established may
cause serious problems for the woman, leading to engorgement, mastitis or even a
breast abscess. The woman should be encouraged to mimic normal weaning by
expressing her breasts, reducing the frequency over several days or possibly weeks.
The gradual reduction in the volume of milk removed from the breasts results in a
corresponding diminution in the production of milk. Eventually the woman should be
encouraged to express only if she feels uncomfortable. Pharmacological suppression
using cabergoline might be appropriate following the death of a baby.
Returning to work
I f the breastfeeding mother returns to work, her baby will require feeding in her
absence. I f the woman wishes her baby to continue taking breastmilk, she will need to
express her milk in advance. However, if the woman finds it difficult to express her
milk at work, her baby could receive a formula feed (or solid food, if over 6 months),
while she is away, but continue breastfeeding at all other times. Returning to work
does not mean that breastfeeding has to be terminated.
Weaning from the breast
W hen the mother or the baby decides to stop breastfeeding, feeds should be tailed off
gradually. Breastfeeds may be omi ed, one at a time, and spaced further apart.
A dding supplementary foods should not begin until about 6 months of age. I f the
mother uses solid food to give the baby tasters and the experience of different textures
before weaning, these should be given after the breastfeed. S olid foods given to the
baby before the breastfeed (weaning) will result in them taking less milk from the
breast and less milk being produced. Allowing the baby to lead the process of weaning
(Rapley 2012) may make the transition much easier.
Complementary and supplementary feeds
Complementary feeds or top-ups are feeds given to the baby after a breastfeed.
Complementary feeds of breastmilk substitutes (formula milk) should be given as a
last resort, not as an alternative to helping the mother with breastfeeding or
expressing milk. Exposure to non-human milk proteins has been implicated in the
development of type 1 diabetes, eczema and wheeze/asthma (Renfrew et al 2012). Even
a single exposure can sensitize susceptible infants (Host 1991).
The 2010 I nfant Feeding S urvey M ( cA ndrew et al 2012) found that 31% of babies
born in UK hospitals received breastmilk substitutes while in hospital. The mothers of
these babies were three times more likely to have given up breastfeeding by the time
their baby was a week old, in comparison with mothers whose babies received only
breastmilk.
A bout 10% of newborns are at risk of hypoglycaemia (Chapter 33), and may thus
need a higher calorific intake straight from birth than their mothers can provide.
W here possible this should be the mother's expressed colostrum or human milk
obtained from a human milk bank.
Babies who are well but sleepy (Box 34.2), jaundiced (Chapter 33), unse led (Box
34.3), or difficult to a ach (see Box 34.1 above), should be given their mother's own
expressed milk if necessary, in addition to being offered the breast.
Box 34.2
‘S le e py’ ba bie s
Provided that the baby is otherwise well, which will be determined by
examining the baby from time to time, there is no evidence that long
intervals between feeds have any adverse affect. A s few as three feeds in
the first 24 hours of life is within the normal range.
• The baby should remain close to the mother, in accordance with
UNICEF–UK (2012b guidelines). The mother will thus be able to respond
immediately to her baby's feeding cues.
• The baby could be roused at intervals, possibly by changing the nappy,
and being offered the breast.
• The baby could be undressed down to the nappy and placed in skin
contact with the mother and offered the breast.
• The mother could be shown how to hand express some colostrum, and
how to give this to the baby.
• It is unnecessary to measure the baby's blood glucose levels (see Chapter
33).
Box 34.3
I f t he ba by is unse le d
A n unse led baby of any age that is crying again soon after he has been fed
may not have been well attached.
• Observe what the mother is doing and, if necessary, guide her or help her
directly.
• If the attachment is good, then the baby may be reacting to being
removed from the closeness of the mother's body. If the mother needs to
sleep, suggest that she feeds lying down and help her if necessary.
However, it is imperative that the baby's safety is maintained should the
feed take place in the bed.
• The mother might try to express some colostrum/milk to give to the baby
if she is concerned that the baby has not received all that he can from the
breast
• Some babies will appear unsettled even if they have fed well at the breast.
The baby may be uncomfortable. The act of changing the nappy may help;
so may wrapping the baby comfortably but securely and providing
rhythmic motion, such as walking or holding the baby over the shoulder
or over the forearm, both of which apply gentle pressure to the baby's
abdomen to help settle him down
• Show the mother what you are doing, so that she learns appropriate
coping strategies from you.
• If you give the baby formula or a dummy to settle him, that is what the
mother will do when she goes home
• Do not offer to remove the baby. Separating mother and baby, particularly
removing the baby at night in the mistaken belief that the mother will
benefit if she does not wake to breastfeed her baby at night, is strongly
correlated with reduced breastfeeding success (WHO, 1998).
• If the mother asks you to, and you agree to take the baby away to settle,
return the baby to her when he wakes again to be fed.
I f complementary feeds are clinically indicated and the mother cannot express
sufficiently, donor milk from a human milk bank could be used. D onors are
serologically tested for HIV and other conditions.
I f the baby is very young, additional feeds should be given by oral syringe or cup,
rather than by bo le. A n oral syringe (or dropper) will reduce wastage and the use of a
cup would allow the baby to remain more in control of their intake. I f the difficulty
persists, for example with a achment, the mother may find it quicker and more
efficient to give her expressed milk to the baby by bo le. There is no evidence that the
baby will subsequently refuse the breast in these circumstances (Brown et al 1999;
Howard et al 2003; Flint et al 2007).
Supplementary feeds are feeds given in place of a breastfeed. There is no justification
for their use except in exceptional circumstances, such as severe illness or
unconsciousness. This is because each breastfeed that is missed by the baby interferes
with the establishment of lactation and affects the mother's confidence in being able
to successfully breastfeed her baby.
Human milk banking
Research over the past couple of decades has demonstrated the effectiveness of
pasteurization as a means of destroying HI V (E glin and Wilkinson 1987) and the
importance of human milk in preventing necrotizing enterocolitis (NEC) (Q uigley et al
2008). This resulted in the formation of the UK A ssociation for Milk Banking (UKA MB
in 1998 and re-establishing human milk banks.
Banked human milk is used predominantly for preterm and sick babies.
O ccasionally, if there is sufficient, it is used for term babies whose mothers are
temporarily unable to meet their babies' needs with their own expressed milk.
Mothers who are offered donated milk for their babies must have sufficient
information about the collection and screening of human milk to enable them to make
an informed choice whether or not to accept it (see Box 34.4).
Box 34.4
D ona t e d bre a st m ilk
I f you are offering a mother donated human milk for her baby for any
reason, she might find the information below helpful in deciding whether
to accept it.
• All human milk donors meet the same criteria as blood donors; they are
in a low risk group to start with and give consent to an HIV blood test
• All human milk donors sign a form to that effect and all have their blood
tested.
• Almost all donors are currently feeding their own baby while donating.
• No donated milk is used for any baby until the results of the donor's
blood test have been received.
• All donated milk is collected in sterilized bottles, kept in the fridge and
frozen within 24 hours of expression.
• When it arrives, still frozen, at the milk bank, it is thawed, a small sample
taken for bacteriological screening and the rest is pasteurized.
• After pasteurization another small sample is taken (for post-
pasteurization bacteriological screening) and the rest refrozen in a
holding freezer.
• Only when the results of both samples have been received is the milk
transferred to the freezer from which it can be used for preterm and term
babies.
• Donors are not paid for the milk they donate: it is freely given! Quite
often, mothers choose to donate milk because their own babies were
themselves helped in this way by the generosity of other mothers.
Choosing breast or formula milk
A lthough the majority of women who choose to breastfeed have made this decision
very early on, some may not make a final decision until after giving birth. The subject
of infant feeding should be part of an ongoing conversation that the woman has with
her midwife as her pregancy progresses. D uring these conversations the midwife
should share the value of skin contact for all mothers and babies, explore what parents
already know about breastfeeding and help them to appreciate the value of
breastfeeding as protection, comfort and food so they can make an informed choice
(UNICEF–UK 2012b).
O bserving a baby being breastfed can strongly influence the decision to breastfeed
either positively or negatively, depending on the context (Hoddino and Pill 1999).
This is of particular relevance for women for whom theoretical knowledge may have
less power than embodied knowledge. Peer group support can influence both
initiation and continuation of breastfeeding (Fairbank et al 2000) and introducing
pregnant women to other mothers who are breastfeeding young babies may also be
helpful. This is now done in many ‘Baby Cafés’ throughout the UK.
Time should be taken during the antenatal period to talk briefly about the day-to-
day progress and management of early breastfeeding. The woman should be aware
that:
• Breastfeeding is a learned skill.
• It should not hurt.
• She does not need to be taught the major details of management until after the baby
is born.
The midwife's responsibility to the woman is to ensure that her choice is fully
informed, rather than to persuade her to breastfeed. This cannot be achieved if the
midwife withholds information from her. The nutritional and immunological
consequences of not breastfeeding are seen in population studies, and are to do with
relative risks. I t is not possible to narrow the risk down to the individual.
N evertheless, all pregnant women should be made aware that, compared with a fully
breastfed baby, a baby fed on formula milk from birth is:
• five times more likely to be hospitalized with gastroenteritis (within the first 3
months of life)
• five times more likely to suffer from urine infections (within the first 6 months of
life)
• twice as likely to suffer from chest infections (within the first 7 years of life)
• twice as likely to suffer from ear infections (within the 1st year of life)
• twice as likely to develop atopic disease where there is a family history
• up to 20 times more likely to develop necrotizing enterocolitis if born prematurely.
A dditionally, the pregnant woman should know that she may increase her own risk
of postnatal depression, premenopausal breast cancer, ovarian cancer and
osteoporosis if she does not breastfeed (UNICEF and Department of Health 2012).
Feeding with formula milk
Most breastmilk substitutes (infant formulae) are modified cow's milk. The minimum
and maximum permi ed levels of named ingredients, and named prohibited
ingredients in all cow's milk-based (and soya infant) formulae have to meet strict
criteria (I nfant Formula and Follow-on Formula Regulations 2007 ). However,
considerable variations in composition exist within the legally permitted ranges.
The two main components are skimmed milk, which is a by-product of bu er
manufacture, and whey, which is a by-product of cheese manufacture. Breastmilk
substitutes may contain fats from any source, animal or vegetable, except from sesame
and co on, provided that they do not contain >8% trans isomers of fa y acids. The fat
source may not always be apparent from reading the label: for example oleo is beef fat
and would be unacceptable to Hindus and vegetarians, and oils of vegetable origin may
have come from marine algae. Formula milks may also contain soya protein,
maltodextrin, dried glucose syrup and gelatinized and pre-cooked starch.
Types of formula milk
There are two main types of formula milk: whey-dominant and casein-dominant. Both
can be used from birth. There is a comprehensive and quarterly updated report for
health professionals called I nfant M ilks in the U K (Crawley and Westland 2013)
produced by an independent charity, First Steps Nutrition Trust.
Whey-dominant formulae
I n these, a small amount of skimmed milk is combined with demineralized whey. The
ratio of proteins in the formulae approximates to the ratio of whey to casein found in
human milk (60 : 40). These feeds are more easily digested than the casein-dominant
formulae, which have an effect on gastric emptying times, with feeding pa erns that
more closely resemble those of breastfed babies.
Casein-dominant formulae
A lthough these formulae are also promoted as suitable for use from birth and are
aimed at mothers whose babies are hungrier, their use is not recommended for young
babies. W hilst the macronutrient proportions (fat, carbohydrate, protein, etc.) are the
same as in whey-dominant formulae, more of the protein is in the form of casein (20 :
80). The higher casein content causes large, relatively indigestible curds to form in the
baby's stomach, intending to make them feel full for longer. There is no evidence that
babies se le be er or sleep longer if given these milks ( Tai and S choley 1989;
Thorkelsson et al 1994).
Milks for babies intolerant of standard formulae
Predicting which babies will be prone to allergies is an inexact science. I t is estimated
that the likelihood of a baby being predisposed to allergy is about 20–35% if one
parent is affected, 40–60% if both parents are affected and 50–70% if both parents have
the same allergy (Brostoff and Gamlin 1998).
Hydrolysate formula
Hydrolysate formula is made of cow's milk, cornstarch and other foods, treated with
digestive enzymes so that the milk proteins are partially broken down. I t has been
thought in the past that these alternatives carry less risk of allergy than standard
formulae.
S ome of these (prescription-only) hydrolysates are intended to treat an existing
allergy, and others are designed for preventative use in babies who are at high risk of
developing cow's milk protein allergy and who are not breastfeeding (Brostoff and
Gamlin 1998). N ot only are these substances considerably more expensive than either
standard or soya-based formula, N I CE (2008) guidance now maintains that there is
insufficient evidence that infant formula based on partially or extensively hydrolysed
cow's milk protein helps prevent allergies.
Whey hydrolysates
These formulae are made from the whey of cow's milk (rather than from whole milk)
and have been thought to be potentially more useful for highly allergenic babies.
Amino-acid-based formula, or elemental formula
A mino-acid-based formula, or elemental formula has a completely synthetic protein
base, providing essential and non-essential amino acids, together with fat,
maltodextrin, vitamins, minerals and trace elements. This type of formula milk is very
expensive.
Soya-based formula
S oya-based formula was developed as a response to the emergence of cow's milk
protein intolerance in babies fed on formula milk. However, there has been mounting
evidence that soya-based formula's high phytoestrogen content could pose a risk to
the long-term reproductive health of infants (Martyn 1999; Minchin 2001).
Consequently soya-based formula milk should be used only in exceptional
circumstances to ensure adequate nutrition, for example with babies of vegan parents
who are not breastfeeding or babies who are unable to tolerate alternatives, such as
amino-acid formulae (Crawley and Westland 2013).
Many babies who are intolerant of cow's milk are also intolerant of soya. Early soya
formula feeding runs the risk of inducing soya protein intolerance in the child and
soya protein is much harder to avoid in the weaning diet than dairy products.
Goat's milk formula
T h e European Food S tandards A gency (EFS A) (2006)concluded that there were
insufficient data to establish the suitability of goat's milk protein as a protein source in
infant formula, and since March 2007 infant milks based on goat's milk were no longer
sold in the UK. However, in 2012, EFS A revised their conclusion on the suitability o
goat's milk as a protein source for infant and follow-on formula milks and the
expectation was that the I nfant Formula and Follow-on Formula (England) Regulations
(2007) would be changed sometime in 2013 to allow goat's milk-based infant milks
(Crawley and Westland 2013). However, at the time of going to press these changes
have yet to be made.
Choosing a breastmilk substitute
A lthough not always enforced, it is an offence under UK law to sell any infant formula
as being suitable from birth unless it meets the criteria set out in the I nfant Formula
and Follow-on Formula Regulations (2007). D espite claims made by formula
manufacturers, there is no obvious scientific basis on which to recommend one brand
over another.
I t is not necessary for the mother to stick to one brand, and if she finds that one
formula milk does not suit her baby she could try an alternative brand. This has been
made easier by the availability of ready-to-feed sachets or cartons, with which mothers
can experiment without having to buy large quantities of formula milk. Babies with
underlying metabolic disorders, such as galactosaemia or phenylketonuria, however,
require the appropriate, prescribable breastmilk substitute.
A s formula milks are highly processed, factory-produced products, there inevitably
can arise inadvertent errors, such as too much or too li le of an ingredient, accidental
contamination, incorrect labelling and foreign bodies. I t is therefore imperative that
mothers are advised to inspect the contents of the tin or packet before use and if it
looks or smells strange, return it to the seller.
Preparation of an artificial feed
The introduction of ready-to-feed formula in hospital may save staff time, but it
reduces the likelihood that the mother who chooses to feed her baby with formula
milk will have been shown how to prepare a bo le feed safely before she goes home
(Kaufmann 1999). I t is now required, in Baby Friendly-accredited hospitals that all
mothers intending to formula-feed their baby are given the information they need to
do so in a way that reduces the risk to the baby (UNICEF–UK 2012b).
A ll powdered formula feed available in the UK is now reconstituted using one
scoopful (the scoop being provided with the powder) to 30 ml of cooled boiled water.
Clear instructions about the volumes of powder and water are also printed on the
container. Many of the major UK manufacturers of formula milk now produce ready-
to-feed cartons, reducing the risk of over- or under-concentration, but precluding
universal use through higher cost. A nother advantage of ready-to-feed formula is that
the contents are sterile whereas powdered milk, in tins or packets, is not.
I n response to growing concerns about bacterial contaminants in these powders, the
W HO produced guidelines on the safe preparation, storage and handling of powdered
infant formula (WHO 2007), and the Food S tandards A gency (FS A) and D epartment of
Health subsequently changed their recommendations in relation to reconstitution.
A nyone making up feeds from powder is advised to make each feed just before it is
needed, using water that has boiled and cooled to 70 °C, adding the powder, allowing
the milk to cool and giving the feed straight away. A ny remaining milk should be
discarded (DH 2012).
The water supply
I t is essential that the water used is free from bacterial contamination and any harmful
chemicals. I t is generally assumed in the UK that boiled tap water will meet these
criteria, but from time to time this is shown not to be the case. I f bo led water is used,
a still, non-mineralized variety suitable for babies must be chosen and it should be
boiled as usual. Softened water is usually unsuitable.
Feeding equipment
Concern over the nitrosamine content of rubber teats and dummies was addressed in
the EU in 1993, and since 1995, teats and dummies that do not comply with the 1993
directive (EFS A 1993) have been prohibited. However teats that are frequently boiled
can quickly become spongy and swollen. The alternative, silicone teats, have been
known to split with repeated use. Mothers should be advised to check teats regularly
for signs of damage and discard them if in doubt.
N o bo le teat is like a breast. Real-time ultrasound measurements of infants during
sucking using different types of teats were made by researchers (N owak et al 1994) to
determine the percentage of lengthening, lateral compression and fla ening of the
teats. Comparison with data obtained from studies using breastfed infants showed
none of the teats lengthened like the human nipple. Scheel et al (2005) investigated the
relative merits of three different types of teats. The rate of milk transfer for the
preterm babies studied was the primary outcome measure. S uction amplitude and
duration of the generated negative intraoral suction pressure were also measured. N o
type of teat had any advantage over any other. The mother should feel free to
experiment, and use the type of teat that seems to suit her baby. I t may be easier for
the baby to use a simple soft long teat than industry-labelled orthodontic teats
(Kassing 2002).
Feeding bo les must also meet the UK standard. This means they will be made of
food-grade plastic and have relatively smooth interiors. Crevices and grooves in a
bo le make cleaning difficult. Pa erned or decorated bo les make it less easy to see
whether the bottle is clean.
Sterilization of feeding equipment
Effective cleaning of all utensils used should be demonstrated to the mother and
methods of sterilization discussed. The most important prerequisite is that all
equipment is thoroughly washed in hot, soapy water and well rinsed before
proceeding further. I f boiling is to be used, full immersion is essential and the
contents must be boiled for 10 minutes. I f cold sterilization using a hypochlorite
solution is the method of choice, the utensils must be fully immersed in the solution
for the recommended time. The manufacturer's advice must be followed when rinsing
items removed from the solution. I f the item is to be rinsed, previously boiled water
should be used and not water directly from the tap. S team and microwave sterilization
are also possible, but the mother should check that her equipment can withstand such
methods.
Bottle teats
The size of the hole in the teat causes much anxiety to mothers. I t is probably a good
idea to have several teats with holes of different sizes so that the mother can
experiment as necessary. To test the hole size, turn the bo le upside down and the milk
should drip at a rate of about one drop per second.
Feeding the baby with the bottle
The baby must never be left una ended while feeding from a bo le and mothers
should be warned about the dangers of bo le propping . The mother should try to
simulate breastfeeding conditions for the baby by holding the baby close, maintaining
eye-to-eye contact and allowing the baby to determine his intake. The baby should be
held fairly upright, with his head supported in a comfortable, neutral position.
The innate skills a baby has for breastfeeding should also be used when feeding
from a bo le. The baby's lips should be touched to elicit the mouth to open wide and
the teat should follow the line of the baby's tongue, so that the baby uses the teat
effectively. The bo le should be held horizontal to the ground, tilted just enough to
ensure the baby is taking milk, not air, through the teat (UNICEF–UK 2010b).
W hen correctly prepared, modern formula milks do not cause hypernatraemia as
did the older types. There is therefore no need to give the baby extra water.
The stools and vomit of a baby fed on formula milk have an unpleasant sour smell.
The stools tend to be more formed than those of a breastfed baby and, unlike a
breastfed baby, there is a real risk that the artificially fed baby may become
constipated.
Healthy Start (and the Welfare Food Scheme)
I n 1940 the Welfare Food S cheme was established in the UK, providing tokens to
families on low incomes to be exchanged for liquid milk or breastmilk substitutes.
This scheme was replaced, in N ovember 2006, by the H ealthy Start I nitiative. This
scheme broadened the nutritional base of the Welfare Food S cheme to allow fruit and
vegetables as well as liquid milk or breastmilk substitutes to be obtained through the
exchange of fixed value vouchers at a range of food and supermarket outlets. Those
eligible to receive the vouchers include:
• Pregnant women and families with children under the age of 4 years who receive:
▪ Income Support
▪ Income-based Jobseeker's Allowance or
▪ Child Tax Credit (but not Working Tax Credit), with an annual family income of
≤£16 190 a year 2013/2014)
• All pregnant women under the age of 18, whether or not they are receiving benefits
or tax credits.
Those eligible for vouchers are also entitled to free vitamin supplements for
themselves, and for their children from 6 months until their 4th birthday.
Midwives and the International Code of Marketing of
Breastmilk Substitutes
I n 1981, the combined forces of W HO and UN I CEF produced a marketing codeWHO (
1981), which was adopted at the 34th W orld Health A ssembly. The code has major
implications for the work of midwives. A lthough it is at present a voluntary code in
most countries, some countries now have the code enshrined in law.
Recommendations include:
• No advertising or promotion in hospitals, shops or to the general public (this
includes posters and advertisements in mother-and-baby books).
• Not giving free samples of breastmilk substitutes to mothers.
• No free gifts relating to products within the scope of the code to be given to mothers
(including discount coupons or special offers).
• No financial or material gifts to health workers for the purpose of promoting
products, nor free or subsidized supplies to hospitals or maternity wards.
• Information provided by manufacturers to health workers should include only
scientific and factual material, and not create or imply a belief that bottle-feeding is
equivalent or superior to breastfeeding.
• Health workers should encourage and protect breastfeeding.
The code does not prevent mothers from feeding their babies with infant formula,
but rather seeks to contribute to safe, adequate nutrition for babies and to promote
and protect breastfeeding.
The baby friendly hospital initiative
The Baby Friendly Hospital I nitiative (BFI ) was an initiative launched worldwide in
1991 (and in the UK in 1994) by W HO and UN I CEF to encourage hospitals to promot
practices supportive of breastfeeding. I t was focused around the 10 steps to successful
breastfeeding (Box 34.5), with which all hospitals who wish to achieve Baby Friendly
status must comply (WHO/UNICEF 1989). Evidence for the 10 steps is contained in the
W HO /UN I CEF document of the same nameVallenas ( and S avage 1998). This has
subsequently been extended to community-based facilities, neonatal units and
university training programmes for midwifery and health visiting, all of which can be
BFI -accredited in their own right. I n addition, all accredited Baby Friendly facilities
must fully implement the I nternational Code on the Marketing of Breastmilk
Substitutes.
Box 34.5
T he 1 0 st e ps t o succe ssful bre a st fe e ding
1. Have a written breastfeeding policy that is routinely communicated to
all healthcare staff.
2. Train all healthcare staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding soon after birth.
5. Show mothers how to breastfeed and how to maintain lactation even if
they should be separated from their infants.
6. Give newborn infants no food or drink other than breastmilk, unless
medically indicated.
7. Practice rooming-in: allow mothers and infants to remain together 24
hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or dummies to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from hospital or clinic.
WHO/UNICEF 1989
Mothers should expect a certain standard of care from a Baby Friendly hospital
(UNICEF–UK 2011c):
When pregnant:
• To have a full discussion about caring for and feeding their baby, including the
benefits of breastfeeding, so that they have all the facts to make an informed
choice.
When the baby is born:
• To be given their baby to hold against their skin straight after they are born, for
as long as they want
• To have a midwife offer them help to start breastfeeding as soon as possible after
the baby is born
• To have their baby stay with them at all times.
If they decide to breastfeed:
• To be shown how to hold the baby and how to help him latch on – making sure
the baby gets enough milk and feeding is not painful
• To be given accurate and consistent advice about how to breastfeed and to make
enough milk for the baby
• To be shown how to express milk by hand
• To receive information about how to get more support for breastfeeding, should
they need it, once they leave hospital
• That the baby will not be given water or artificial baby milk, unless this is needed
for a medical reason.
A mother can expect that staff will support her if she decides that she wants to care
for her baby differently or she does not want the information offered. I f she decides to
feed her baby with formula milk, she can expect to be asked if she wants to be shown
how to make up a bottle feed safely and correctly.
The N ational I nstitute for Health and Clinical Excellence N ( I CE 2006a)
recommended that all maternity care providers should implement an externally
evaluated, structured programme encouraging breastfeeding, using the BFI as a
minimum standard. Thus all such healthcare providers should either implement N I CE
guidance or perform a risk assessment if they reject it (that is, placed on a risk
register). Rejection on the grounds of cost, which has often been cited as a reason for
not implementing BFI in the past, is unlikely to be acceptable, as N I CE economists
have documented the fact that implementation would be cost-effective (N I CE 2006b;
UNICEF–UK 2012a).
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Further reading
Hale T, Hartmann P. Hale and Hartmann's textbook of human lactation. Hale
Publishing: Amarillo TX; 2007.
A multi-author textbook, in six sections: anatomy and biochemistry, immunobiology,
management of the infant, management of the mother, maternal and infant nutrition
and medications..
Hall Moran V. Maternal and infant nutrition and nurture: controversies and
challenges. 2nd edn. Quay Books: London; 2012.
This multi-author book uses a sociobiological perspective to examine the complex
interaction between political, sociocultural and biological factors in food and health in
relation to maternal and infant nutrition..
Inch S, Fisher C. Breast-feeding: into the 21st century. [NT clinical monographs, No.
32] Emap Healthcare: London; 1999 www.amazon.ca/dp/190249976X.
A concise but wide-ranging review of the importance of breastfeeding, the difficulties
facing midwives who want to help breastfeeding women and the ways in which these
might be overcome..
Infant Formula and Follow-on Formula Regulations. Stationery Office: London;
1995 www.legislation.gov.uk/uksi/2007/3521/contents/made.
This is the UK government's response to the European Directive 1991 (91/321/EEC OJ
No. L175, 4.7.91), which sought to persuade all EU countries to adopt the
International Code of Marketing of Breastmilk Substitutes. It still falls short of the
code in several important respects, notably in relation to advertising..
Palmer G. The politics of breast-feeding. 3rd edn. Pinter and Martin: London; 2009.
This book links biology and politics (sexual, economic and environmental) in an
exploration of the consequences of women's changing role in society and the
acceleration of the Industrial Revolution, which created the demand for ‘artificial
milks’..
Renfrew MJ, Fisher C, Arms S. Breastfeeding: how to breastfeed your baby. 3rd edn.
Celestial Arts: Berkeley, CA; 2004.
Taking up where texts addressed primarily to health workers leave off, the authors
blend wisdom, experience, idealism and learning to produce a clear, basic
breastfeeding guide that is focused primarily at mothers..
World Health Organization (WHO)/UNICEF. International Code of Marketing of
Breast Milk Substitutes. [Online. Available at]
1981 www.babymilkaction.org/regs/thecode.html.
This was adopted by a resolution (WHA34.22) of the World Health Assembly in 1981.
A copy of the code can also be obtained from Baby Milk Action (see Useful Websites
and Contact Details, below)..
World Health Organization (WHO). Protecting, promoting and supporting breast-
feeding: the special role of maternity services. A Joint WHO/UNICEF Statement.
WHO: Geneva; 1989.
This is the document that first set out the 10 steps for successful breastfeeding, which
formed the basis of the global Baby Friendly Hospital Initiative, and makes
recommendations concerning the structure and function of (maternity) healthcare
services..
Useful websites and contact details
Association of Breastfeeding Mothers. www.abm.me.uk.
Helpline: tel 0300 330 5453.
Baby Milk Action. www.babymilkaction.org.
34 Trumpington Street, Cambridge CB2 1QY. Tel 01223 464420.
Baby Feeding Law Group. www.babyfeedinglawgroup.org.uk/.
The Baby Feeding Law Group is made up of leading UK health professional and mother
support organizations working to strengthen UK baby feeding laws in line with UN
recommendations..
Breastfeeding Network. www.breastfeedingnetwork.org.uk.
BfN Supporterline: tel 0300 100 0210.
CLAPA (Cleft Lip And Palate Association). www.clapa.com.
235–237 Finchley Road, London NW3 6LS. Tel 020 7431 0033.
Healthy Start Initiative. www.healthystart.nhs.uk.
La Leche League. www.laleche.org.uk.
Helpline: tel 0845 120 2918.
National Childbirth Trust. www.nct.org.uk.
Tel: 0870 444 8708; enquiry line: 0870 444 8707.
UNICEF UK Baby Friendly Initiative. www.babyfriendly.org.uk.
Africa House, 64–78 Kingsway, London WC2B 6NB. Tel: 0300 330 0700.
[A short video How to hand express is available at]
www.unicef.org.uk/BabyFriendly/Resources/AudioVideo/Hand-expression/.
Glossary of terms and acronyms
Abruptio placenta: Premature separation of a normally situated placenta. This term is
commonly used from viability (24 weeks).
Acridine orange: A stain used in fluorescence microscopy; it that causes bacteria to
fluoresce green to red.
Aetiology: The science of the cause of disease.
Affective awareness: An awareness of feelings and ability to express them.
Affective neutrality: Known as professional detachment.
Alveoli: Terminal sacs at the end of the bronchial tree where gaseous exchange takes
place.
Anhedonia: The loss of pleasure.
Amenorrhoea: Absence of menstrual periods.
Amniotic fluid embolism (AFE): The escape of amniotic fluid through the wall of the
uterus or placental site into the maternal circulation, triggering life-threatening
anaphylactic shock in the mother. (The word ‘embolism’, denoting a clot, is a misnomer.)
Amniotomy: Artificial rupture of the amniotic sac.
Anteflexion: The uterus bends forwards upon itself.
Anterior obliquity of the uterus: Altered uterine axis. The uterus leans forward due to
poor maternal abdominal muscles and a pendulous abdomen.
Anteversion: The uterus leans forward.
Antigen: A substance that stimulates the production of an antibody.
Anuria: Lack of urine production.
Apnoea: An absence of breathing for more than 20 seconds.
Asynclitism: The presentation of the fetal head at an oblique angle between the axis of
the presenting part of the fetus and the pelvic planes during labour/childbirth (also
known as obliquity).
Atresia: Closure or absence of an usual opening or canal.
Augmentation of labour: Intervention to correct slow progress in labour.
Bandl's ring: An exaggerated retraction ring seen as an oblique ridge above the
symphysis pubis between the upper and lower uterine segments, which is a sign of
obstructed labour.
Basal body temperature: The temperature of the body when at rest. In natural family
planning, it is taken as soon as the woman wakes from sleep and before any activity
occurs or after a period of at least 1 hour's rest.
Basal plate: The maternal side of the placenta.
Beneficence: To do good.
Bicornuate uterus: A structural congenital malformation of the uterus that results in
two horns; commonly referred to as a ‘heart-shaped’ uterus.
Bioavailability: The degree to which or rate at which a drug or other substance
becomes available to the target tissue after administration.
Bioequivalent: Acting on the body with the same strength and similar bioavailability
as the same dosage of a sample of a given substance.
Bipolar disorder: A mental illness or mood disorder where the individual experiences
periods of depression and elevated mood (mania). (Previously known as manic
depression.)
Birth centres: These may be freestanding (away from hospital) or in hospital grounds or
in the hospital. The emphasis is on providing a less medical environment and
supporting normal birth.
Bishop's Score: Rating system to assess suitability of cervix for induction of labour.
Bregma: Anterior fontanelle.
Burns–Marshall manoeuvre: A method of breech birth involving traction to prevent
the fetal neck from bending backwards.
Caput succedaneum: A diffuse oedematous swelling under the scalp but above the
periosteum.
Cardiotocogram/graphy (CTG): Measurement of the fetal heart rate and uterine
contractions on a machine that is able to provide a paper printout of the
information it records.
Care of the Next Infant (CONI): A programme of support facilitated by The Lullaby
Trust (previously known as the Foundation for the Study of Infant Deaths [FSID]).
Caseload practice: A personal caseload where named midwives care for individual
women.
Central venous pressure (CVP) line: An intravenous (IV) tube that measures the
pressure in the right atrium or superior vena cava, indicating the volume of blood
returning to the heart and by implication, hypovolaemia.
Cephalhaematoma (cephalohaematoma): An effusion of blood under the periosteum
that covers the skull bones.
Cephalopelvic disproportion (CPD): Disparity between the size of the woman's pelvis
and the fetal head.
Cerclage: Non-absorbable suture inserted to keep cervix closed.
Cervical eversion: Physiological response by cervical cells to hormonal changes in
pregnancy. Cells proliferate and cause the cervix to appear eroded.
Cervical intra-epithelial neoplasm (CIN): Progressive and abnormal growth of cervical
cells.
Cervical ripening: Process by which the cervix changes and becomes more susceptible
to the effect of uterine contractions. Can be physiological or artificially produced.
Cervicitis: Inflammation of the cervix.
Choanal atresia: (Bilateral) membranous or bony obstruction of the nares; the baby
appears blue when sleeping and pink when crying.
Chorionic plate: The fetal side of the placenta.
Choroid plexus cyst: Collection of cerebrospinal fluid within the choroid plexi, from
where cerebrospinal fluid is derived.
Chromosome: An organized structure of DNA and organized proteins that carries
genes.
Coloboma: A malformation characterized by the absence of or a defect in the tissue of
the eye; the pupil can appear keyhole-shaped. It may be associated with other
anomalies.
Colposcopy: Visualization of the cervix using a colposcope.
Commensal: Micro-organisms adapted to grow on the skin or mucous surfaces of the
host, forming part of the normal flora.
Conjoined twins: Identical twins where separation is incomplete so their bodies are
partly joined together and vital organs may be shared.
Coronal suture: Membranous tissue separating the frontal bones from the parietal
bones.
Couvelaire uterus (uterine apoplexy): Bruising and oedema of uterine tissue seen in
placental abruption when leaking blood is forced between muscle fibres because
the margins of the placenta are still attached to the uterus.
Cricoid pressure: A technique whereby pressure is exerted on the cartilaginous ring
below the larynx (the cricoid) to occlude the oesophagus and prevent reflux. Cricoid
pressure is employed during the induction of a general anaesthetic to prevent acid
aspiration syndrome.
Cryotherapy: Use of cold or freezing to destroy or remove tissue.
Cryptorchidism: Undescended testes, which may be unilateral or bilateral.
Decidualization: The structural changes that occur in the endometrium in preparation
for implantation.
De-infibulation: Being opened.
Delusion: A false fixed belief that is impenetrable to reason.
Deontology: Duty-based theory.
Deoxyribonucleic acid (DNA): The substance containing genes. DNA can store and
transmit information, can copy itself accurately and can occasionally mutate.
Diastasis symphysis pubis: A painful condition in which there is an abnormal
relaxation of the ligaments supporting the pubic joint; also referred to as pelvic
girdle pain.
Dichorionic twins: Two individuals who have developed in their own separate
chorionic sacs.
Diploid: Containing two sets of chromosomes.
Disseminated intravascular coagulation/coagulopathy (DIC): A condition secondary
to a primary complication where there is inappropriate blood clotting in the blood
vessels, followed by an inability of the blood to clot appropriately when all the
clotting factors have been used up.
Dizygotic (binovular): Formed from two separate zygotes.
Ductus arteriosus: A temporary fetal structure which leads from the bifurcation of the
pulmonary artery to the descending aorta.
Ductus venosus: A temporary fetal structure which connects the umbilical vein to the
inferior vena cava.
Dyspareunia: Painful or difficult intercourse experienced by the woman.
Ectoderm: The outermost layer of three primary germ cell layers present in the early
embryo.
Ectopic pregnancy: An abnormally situated pregnancy, most commonly in a uterine
tube.
Endocervical: Relating to the internal canal of the cervix.
Endoderm: The innermost layer of three primary germ cell layers present in the early
embryo.
Epicanthic folds: A vertical fold of skin on either side of the nose which covers the
lacrimal caruncle. They may be common in Asian babies, but may indicate Down
syndrome in other ethnic groups.
Episiotomy: A surgical incision made to enlarge the vaginal orifice during childbirth.
Erb's palsy: Paralysis of the arm due to the damage to cervical nerve roots 5 and 6 of
the brachial plexus.
Erythematous: Reddening of the skin.
Erythropoiesis: The process by which erythrocytes (red blood cells) are formed. After
the 10th week of gestation, erythropoiesis production rises and seems to be involved
in red cell production in the bone marrow during the third trimester.
Exomphalos (omphalocele): A defect in which the bowel or other viscera protrude
through the umbilicus.
External cephalic version (ECV): The use of external manipulation on the pregnant
woman's abdomen to convert a breech to a cephalic presentation.
False-negative rate: The proportion of affected pregnancies that would not be
identified as high risk. Tests with a high false-negative rate have low sensitivity.
False-positive rate: The proportion of unaffected pregnancies with a high-risk
classification. Tests with a high false-positive rate have low specificity.
Female genital mutilation (FGM): Also known as female circumcision. Any procedure
that intentionally alter or cause injury to the external female genital organs for non-
medical reasons. Four main types are reported.
Ferguson reflex: Surge of oxytocin, resulting in increased contractions, due to
stimulation of the cervix, and upper portion of the vagina.
Fetal reduction: The reduction in the number of viable fetuses/embryos in a multiple
(usually higher multiple) pregnancy by medical intervention.
Feto-fetal transfusion syndrome: Also known as twin-to-twin transfusion syndrome
(TTTS). Condition in which blood from one monozygotic twin fetus transfuses into
the other fetus via blood vessels in the placenta.
Fetus-in-fetu: Parts of a fetus may be lodged within another fetus. This can only
happen in monozygotic twins.
Fibroid (fibromyoma): Firm, benign tumour of muscular and fibrous tissue.
Foramen magnum: A large opening in the occipital bone of the skull through which
the spinal cord exits.
Foramen ovale: A temporary structure of the fetal circulation allowing blood to be
shunted from the right to left atrium in utero.
Fossa ovalis: Oval shaped depression in the intra-atrial septum. Formed following the
closure of the foramen ovale at birth.
Framing effect: A means of cognitive bias insofar that individuals react differently to a
particular choice such as antenatal screening tests, based on the manner in which
the information is presented, i.e. whether they perceive the risk of screening as a
loss or a gain.
Fraternal twins: Dizygotic (non-identical).
Fundal height: The distance between the upper part of the uterus (the fundus) and the
upper part of the symphysis pubis (the junction between the pubic bones). This
assessment is undertaken to assess the increasing size of the uterus antenatally and
decreasing size postnatally.
Funis: The umbilical cord.
Gastroschisis: A paramedian defect of the abdominal wall with extrusion of bowel that
is not covered by peritoneum.
Glabella: The area between the eyebrows.
Globalization: The increased interconnectedness and interdependence of people and
countries.
Grande multipara: A woman who has given birth five times or more.
Greater vestibular glands (Bartholin's glands): Two small glands that open on either
side of the vaginal orifice, located in the posterior part of the labia majora.
Group practice: A small group of midwives who provide care for a group of women.
Haematuria: Blood in the urine.
Haemostasis: The arrest of bleeding.
Hallucinations: A sensory perception in the absence of any stimulus. Any of the five
sensory modality can be affected.
Haploid: Containing only one set of chromosomes.
HELLP syndrome: A condition of pregnancy characterized by haemolysis, elevated
liver enzymes and low platelets.
Herpes gestationis: An autoimmune disease precipitated by pregnancy and
characterized by an erythematous rash and blisters.
Homan's sign: Pain is felt in the calf when the foot is pulled upwards (dorsiflexion).
This is indicative of a venous thrombosis and further investigations should be
undertaken to exclude or confirm this.
Homeostasis: The condition in which the body's internal environment remains
relatively constant within physiological limits.
Hydatidiform mole: A gross malformation of the trophoblast in which the chorionic
villi proliferate and become avascular.
Hydropic vesicles: Fluid-filled sacs, or blisters.
Hypercapnia: An abnormal increase in the amount of carbon dioxide in the blood.
Hyperemesis gravidarum: Protracted or excessive vomiting in pregnancy.
Hypertrophy: Overgrowth of tissue.
Hypogastric arteries: Temporary fetal structures that branch off from the internal iliac
arteries and become the umbilical arteries when they enter the umbilical cord.
Hypospadias: A condition where the urethral meatus opens on to the undersurface of
the penis.
Hypothermia: A core body temperature below 36 °C.
Hypotonia: The loss of muscle tension and tone.
Hypovolaemia: Reduced circulating blood volume due to external loss of body fluids
or to loss of fluid into the tissues.
Hypoxia: Lack of oxygen.
Hypoxic ischaemic encephalopathy (HIE): Condition where there is evidence of
hypoxia and ischaemia.
Hysteroscope: An instrument used to access the uterus via the vagina.
Immunoglobulins: Antibodies.
Induction of labour: Intervention to stimulate uterine contractions before the onset of
spontaneous labour.
Intermittent positive pressure ventilation (IPPV): Inflation breaths are given to clear
lung fluid and ventilatory breaths are given to remove excess CO2 and provide
oxygen.
Internationalization: Has no agreed definition but best describes the process of
harmonizing relationships from a cross-cultural or international perspective.
Intervillous spaces: The spaces between the chorionic villi that fill with maternal
blood.
Intraepithelial: Within the epithelium, or among epithelial cells.
Intrahepatic cholestasis of pregnancy (ICP): An idiopathic condition of abnormal liver
function.
Jaundice: Yellow coloration of the skin and the sclera caused by a raised level of
bilirubin in the circulation (hyperbilirubinaemia).
Kleihauer test: A standard blood test used to quantitatively assess or measure the
degree of feto-maternal haemorrhage.
LAM: A method of contraception based upon an algorithm of lactation and
amenorrhoea over a 6-month time period.
Lamda: Posterior fontanelle.
Lamdoidal suture: Membranous tissue separating the occipital bone from the two
parietal bones of the fetal skull.
Lanugo: Soft downy hair that covers the fetus in utero and occasionally the neonate. It
appears at around 20 weeks' gestation and covers the face and most of the body. It
disappears by 40 weeks' gestation.
Layer of Nitabusch: A collaginous layer between the endometrium and myometrium.
Ligamentum arteriosum: Permanent ligament formed from the ductus arteriosus
following birth.
Ligamentum teres: Permanent ligament formed from the umbilical vein following
birth.
Ligamentum venosum: Permanenet ligament formed from the ductus venosus
following birth.
Linea nigra: A common dark line of pigmentation running longitudinally in the centre
of the abdomen below and sometimes above the umbilicus.
Lochia: A Latin word traditionally used to describe the vaginal loss a woman
experiences following the birth of a baby.
Løvset manoeuvre: A manoeuvre for the birth of the fetal shoulders and extended
arms in a breech presentation.
Macrosomia: Large baby weighing 4–4.5 kg or greater.
Malposition: A cephalic presentation other than normal well-flexed anterior position
of the fetal head, e.g. occipitoposterior.
Malpresentation: A presentation other than the vertex, i.e. face, brow, compound or
shoulder.
Mauriceau–Smellie–Veit manoeuvre: A manoeuvre to assist the birth of the fetal head
in a breech presentation that involves jaw flexion and shoulder traction.
McRoberts manoeuvre: A manoeuvre to rotate the angle of the symphysis pubis
superiorly and release the impaction of the anterior shoulder of the fetus when
there is shoulder dystocia. The woman brings her knees up to her chest.
Mendelson's syndrome: A chemical pneumonitis caused by the reflux of gastric
contents into the maternal lungs during a general anaesthetic.
Meningitis: Inflammation of the membranes covering the brain and spinal column.
Mentum: Chin.
Mesenchyme: A mesh of embryonic connective tissue.
Mesoderm: The middle layer of three primary germ cell layers present in the early
embryo.
Microchimerism: The presence of a small number of cells in one individual that
originated in a different individual.
Midwife-led care: Midwives or a midwife take the lead role in care of a woman or
group of women.
Miscarriage: Spontaneous loss of pregnancy before viability.
Modified Early Obstetric Warning Score (MEOWS): A chart or track and trigger
system used to record maternal observations or physiological vital signs antenatally
and postnatally for all mothers who are hospitalized in the maternity service.
Monoamniotic twins: Two individuals who have developed in the same amniotic sac.
Monochorionic twins: Two identical individuals who have developed in the same
chorionic sac.
Monozygotic (monozygous): Formed from one zygote (identical twins).
Moulding: The change in shape of the fetal head that takes place during its passage
through the birth canal.
Multifetal reduction: see Fetal reduction.
Naegele's rule: A method of calculating the expected date of birth.
Natural family planning (NFP): Methods of contraception based on observations of
naturally occurring signs and symptoms of the fertile and infertile phases of the
menstrual cycle.
Necrotizing enterocolitis (NEC): An acquired disease of the small and large intestine
caused by ischaemia of the intestinal mucosa.
Neonatal encephalopathy: A clinical syndrome of abnormal levels of consciousness,
tone, primitive reflexes, autonomic function and sometimes seizures in newborn
babies.
Neoplasia: Growth of new tissue.
Neurulation: The formation of the neural plate and its transformation in to the neural
tube.
Nerve innervation: Nerve supply.
Neutral thermal environment (NTE): The range of environmental temperature over
which heat production, oxygen consumption and nutritional requirements for
growth are minimal, provided the body temperature is normal.
Non-maleficence: Do no harm.
Oedema: The effusion of body fluid into the tissues.
Oligohydramnios: Abnormally small amount of amniotic fluid in pregnancy.
Oliguria: The production of an abnormally small amount of urine.
One-to-one midwifery: One midwife takes responsibility for individual women with a
partner backing up the named midwife. Such a system integrates a high level of
continuity of caregiver and midwifery-led care. It is geographically based and
includes women who are both ‘high risk’ and ‘low risk’.
Paco2: Carbon dioxide partial pressure. Measures the partial pressure of dissolved
carbon dioxide. This dissolved CO2 has moved out of the cell and into the
bloodstream. The measure of a Paco2 accurately reflects the alveolar ventilation.
Pao2: Arterial oxygen partial pressure. Measures the partial pressure of oxygen in the
arterial blood. It reflects how the lung is functioning but does not measure tissue
oxygenation.
Paronychia: An inflamed swelling of the nail folds; acute paronychia is usually caused
by infection with Staphylococcus aureus.
Partnership: A relationship of trust and equity through which both partners are
strengthened and power is diffused.
Peak mucus day: A retrospective assessment of the last day of highly fertile mucus
which is observed vaginally or felt around ovulation.
Pedunculated: Stem or stalk.
Pemphigoid gestationis: see Herpes gestationis.
Perinatal: Events surrounding labour and the first 7 days of life.
Perinatal mental illness: A term used both nationally and internationally to emphasize
the importance of psychiatric disorder in pregnancy as well as following childbirth
and the variety of psychiatric disorders that can occur at this time, in addition to
postnatal depression.
pH: A solution's acidity or alkalinity is expressed on the pH scale, which runs from 0
to 14. This scale is based on the concentration of hydronium (H+) ions in a solution
expressed in chemical units called moles per litre (mol/l). Solutions with a pH less
than 7 are said to be acidic and solutions with a pH greater than 7 are basic or
alkaline. Pure water has a pH very close to 7. When the fetus is hypoxic the increased
acid produced raises the acidity of the blood and the pH falls.
Phenylketonuria (PKU): An autosomal recessive disorder of protein metabolism.
Pill-free interval: The 7 days when no pills are taken during combined oral
contraceptive regimen.
Placenta accreta: Abnormally adherent placenta into the muscle layer of the uterus.
Placenta increta: Abnormally adherent placenta into the perimetrium of the uterus.
Placenta percreta: Abnormally adherent placenta through the muscle layer of the
uterus.
Placenta praevia: A condition in which some or all of the placenta is attached in the
lower segment of the uterus.
Placental abruption: see Abruptio placenta.
Placentation: The forming of the placenta.
Polyhydramnios: An excessive amount of amniotic fluid in pregnancy. Also referred to
as hydramnios.
Polyp: Small growth.
Porphyria: An inherited condition of abnormal red blood cell formation.
Postnatal blues: A transitory emotional or mood state, experienced by 50–80% of
women depending on parity.
Postnatal period: The period after the end of labour during which the attendance of a
midwife upon the woman and baby is required, being not less than 10 days and for
such longer period as the midwife considers necessary.
Postpartum: After labour.
Precipitate labour: The expulsion of the fetus within 3 hours of commencement of
contractions.
Pre-eclampsia: A condition peculiar to pregnancy, which is characterized by
hypertension, proteinuria and systemic dysfunction.
Primary postpartum haemorrhage (PPH): A blood loss in excess of 500 ml or any
amount that adversely affects the condition of the mother within the first 24 hours
of birth.
Progestogen: Synthetic progesterone used in hormonal contraception.
Prostaglandins: Locally acting chemical compounds derived from fatty acids within
cells. They ripen the cervix and cause the uterus to contract.
Proteinuria: Protein in the urine.
Proteolytic enzymes: Enzymes that break down proteins.
Pruritus: Itching.
Psychosis: A disorder of the mental state that affects mood and cognitive processes
which may cause the individual to lose touch with reality (i.e. hallucinations and
delusional thoughts are usually present).
Ptyalism: Excessive salivation.
Pudendal block: This is the procedure where local anaesthetic is infiltrated into the
tissue around the pudendal nerve within the pelvis; employed for some operative
procedures during vaginal births.
Puerperal psychosis: Describes a rare but serious psychiatric emergency and the most
severe form of postpartum affective (mood) disorder.
Puerperal sepsis: Infection of the genital tract following childbirth; still a major cause
of maternal death where it is undetected and/or untreated.
Puerperium: A period after childbirth where the uterus and other organs and
structures that have been affected by the pregnancy are physiologically returning to
their non-gravid state, lactation is establishing and the woman is adjusting socially
and psychologically to motherhood. Usually described as a period of up to 6–8
weeks.
Quickening: The first point at which the woman recognizes fetal movements in early
pregnancy.
Reciprocity: A mutual relationship between two individuals where there is an
exchange of positive regard for each other.
Regional anaesthesia: More commonly are epidural and intrathecal (spinal)
anaesthetic.
Retraction: The process by which the uterine muscle fibres shorten after a contraction.
This is unique to uterine muscle.
Rubin's manoeuvre: A rotational manoeuvre to relieve shoulder dystocia. Pressure is
exerted over the fetal back to adduct and rotate the shoulders.
Sandal gap: Exaggerated gap between the first and second toes.
Secondary postpartum haemorrhage: Any abnormal or excessive bleeding from the
genital tract occurring between 24 hours and 12 weeks postnatally.
Selective fetocide: The medical destruction of a malformed twin fetus in a continuing
pregnancy.
Sinciput: The forehead.
Sheehan's syndrome: A condition where sudden or prolonged shock leads to
irreversible pituitary necrosis characterized by amenorrhoea, genital atrophy and
premature senility.
Short femur: Shorter than the average thigh bone, when compared with other fetal
measurements.
Shoulder dystocia: Failure of the shoulders to spontaneously traverse the pelvis after
birth of the fetal head.
Speculum (vaginal): An instrument used to open the vagina.
Subinvolution: The uterine size appears larger than anticipated for the number of
days postpartum, and may feel not well contracted. Uterine tenderness may be
present.
Succenturiate lobe: A small extra lobe of placenta separate from the main placenta.
Surfactant: Complex mixture of phospholipids and lipoproteins produced by type 2
alveolar cells in the lungs that decreases surface tension and prevents alveolar
collapse at end expiration.
Symphysiotomy: A surgical incision to separate the symphysis pubis and enlarge the
pelvis to aid birth of the baby.
Symphysis pubis dysfunction: see Diastasis symphysis pubis.
Tachypnoea: Increased respiratory rate that occurs as the baby attempts to
compensate for an increased carbon dioxide concentration in the blood and
extracellular fluids.
Talipes: A complex foot deformity, affecting 1/1000 live births and more common in
males. The affected foot is held in a fixed flexion (equinus) and in-turned (varus)
position. It can be differentiated from positional talipes because the deformity in
true talipes cannot be passively corrected.
Team midwifery: Midwives are team-based rather than on a ward or within a
community base. The team takes responsibility for a number of women. Teams may
be restricted to hospital or community, or cover both.
Tentorium cerebelli: An arched fold of the dura mater, covering the upper surface of
the cerebellum.
Teratogen: An agent believed to cause congenital malformations, e.g. thalidomide.
Tocophobia: A fear of childbirth.
Torsion: Twisting.
Torticollis: The result of tightness and shortening of one sternomastoid muscle.
Tregs: Adapted T regulator cells that play a part in immunity.
Trizygotic: Formed from three separate zygotes.
Trophoblasts: Peripheral cells surrounding the blastocyst.
Twin-to-twin transfusion syndrome: see Feto-fetal transfusion syndrome.
Uniovular: Monozygotic.
Unstable lie: After 36 weeks' gestation, a lie that varies between longitudinal and
oblique or transverse is said to be unstable.
Uterine involution: The physiological process that starts from the end of labour and
results in a gradual reduction in the size of the uterus until it returns to its non-
pregnant size and location in the pelvis.
Uterotonics: Also known as oxytocics or ecbolics. Pharmacological agents/drugs (e.g.
syntometrine, syntocinon, ergometrine and prostaglandins) that are used in the
active management of the third stage of labour to stimulate the smooth muscle of
the uterus to contract.
Utilitarianism: Providing the greatest good for greatest number.
Vanishing twin syndrome: The reabsorption of one twin fetus early in pregnancy
(usually before 12 weeks).
Vasa praevia: A rare occurrence in which umbilical cord vessels pass through the
placental membranes and lie across the cervical os.
Vasculogenesis: The formation of new blood vessels.
Vernix caseosa: White creamy substance protecting the fetus from dessication and
present from 18 weeks gestation.
Wharton's jelly: Gelatinous substance surrounding the umbilical cord.
Withdrawal bleed: Vaginal bleeding due to withdrawal of hormones.
Wood's manoeuvre: A rotational or screw manoeuvre to relieve shoulder dystocia.
Pressure is exerted on the fetal chest to rotate and abduct the shoulders.
Zavanelli manoeuvre: Last choice of manoeuvre for shoulder dystocia. The head is
returned to its pre-restitution position, then the head is flexed back into the vagina.
Birth is by caesarean section.
Zygosity: Describing the genetic make-up of children in a multiple birth.
Acronyms
ABPM: ambulatory blood pressure monitoring
ACE: angiotensin converting enzyme
ACTH: adrenocorticotrophic hormone
ADH: anti-diuretic hormone
AED: antiepileptic drug
AFLD: acute fatty liver disease
AGA: appropriate for gestational age
AIDS: acquired immunodeficiency syndrome
ALT: Alanine Transaminase
ANP: atrial natriuretic peptide
Anti HBe: hepatitis B e-antibodies
APEC: Action on Pre-Eclampsia
APH: Antepartum Haemorrhage
APS: antiphospholipid syndrome
ARB: angiotensin receptor blocker
ARM: artificial rupture of the membranes/Association of Radical Midwives
ART: antiretroviral therapy
ASD: atrial septal defect
ATP: adenosine triphosphate
BALT: bronchus-associated lymphoid tissue
BFI: Baby Friendly Initiative
BMI: body mass index
BMR: basal metabolic rate
BNF: British National Formulary
BNP: brain natriuretic peptide
BOC: British Oxygen Company
BP: blood pressure
BTS: British Thoracic Society
CCG: Clinical Commissioning Group
C. Diff: Clostridium difficile
CHD: congenital heart disease
CHRE: Council for Healthcare Regulatory Excellence (now PSA Professional Standards
Authority)
CIN: cervical intraepithelial neoplasia
CINORIS: Clinical Negligence and Other Risks Indemnity Scheme
CMACE: Centre for Maternal and Child Enquiries
CMB: Central Midwives Board
CEMACH: Confidential Enquiry into Maternal and Child Health.
CESDI: Confidential Enquiries into Stillbirths and Deaths in Infancy
CMV: cytomegalovirus
CNS: central nervous system
CNST: Clinical Negligence Scheme for Trusts
COC: combined oral contraceptive
COMET: The Comparative Obstetric Mobile Epidural Trial
CQC: Care Quality Commission
CRH: corticotrophin-releasing hormone
CRT: capillary refill time
CSF: cerebral spinal fluid
CSII: continuous subcutaneous insulin infusion
CT: computerized tomography
CTG: cardiotograph/cardiotocogram
CVA: cerebral vascular accident
CVS: chorionic villus sampling
DCSF: Department for Children, Schools and Families (until 2010; now DfE)
DDH: developmental dysplasia of the hip
DfE: Department for Education
DH/DoH: Department of Health
DHA: docosahexanoic acid
DMPA: depot medroxyprogesterone acetate
DVT: deep vein thrombosis
EBM: expressed breast milk
ECG: electrocardiogram/graphy
E. Coli: Escherichia coli
ECM: extracellular matrix
EFM: electronic fetal monitoring
EFSA: European Food Standards Agency
eGFR: epidermal growth factor receptor
EHC: emergency hormonal contraception
ELBW: extremely low birth weight (below 1000 g)
ENB: English National Board for Nursing, Midwifery and Health Visiting
ENT: ear,nose and throat
ERPC: evacuation of retained products of conception
ESC: Essential Skills Clusters
EU: European Union
FASD: fetal alcohol spectrum disorders
FBC: full blood count
FIL: feedback inhibitor of lactation
FPA: Family Planning Association
FSA: Food Standards Agency
FSH: follicle stimulating hormone
FSRH: Faculty of Sexual and Reproductive Health
GALT: gut-associated lymphoid tissue
GAS: Group A streptococcus
GBS: Group B streptococcus
GDM: gestational diabetes mellitus
GF: glomerular filtrate
GFR: glomerular filtration rate
GNC: General Nursing Council
GnRH: gonadotrophic-releasing hormone
GP: General Practitioner
GTD: gestational trophoblastic disease
GTI: genital tract infection
GTN: gestational trophoblastic neoplasia
GTT: glucose tolerance test
HAART: highly active antiretroviral therapy
Hb: haemoglobin
HbA: adult haemoglobin
HbAS: sickle cell trait (heterozygous)
HbA1c: glucated/glycosylated haemoglobin
HBeAg: hepatitis B e-antigen
HbF: fetal haemoglobin
HbH: haemoglobin H disease
HbSS: sickle cell anaemia/disease (homozygous)
HBV: hepatitis B virus
HCAI: healthcare-acquired infection
hCG: human chorionic gonadotrophin
hCG-H: hyperglycosylated human chorionic gonadotrophin
hCS: human chorionic somatomammotropin hormone
HDCU: high dependency care unit
HDL: high-density lipoprotein
HDN: haemorrhagic disease of the newborn
HEI: Higher Education Institution
HIV: Human Immunodeficiency Virus
hPGL: human placental growth hormone
hPL: human placental lactogen
HPT: home pregnancy test
HPV: human papilloma virus
HSCIC: Health and Social Care Information Centre
HSE: Health Survey for England
HSV: herpes simplex virus
HVS: high vaginal swab
ICM: International Confederation of Midwives
ICU: intensive care unit
IFCC: International Federation of Clinical Chemistry
IHD: ischaemic heart disease
IOM: Institute of Medicine
IM: intramuscular
IQ: intelligence quotient
ITP: Intention to Practice
IUCD: intrauterine contraceptive device
IUFD: intrauterine fetal death
IUGR: intrauterine growth restriction
IUS: intrauterine system
IV/IVI: intravenous/intravenous infusion
IVF: in vitro fertilization
JEC: Joint Epilepsy Council
L3: third lumbar vertebra
LA: Local Authority
LARC: long-acting reversible contraceptive
LBW: low birth weight (below 2500 g)
LC-PUFA: long chain poyunsaturated fatty acids
LFT: liver function test
LGA: large for gestational age
LH: luteinizing hormone
LMP: last menstrual period
LMWH: low molecular weight heparin
LSA: Local Supervising Authority
LSAMO: Local Supervising Authority Midwifery Officer
MA: mentoanterior
MCH: mean cell/corpuscular haemoglobin
MCV: mean cell/corpuscular volume
MH(P)RA: Medicines and Healthcare Products Regulatory Agency
MI: myocardial infarction
MIDIRS: Midwives Information Resource Service
MODY: mature onset diabetes of the young
MOH: Medical Officer of Health
MPV: mean platelet volume
MRI: magnetic resonance imaging
MRSA: methicillin-resistant Staphylococcus aureus
MSU/MSSU: mid-stream specimen of urine
MSW: Maternity Support Worker
NCT: National Childbirth Trust
NET-EN: norethisterone enanthate
NHS: National Health Service
NHSLA: National Health Service Litigation Authority
NICE: National Institute for Health and Clinical Excellence/National Institute for
Health and Care Excellence (from 2013)
NICU/NNICU: neonatal intensive care unit
NIPE: neonatal and infant physical examination
NMC: Nursing and Midwifery Council
NOP: Notification of Practice
NPEU: National Perinatal Epidemiology Unit
NPSA: National Patient Safety Agency
NTD: neural tube defect
OA: occipitoanterior
OC: obstetric cholestasis
OF: cccipitofrontal
OP: occipitoposterior
PAP: pulmonary artery pressure
PCA: patient-controlled analgesia
PCT: Primary Care Trust
PDA: patent ductus arteriosus
PE: pulmonary embolism/embolus
PET: pre-eclampsia toxaemia
PGP: pelvic girdle pain
PID: pelvic inflammatory disease
PIH: pregnancy-induced hypertension
PND: postnatal depression
POC: point of care
POP: progesterone-only pill
PPI: proton pump inhibitor
PPROM: preterm prelabour rupture of the membranes
PREP: Post-Registration Education and Practice
PROM: prelabour rupture of membranes
PSA: Professional Standards Authority
PTH: parathyroid hormone
RAAS: renin–angiotensin–aldosterone system
RCoA: Royal College of Anaesthetists
RCM: Royal College of Midwives
RCOG: Royal College of Obstetricians and Gynaecologists
RCPCH: Royal College of Paediatrics and Child Health
RCT: randomizd controlled trial
RCUK: Resuscitation Council of the United Kingdom
RHA: Regional Health Authority
RNA: ribonucleic acid
RPF: renal plasma flow
SACN: Scientific Advisory Committee on Nutrition
SANDS: Stillbirth and Neonatal Death Society
SBAR: situation, background, assessment and recommendation
SFH: symphysis fundal height
SGA: small for gestational age
SHA: Strategic Health Authority
SI: Statutory Instrument
SIGN: Scottish Intercollegiate Guidelines Network
SLE: systemic lupus erythematosus
SPRM: selective progesterone receptor modulator
STI: sexually transmitted infection
SUDEP: sudden unexpected death in epilepsy
SUI: stress urinary incontinence
T11: eleventh thoracic vertebra
TBG: thyroxine-binding globulin
TBV: total blood volume
TED: thromboembolism deterrent
TENS: transcutaneous electrical nerve stimulation
TRH: thyrotropin-releasing hormone
TSH: thyroid-stimulating hormone
UK: United Kingdom
UKAMB: United Kingdom Association for Milk Banking
UKCC: United Kingdom Central Council for Nursing, Midwifery and Health Visiting
UKOSS: United Kingdom Obstetric Surveillance System
UNAIDS: United Nations Programme on HIV/AIDS
UNICEF: United Nations International Children' Fund
UPSI: unprotected sexual intercourse
USA: United States of America
US(S): ultrasound (scan)
UTI: urinary tract uifection
VE: vaginal examination
VKDB: vitamin K deficiency bleeding
VLBW: very low birth weight (below 1500 g)
VSD: ventricular septal defect
VTE: venous thromboembolism
WHO: World Health Organization
Index
I llustrations are comprehensively referred to from the text. Therefore, significant
items in illustrations (figures and tables) have only been given a page reference in the
absence of their concomitant mention in the text referring to that illustration.
A
ABC mnemonic for postpartum haemorrhage treatment, 409
ABC(DE) protocol
maternal, 488
eclamptic seizure, 252
neonatal, 612
abdomen (baby)
in breech birth, 384–385
neonatal, examination, 596
abdomen (maternal)
caesarean section incision, 464–465
distension, 163
examination in labour and birth
breech presentation, 357–358
brow presentation, 449
initial, 337
examination in pregnancy, 190–196
hydramnios, 238
multiple pregnancy, 293–294
occipitoanterior position, 436–437
oligohydramnios, 238–239
palpation. See palpation
shoulder presentation, 450
examination in puerperium, 505
muscles, laxity as cause of shoulder presentation, 450
pain, 222
ovulation (=mittelschmerz), 94, 569, 584
pressure (in labour) in upper region, epidural analgesia, 369
ABO blood groups
isoimmunization, 687
typing, 216
booking visit, 188
abortion (induced ending of pregnancy), 227–228, 558–559
combined oral contraceptive pill following, 574
for fetal abnormality, 558–559
for other reasons, 559
abrasions, neonatal, 593, 630
abscess, breast, 721
absence seizures, 278t
accelerations, 346
accountability (and the NMC), 31–32
acetabulum in developmental dysplasia of hips, 606–607
achondroplasia, 662
aciclovir (acyclovir), varicella zoster, 677
acid–base status and labour pain, 352
acini cells, milk-producing, 705
Aconite, labour pain, 352
acrocyanosis (peripheral cyanosis/at extremities), 592, 668–669
acrosome reaction, 95
act utilitarianism, 38–39
active management of 3rd stage of labour, 400–404
acupuncture for hyperemesis gravidarum, 228–229
acyanotic cardiac defects, 657–658
acyclovir, varicella zoster, 677
adenoma, pituitary, 245
adipokines, 254
adjustment reactions, 538
administration. See organization and administration
adoption, relinquishment for, 558
adrenal glands
congenital hyperplasia, 597, 664, 695
fetal, 115
maternal, 170–171
tumour, 248
neonatal disorders, 695
adrenaline (epinephrine)
blood pressure and, 244
labour pain and, 352
stress and, 532
adrenocorticotrophic hormone (ACTH), maternal, 169–171
adult respiratory distress syndrome, 490
adverse incidents, serious, 48–49
advocacy, 17
aerobic glycolysis, neonatal, 598–599
affective awareness, 12
affective neutrality, 11–12
afferent (sensory) pathways and labour pain, 350–351
afterpains, 506
aganglionosis, congenital (Hirschsprung's disease), 653, 672
AIDS. See human immunodeficiency virus
airway (neonatal)
congenital pulmonary airway malformation, 655
upper, obstruction, 681, 722
airway management (in resuscitation)
maternal, 488
eclamptic seizure, 252
hypovolaemic shock, 490
neonatal, 612–613
difficulties in establishing open airway, 613–614
albumin in pregnancy, 154
alcohol, 187
fetal exposure, 664–665
aldosterone, 86, 170–171, 244
excess production (Conn's syndrome), 248
all fours position, 371–372, 378–379
breech birth, 382
Mauriceau–Smellie–Veit manoeuvre, 383
occipitoposterior position, 439
shoulder dystocia, 481
All Wales Clinical Pathway for Normal Labour, 388
allantois, 98–99
allergy
breast vs bottle-feeding, 708
to formula milk components, 727
alloimmune thrombocytopenia, neonatal, 638
alveoli (breast), 705
alveoli (fetal lung), 114–115
ambiguous genitalia, 597, 664, 695
amenorrhoea, 94
lactational, 583–585
amino acids
in formulae milk, 727
in pregnancy, 165
amniocentesis, twin pregnancy, 292
amnion, 106
in twin pregnancy, 291, 298. See also membranes
amniotic cavity, 98
amniotic fluid, 107
embolism, 485–486
in labour, 332
meconium in (meconium staining), 376, 620–621
volume, 107
abnormalities. See oligohydramnios; polyhydramnios
calculation, 236
amniotomy (artificial rupture of the membranes), 267, 296, 333, 424
anaemia
fetal, surveillance for, 217
maternal, 273–274
iron-deficiency. See iron
physiological anaemia, 273
postpartum haemorrhage in, 408
screening for, 215–216
twin pregnancy and, 294
anaerobic glycolysis, neonatal, 598–599
anaesthesia. See general anaesthesia; regional analgesia/anaesthesia
anal…. See anorectum and entries below
anal atresia (imperforate anus), 596, 652
anal cleft (purple) line, 338–340, 369
anal dilatation and gaping, 369
anal incontinence (faecal incontinence), 320, 507, 524
anal sphincters, 57–60
external, 60
internal, 60
obstetric injury (OASIS), 319–320
examination, 314
follow-up, 312
postoperative care after repair, 320
repair, 318–320
anal triangle, 55
analgesia (pain relief)
in caesarean section, 468–471
postoperative, 466
in labour/vaginal birth, 352–356, 374–375
anal sphincter repair, postoperative, 320
in cardiac disease, 267
forceps extraction, 461
multiple pregnancy, 296
non-pharmacological, 352–353
pharmacological, 353–356
ventouse extraction, 458
postnatal
afterpains, 506
perineal pain, 508
anaphylactic shock, 489
anatomical variations, placenta and cord, 108–109
androgen insensitivity syndrome, 664
android pelvis, 68–69, 68t
occipitoanterior position with, 436
anencephaly, 659
face presentation with, 444–445
angiomas, 168
angiotensin, 84, 150–151, 170–171
blood pressure and, 244
angiotensinogen, 84
anhedonia, 543
ankyloglossia, 722
anorectum
maternal, 57–60
examination in perineal trauma, 314
neonatal
examination, 596
malformations, 652. See also anal sphincters; anal triangle
antacids in caesarean section, Mendelson's syndrome prevention, 470
antenatal care/management (incl. visits), 179–202
access, 182
aim, 180–182
breastfeeding preparations, 189, 711, 730
cardiac disease, 266
diabetic women, 260–261
impact of reduced visits, 180
initial assessment. See booking visit
key principles, 180b
models, 182
obese women, 255–256
occipitoanterior position, 437–438
ongoing, 196–199
patterns/schedules, 180–181
referral for additional support. See referral
twin pregnancy, 293
unstable lie, 452
antenatal diagnosis (prenatal diagnosis)
brow presentation, 449
cardiac defects. See heart disease (baby)
congenital malformations. See malformations
face presentation, 445
occipitoanterior position, 436–437, 442
shoulder presentation, 450
termination following, 558–559
antenatal education (for birth and parenting), 127–142
aims, 130b
attendance, maximising, 137–140
content, 133–136
defining learning outcomes, 136–137
evidence, 129
leading group sessions, 129–133
multiple pregnancy, 293
research and policy background, 127–129
antenatal haemorrhage. See haemorrhage (maternal), antenatal
antenatal screening, 203–219
at booking visit, 187–189
congenital malformations. See malformations
discussing options, 206
fetal, 189, 208–214
limitations, 204–205
maternal, 214–217
mental illness, 549
multiple pregnancy, 292
principles, 204–205
roles and responsibilities of midwives, 205–208, 212
set up, 205–208
antepartum…. See entries under antenatal
anteroposterior diameter of pelvic inlet, 66–67
anthropoid pelvis, 68t, 69
occipitoanterior position with, 436
antibiotics
in caesarean section, prophylactic, 464
combined oral contraceptive pill and, 573
neonatal infection
eye, 605–606
group B streptococcus, 675–676
progestogen-only pill and, 575
antibodies (immunoglobulins)
neonatal, 601
breastmilk and, 601, 710
red cell (maternal), 686
screening for, 216–217
therapeutic administration (incl. passive immunization)
anti-D Ig. See anti-D prophylaxis
physiological administration, 684
varicella zoster, 677
anticonvulsants/antiepileptics
maternal
eclampsia, 252
epilepsy, 278–279
folate deficiency caused by, 274–275
as mood stabilizers, 548
neonatal, 640–641
anti-D prophylaxis, 190, 226, 685–686
pregnancy loss, 227–228
antidepressants, 544–547
in bipolar illness, 549
antidiuretic hormone (ADH; vasopressin), 85–86, 151, 169
blood pressure and, 244
anti-emetics with opiates in labour, 354
anti-epileptics. See anticonvulsants
antihypertensive drugs, 247b
in labour, 248
in pre-eclampsia, 250–251
postnatal, 251
anti-infective factors in breastmilk, 710
antipsychotics, 547
antiretroviral drugs, 280–281
antithrombotic therapy, 266
antiviral drugs
HIV, 280–281
varicella zoster, 677
anus. See anorectum and entries under anal
anxiety, 532–533
antenatal screening, 204, 207
postnatal, 543. See also fear
anxiety disorders, 532, 539
aorta
maternal, dissection, 268
neonatal
coarctation, 658
stenosis, 658
Apert's syndrome, 660
Apgar score, 612
apnoea, neonatal, 670
appendix in pregnancy, 163
appetite changes, 162
areola, 705
arms
in breech births, 382
extended, 384–385
in shoulder dystocia, birth of posterior arm, 481–482. See also limbs
aromatherapy, 352
arterial duct. See ductus arteriosus
arteries
fetal development, 112
maternal
blood gases, 159
supply. See blood supply
artifical feeds. See formula feeding
artificial pancreas, 259
artificial rupture of the membranes (chorioamnion), 267, 296, 333, 424
ascorbic acid, breastmilk, 709
asepsis in 3rd stage of labour, 404
asphyxia (fetal)
in breech birth, 387b
in shoulder dystocia, 483
aspirin, pre-eclampsia, 250t
assessment strategies in Global Standards for Midwifery Education (2010), 7
assisted conception, pregnancy problems, 228
asthma, 269–270
asylum-seekers, 16
asynclitism, pelvic brim in, 69b
atherogenic dyslipidaemia, 254
atonic seizures, 278t
atonic uterus, 406, 409
atosiban acetate, 240
atresias
choanal, 613–614, 655–656
gastrointestinal, 650–652
anal (imperforate anus), 596, 652
atrial natriuretic peptide, 151–152, 244
atrial septal defect (ASD), maternal, 268
attachment
to breast, 712–715
difficulties, 718–719, 720b, 722
reattachment after removal, 716
parent–baby, 556
attitude (head), 121, 194
audit, 46
Audit Committee, 29
auscultation, fetal heart, 194
labour
breech presentation, 358
initial, 337
intermittent, 344–345
multiple pregnancy, 294
occipitoanterior position, 437
auscultation, neonatal heart, 603–604
authority rules, 38
autoimmune thrombocytopenia, neonatal, 638
autonomy, respect for, 38
awareness
emotional (midwives'), 8, 12–13
fertility, 582–585
of loss (=realization), 556
B
baby. See fetus; infants; neonates; preterm babies
‘baby brain’, 159
Baby Friendly Hospital Initiative, 718–719, 727, 729–730
backache
with epidural anaesthesia, 356b
in occipitoposterior position, 438
postnatal, 523
bacterial infection, neonatal, 675–676
bacteriuria, asymptomatic, 160b, 282
booking visit assessment for, 188
bag and mask ventilation, neonatal, 613
BALT (bronchus-associated lymphoid tissue), 710
Bandl's ring, 331–332, 429, 484
Barlow manoeuvre, 606–607
baroreceptors and blood pressure, 244
barrier contraceptives, 578–581
spermicide use, 581
Bartholin's glands, 56
basal body temperature in natural family planning, 583
basal metabolic rate in pregnancy, 164, 255
baseline rate on CTG, 345
variability, 346
basic life support, 487–489
bathing
in labour, 343
postnatal perineal pain, 508
battledore insertion of cord, 109
bed-sharing and breastfeeding, 711
beneficence, 38
benign sleep myoclonus, 674
bereavement, 555–567
twin, 304
best practice
Down syndrome screening, 209
in postnatal care, 509
with twins, 720
beta-blockers, 247
bicornuate uterus, 75
bifidus factor, 710
bikini line incision for caesarean section, 464–465
bile-stained vomiting, 672
biliary disease, 235–236
bilirubin
conjugated, 682
physiology, 682
raised levels. See hyperbilirubinaemia
serum measurements in treatment of isoimmunization, 687–688
unconjugated, 682
Billings (cervical secretions) method, 583
bimanual compression/pressure
in postpartum haemorrhage treatment, 409–411
in reversal of face presentation, 447
binovular twins. See dizygotic
biochemistry, pregnant vs non-pregnant, 155t. See also laboratory tests
biparietal diameter, 121
bipartite placenta, 109
biphasic combined oral contraceptive pill, 570
bipolar illness, 539–540
postpartum, 541
in pregnancy, 540
prevention, 549
treatment, 546–548
birth (birthing; delivery)
adaptation to extrauterine life, 117–118, 670
in breech presentation, mode, 359–360
giving. See childbirth
head. See head
multiple, 296–297
delay with second twin, 299
delayed interval birth of second twin, 299
operative. See operative births
trauma, claims arising from, 36
use/definition of term (in place of delivery), 334
weight see weight. See also childbirth
birth marks, vascular, 593, 662–663
birth plans, 15, 199, 334–335
birth pool/water birth, 378
breech birth and, 381
birthing ball, 371–372
birthing room
environmental considerations, 336
equipment, 343
low birth weight babies and, 622
music therapy provision, 353
transfer from, 406
bisacromial diameter, 121
bitemporal diameter, 121
bitrochanteric diameter, 121
black and ethnic minority women, 15–16
bladder, 87–88
full (immediately after birth), problems caused by, 405, 407
in labour, care, 344
in 2nd stage, 377
in pregnancy and childbirth, 156, 160
voiding. See micturition
blastocele, 96–97
blastocyst, 96–97
implantation. See implantation
blastomeres, 96–97
blastulation, 96–97
bleeding/blood loss (vaginal)
antenatal, early, 222–226
discussed at antenatal visit, 190
antenatal, later. See haemorrhage (maternal), antenatal
in caesarean section, postoperative, 467
menstrual. See menstruation
neonatal, 639, 688
in vitamin K deficiency, 637–638, 688, 709
postpartum, 506–507
after operative birth, 519–520
after vaginal birth, 518–519
stopping see haemostasis. See also haemorrhage
blistering rash, 669–670
blood
circulation/flow. See circulation
clot and clotting. See clot; clotting
cord, sampling, 404
fetal (in labour), sampling, 347–348
gases (maternal), 159
loss, 3rd stage of labour, estimation, 404. See also bleeding; haemorrhage
neonatal
intracranial haemorrhages due to disrupted flow of, 635–637
physiology, 600
volume increases (hypervolaemia), maternal, 150–153, 272
blood (vascular) supply
anorectum, 60
bladder, 88
breast, 705
kidney, 83
levator ani, 62
ovaries, 77
testes/scrotum, 78
ureters, 87
urethra, 89
uterine tube, 76
uterus, 74
vagina, 72
vulva, 56. See also haematology
blood cells
full count at booking visit, 188
red. See red blood cells
white, in pregnancy, 156–157
blood group assessment, 216–217
booking visit, 188. See also isoimmunization
blood pressure in pregnancy, 152–153, 244–245
abnormalities. See hypertension; supine hypotensive syndrome
adaptations (in pregnancy), 152–153, 245
at booking visit, 188
measurement/monitoring, 245
in diabetics, 261
in eclampsia, 253
in labour, 341
postnatal, 505
in pre-eclampsia, 250t
regulation, 244. See also central venous pressure
blood tap in spinal anaesthesia, 469
blood tests
booking visit, 188
pre-eclampsia, 250t
blood vessels (vasculature)
fetal development, 112–114
in pregnancy, changes, 149–153
in resistance, 144–148
blue skin, neonatal, 592, 612, 668–669
with good muscle tone, 613
‘blues’, postnatal, 536–537, 541
differentiation from psychosis, 541
body mass index (BMI), 165–166, 254–255
at booking visit, 187–188, 255
size classification using, 254
Bolam standard, 35
bonding/attachment, 556
bone
brittle, 662
fractures, neonatal, 633
mineral density and depot medroxyprogesterone acetate, 575–576
booking (for antenatal visit), late, 182
booking visit (initial assessment), 183–187
body mass index at, 187–188, 255
bottle feeding. See formula feeding
bowel (intestine)
maternal, postnatal problems, 507, 524
neonatal
malrotation/volvulus, 652–653
protrusion through umbilicus (omphalocele), 650 see also specific parts
Bowman's capsule, 83, 85
bra (brassiere), milk-expressing, 719
brachial plexus trauma, 632–633
brain
fetal, 115
maternal/in pregnancy, 159
cardiovascular centre, 244
shock effects, 490
neonatal, intracranial haemorrhage and stage of development, 635–636. See
also central nervous system; encephalopathy; neurological disorders
brain natriuretic peptide, 151–152
Braxton Hicks contractions, 145–146, 148, 333–334
breast, 704–710
anatomy and physiology, 704–705
cancer (incl. carcinoma)
breastfeeding contraindicated, 723
combined oral contraceptive pill and, 572
first, finishing feeding, 716
massage/stimulation
for expressing milk, 719
inducing labour, 426
one-breast-only breastfeeding, 723
postnatal
care, 505, 719
deviation from normal physiology and potential morbidity, 518f
engorgement, 720
factors affecting breastfeeding, 723
problems, 525, 719–720
weight in pregnancy, 166
breast pumps, 719
with attachment difficulties, 720
with engorgement, 720
breastfeeding, 704, 710–725
1st feed, 711
2nd (next) feed, 711
amenorrhoea, 583–585
antenatal help and preparation, 189, 711, 730
behaviour, 716–718
cardiac disease and, 268
contraindications, 723
depressive illness and, 545
drug intake considerations
anticonvulsants, 548
antipsychotics, 547
lithium, 548–549
SSRIs, 547
tricyclic antidepressants, 546
exclusive (up to 6 months), 710–711
management, 710–725
obesity and, 256
problems and difficulties, 718, 720–721
promotion initiative (worldwide) from 1991, 729–730
soon after birth, benefits, 405–406
twins, 299–301
preparation for, 293
separate vs simultaneous, 301
uterine contraction with, 398
vitamin K deficiency and, 637, 709. See also lactation; rooting reflex; sucking reflex
breastmilk, 704–710
banking for donation, 725
components, 707–710
antibodies, 601, 710
ejection (let-down) reflex, 705–706, 720–721
expressing, 718–719
production. See lactation
properties, 707–710
storage, 719
substitutes. See formula feeding
transfer
monitoring/assessment, 718
rate determining length of feed, 707
breathing
maternal, eclamptic seizure, 252
neonatal, 598, 612–613
LBW babies, 624
management in respiratory distress, 679. See also rescue breaths; ventilatory
breaths
breathlessness, 158b
breech presentation, 193, 356–360
1st stage of labour, 356–360
assessment, 341b
2nd stage of labour, 380–387
complications, 387
causes, 357
cord prolapse, 477
diagnosis, 357–359
engagement with, 193
incidence, 356–357
injury, 631
positions, 357, 381
professional responsibilities, 387
sacrum (as denominator) with, 196
types, 357, 381
undiagnosed, 381
vaginal birth. See vaginal birth
bregma, 120
brittle bone disease, 662
broad ligaments, 73
in pregnancy, 144
bromocriptine
lactation suppression, 723–724
prolactinoma, 264
bronchoconstriction in asthma, 270
bronchodilators, asthma, 270
bronchus-associated lymphoid tissue (BALT), 710
brow presentation, 121, 448–449
occipitoposterior position converted to, 442
bruises, neonatal, 593, 669
buttocks, 631
face (with face presentation), 448
bulbospongiosus muscle, 57
bulbourethral glands, 79
bullous (blistering) rash, 669–670
burden of proof of negligence, 36
burial, 224, 564
Burns Marshall manoeuvre, 382–383
buttocks
bruising/oedema, 631
internal rotation, 380
restitution, 380
button-hole tear of rectal mucosa, 312t, 314, 442
C
cabergoline, lactation suppression, 723–724
caesarean section, 463–472
breastfeeding and, 711
indications and their classification, 463–464
induction of labour and scar from, 424
malpresentations
breech, 359
shoulder, 451
multiple pregnancy, 294
operative procedure, 464–465
postnatal ward care after, 467–468
postoperative care, 466–468
postpartum haemorrhage with, 408
post-traumatic stress disorder, 537
psychological support and role of midwife, 465
requested by women, 465
research and incidence of, 471–472
tackling high/rising rates, 470
vaginal birth after, 466
wounds and their healing, 521–522
calcium
maternal intake, 165
neonatal/infant, 692
breastfeeding and, 710
imbalances, 692
calcium channel blockers in pregnancy, 247
calendar method of contraception, 583–584
cancer (malignancy)
breast. See breast
cervical, 223–224
cervical. See cervix
combined oral contraceptive pill and, 572
Candida albicans (incl. thrush), 678
maternal, 279
postnatal, and feeding, 720
neonatal, 678
cannulas. See catheters and cannulas
capacity/competency (mental) and consent, 35, 207
labour and, 337
capillary haemangiomata (strawberry marks), 662–663
capillary malformations, 662
caput succedaneum, 369–370, 372, 376, 630–631
cephalhaematoma and, 633–634
carbamazepine, 548
carbetocin, 401
carbohydrates
breastmilk, 707
metabolism, 164
wound healing and, 521t
carbon dioxide (blood)
maternal, arterial partial pressure, 159
neonatal, accumulation/excess, 612–613
carbon monoxide screening at first antenatal visit, 187
carboprost, postpartum haemorrhage, 409
carcinoma
breast. See breast
cervical, 223–224
chorionic (choriocarcinoma), 226–227
cardiac… see heart and entries under cardio…
cardinal ligaments, 72
cardinal veins, 112
cardiogenic shock, 489
cardiomyopathy, peripartum, 269
cardiopulmonary resuscitation. See resuscitation
cardiotocography (CTG; electronic fetal monitoring)
labour, 333
continuous, 345–347
normal, 346, 347b
pathological, 347, 347b, 348f
suspicious, 347, 347b, 348f, 376
multiple pregnancy, 295–296
cardiovascular centre of medulla oblongata, 244
cardiovascular system
amniotic fluid embolism signs and symptoms, 485
fetal, 112–114
neonatal, 600
NIPE (Newborn and Infant Physical Examination), 602
pregnancy-related changes, 149–157. See also circulation
care (maternity - general aspects)
antenatal. See antenatal care
duty of. See duty of care
NHS outcomes framework relating to, 46b
organization, 11
postnatal. See postnatal period
women-centred, 13
Care of the Next Infant (CONI), 185
carers in loss, formal, 563–564
caries, dental, 161–162
Caring for Our Baby (theme in antenatal education programme), 136
casein-dominant formulae, 726
casuistry, 39
catheters and cannulas
intravascular, bleeding associated with, 639
subarachnoid space misplacement, 469–470
urinary, caesarean section, 464
causation in negligence claims, 36
caution order, 30
cavernous haemangioma, 593
Central Midwives Boards, 27, 39–40
episiotomies and, 321
central nervous system
neonatal
assessment, 671
malformations, 658–660
in pregnancy, 159. See also neurological disorders
central venous pressure monitoring in shock, 491
cephalic presentation. See head
cephalic version, external, 357, 450
cephal(o)haematoma, 633–634
and caput succedaneum, 633–634
cerebral haemorrhage with face presentation, 448
cerebral palsy arising from negligence, 36
cerebrospinal fluid leak, neonatal, 598
cervical ligaments, transverse, 72
cervix (uterine neck), 73
canal, 73
cancer
combined oral contraceptive pill, 572
in pregnancy, 223–224
diaphragm covering, 580
dilatation (in labour), 329–330
charting (cervicograph), 338
checking before encouraging pushing, 385
examination/assessment
for labour induction, 422
in labour, 341b
mucus plug. See mucus plug
os (in pregnancy)
multips, 330
in placenta praevia, 231, 232f
palpation, as natural family planning method, 583
in pregnancy, 148–149
carcinoma, 223–224
cerclage, 226
ectropion, 223
effacement/taking up, 149, 329–330
inelastic/incompetent, 226
os see subheading above
polyps, 223
ripening and other changes (in pregnancy), 148, 422
drugs inducing, 267, 423–424
secretions (natural family planning method), 583
sweep (of membranes - CMS), 419–420, 422–423
vault caps covering, 581
Chadwick's sign, 149, 171
Changes for Me and Us (theme in antenatal education programme), 133–134
chemoreceptors and blood pressure, 244
chest
maternal, compressions, 488–489
neonatal, examination, 596
chickenpox (varicella), 677
fetal/congenital/neonatal, 669, 677
maternal, 677
childbirth (giving birth; intrapartum period)
antenatal education for. See antenatal education
brow presentation diagnosed in, 449
caesarean section indicators in, 464
cardiac disease and, 267
diabetes management, 261–262
eclampsia and, 252
expected date, determination, 184–185
face presentation diagnosed in, 445
fear, 533–534
language, 334
midwife–woman relationships and, 10–11
mother's experience of, 559
loss of anticipated experience, 559
making it a positive one, 430–431
multiple pregnancy, 296–297
delay of birth of second twin, 299
delayed interval birth of second twin, 299
obesity risks, 256
occipitoposterior position in, 442
diagnosis of, 438
operative methods. See operative births
pelvis in, 65
personal account, 388b
place for. See place
plans, 15, 199, 334–335
previous history. See obstetric history
prolactinoma, 265
shoulder presentation, diagnosis, 450–451
social context, 13–18
unstable lie in, management, 452
urinary tract changes in, 89–90
uterine rupture in, signs, 484. See also birth; labour
children. See infants; minors; neonates; teenage mothers
Children's Centres, 138, 501–502, 510
Chlamydia trachomatis, 279–280
neonatal, 279–280, 595, 605–606, 678
screening, 189
chloasma, 167–168
choanal atresia, 613–614, 655–656
cholestasis, obstetric, 235–236, 257
cholesterol
in breastmilk, 707
pregnancy and, 165
chorioamnion. See membranes
chorioamnionitis, 239
choriocarcinoma, 226–227
chorion, 104, 106
chorion frondosum, 103
chorion laeve, 103
villus/villi, 103
villus/villi, sampling (CVS)
dichorionic placenta, 292
Down syndrome, 209–210
women with cardiac defects/disease, 266
chorionicity of twins
determination, 288–292
importance, 291–292
relationship between zygosity and, 291t
chromosomes, 95b
abnormalities causing malformations, 648–650
sex. See sex chromosomes
circulation (blood flow)
at birth, adaptations, 117–118
failure. See shock
fetal, 116–117
postnatal, 522
deviation from normal physiology and potential morbidity, 518f
disorders, 522
observation, 505
in pregnancy, regional, 153
eclamptic seizure, management, 252
placental, 106, 146
uterine, 146. See also cardiovascular system
circumcision
female. See female genital mutilation
male, hypospadias and, 596
circumvallate placental, 109
citalopram, 547
clavicular fracture, 633
cleanliness in labour, 343
environmental, 336
cleft lip and/or palate, 594–595, 653–654, 722
Clinical Commissioning Groups, 44
clinical effectiveness, 44
clinical governance, 44–49
Clinical Negligence Scheme for Trusts, 47
clinical preceptor/teacher in Global Standards for Midwifery Education (2010), 6
clitoris, 56
partial or total removal/excision, 315, 316f, 317
clonic convulsions, neonatal, 640
Clostridium difficile, 46
clot(s) (blood), placental, assessment, 405
puerperal, 507
clothing in labour
maternal, 343
midwife's, 337
clotting (coagulation), maternal, 156
disorders/failure, 234–235
with amniotic fluid embolism, 486
postpartum haemorrhage in, 412
hypercoagulable state, 156, 266, 272
normal (in pregnancy), 230, 234
clotting (coagulation), neonatal, 600
disorders, haemorrhage with, 637–639
clozapine, 547
clubfoot
positional, 597–598
structural (congenital talipes equinovarus), 597, 661
CMV. See cytomegalovirus
coagulation. See clotting
cocaine, 697
coccyx, 64
Code, The, 32–34, 501b
record-keeping, 509b
coitus interruptus, 582
colic in breastfed baby, 721–722
collapse, postnatal, 517
collective responsibility, 31
collegial relationships, 11
colloids, hypovolaemic shock, 490
coloboma, 605
colon in pregnancy, 163
colostrum, 601, 707–708
expressed, 718, 720, 724–725
hypoglycaemia and, 730
vitamins in, 708–709
colour, neonatal skin, 612
assessment, 592, 668–669
coma, myxoedema, 263
combined hormonal contraceptives
injectable, 574
oral (COC), 570–574
future developments, 586–587
hypertension and, 279, 572
missed, 573
patch, 574
vaginal ring, 574
comfort in labour
in 1st stage, 343
in 2nd stage, 377
communication (with mothers/parents), 534
at booking visit, 183–184
of congenital malformations, 650–652
difficulties, 16–17
emergency, 476
in labour, 334
neonatal examination, 598
in resuscitation with parents present, 614. See also information; talking
community setting. See home (or community setting)
compaction with fetal descent, 380
companion (birthing), 335
support in 2nd stage of labour for, 375–376. See also partner
compensated shock, 489
competency (mental). See capacity
complementary feeds (to breastfeeding), 724–725
compound presentation, 452, 477
compression support stockings
thromboembolism prevention, 266–268, 271, 277, 467, 522, 525–526
varicosities, 190
conception
assisted, pregnancy problems, 228
evacuation of retained products of, 225. See also pre-conception period
condition. See health and well-being
conditions of practice order, 30
interim, 30
condom
female, 579
male, 579
spermicide-lubricated, 581
conduct, standards of, 34
Conduct and Competence Committee, 30
Confidential Enquiries into Maternal Deaths, psychiatric causes, 538, 550
Congenital Disabilities (Civil Liability) Act (1976), 36
congenital infections
chickenpox/varicella, 669, 677
rubella, 676–677
syphilis, 281
congenital malformations. See malformations
conjoined twins, 298
conjoint longitudinal coat of anal sphincters, 60
conjugate (anteroposterior) diameter of pelvic inlet, 66–67
conjunctival haemorrhage, 595
conjunctivitis, neonatal (ophthalmia neonatorum), 595, 596f, 605–606, 678
Conn's syndrome, 248
consensual panel determination (NMC), 30–31
consent (inc. informed consent), 35–36
antenatal screening, 206–207
labour and, 337
mental capacity and, 35, 207
consequentialism (utilitarianism), 38–39
constipation, 164b
with analgesia in postoperative anal sphincter repair, 320
consumptive coagulopathy. See disseminated intravascular coagulation
contact (mother–baby), 625–626
lost baby, 560–561
skin-to-skin, 296, 299, 398, 465, 499–500, 599–600, 622, 711
social, 625
continence, postnatal, 507. See also anal incontinence; urinary incontinence
continuing professional development standard, 35
continuous care and support in labour, 336
prolonged labour, 428
continuous electronic fetal monitoring, 345–347
continuous subcutaneous insulin infusion pumps, 258–259
contraception, 569–588
barrier methods. See barrier contraceptives
counselling. See counselling
emergency, 581–582
future of, 586
hormonal methods. See hormones
hypertensive women, 279
long-acting reversible, 575–578, 586
natural methods, 582–585
role of midwife, 570
contractions (uterine), 331
in 2nd stage of labour, 368–369, 376
expulsive, 369
in 3rd stage of labour, 397
rub up, 409
Braxton Hicks, 145–146, 148, 333–334
intensity, 331
at onset of labour, 329
sustaining (with uterotonics) in treatment of postpartum haemorrhage, 409
contractual accountability, 31–32
convoluted tubules, 83
convulsions. See seizures
cooling
neonate
induced, in encephalopathy, 673–674
unwanted, 598–599
postnatal perineal pain, 508
copper IUCD. See intrauterine systems
cord. See umbilical cord
cornea (neonatal), examination, 595
coronal suture, 118
coronary angioplasty, 269
corpora cavernosa, 79
corpus luteum, 94, 143
corpus spongiosum, 79
cortical nephrons, 83
cortical reaction (at fertilization), 95
corticosteroids (steroids), asthma
inhaled, 270
tablets, 270
cortisol, maternal, 169, 171
cotyledon, 104
broken fragments, 405
retained, 407
counselling
antenatal screening, 207
Down syndrome, 209
haemoglobinopathies, 211
contraception
sterilization, 585–586
subdermal contraceptive implants, 577
grief and bereavement, 665
multifetal pregnancy reduction, 305
neural tube defect, 660
preconception, 266, 276, 278
termination of pregnancy for fetal abnormality, 559
Couvelaire uterus, 233
cow's milk protein intolerance, 727
creatinine measurements in pregnancy, 155t, 161
cremation, 224, 564
cretinism, 170
cricoid pressure in caesarean section in Mendelson's syndrome prevention, 470
crowning, 377
right occipitoposterior position, 440
crown–rump length and Down syndrome, 209
crying (midwife) with bereaved parents, 564
cryptorchidism, 664
crystalloids, hypovolaemic shock, 490
culture
diaphragm (contraceptive) and, 580
emotion and, 12
loss and, 557
curriculum in Global Standards for Midwifery Education (2010), 7
Cushing's syndrome, 248
cuts and lacerations, neonatal, 593, 629–630
cyanocobalamin supplements, 275
cyanosis, neonatal, 592, 669
cardiac defects causing, 656–657
peripheral/at extremities (acrocyanosis), 592, 668–669
cyproterone in combined oral contraceptive pill, 570–571
cystic fibrosis, meconium ileus, 653
cystic kidney, 663–664
cytomegalovirus (CMV), 280
screening, 189
cytotrophoblast, 97, 102–103, 168
D
dating of pregnancy, ultrasonography, 418
deaths/mortalities
fetal
induction of labour, 421
vasa praevia, 477
infants (incl. neonates)
early, 558
multiple, 304
sudden infant death syndrome, previous occurrence (woman or in family), 185
maternal, 564
in epilepsy, 278
in genital tract infection, 279
in psychiatric illness, 550
in septic shock, 492
in shoulder dystocia, 483
perinatal (in general), 557–558. See also abortion; bereavement; feticide; life-
threatening conditions; loss; miscarriage; stillbirths
decelerations, 346
atypical variable, 346
late, 346
typical variable, 346
decidua, 101, 146
decidua basalis, 101, 103
decidua capsularis, 101, 103
decidua vera/parietalis, 101
reaction (decidualization), 101, 104–105, 143, 168
decubitus ulcer prevention in labour, 343
deep transverse arrest, 442
deep vein thrombosis (DVT), 190, 229, 271–273, 522
defence mechanisms in loss and grief, 556
deflexion of head in occipitoanterior position, 437f–438f, 442–443, 451
deformations
developmental. See malformations
pelvic, 69
deinfibulation, 317–318
personal account, 323
delivery (birthing)
baby. See birth
placenta, cardiac disease and, 267. See also birth; caesarean section; vaginal birth
delusions, psychotic, 541
denial (of loss), 556
denominators (with presentations), 196
dental health, 161–162
deontology, 39
depot medroxyprogesterone acetate, 575–576
depression (and depressive illness), 537
postnatal, 136. See also antidepressants; bipolar illness
deprivation (poverty), 15
dermatitis, breast, 720
dermatology. See skin
descent
fetal head. See head
placenta. See placenta
desogestrel in combined oral contraceptive pill, 570–571
development
fetal. See fetus
neonatal/postnatal
intracranial haemorrhage and stage of brain development, 635–636
LBW/preterm baby, 625
twins, 302
sex, disorders, 597, 664, 695
structural abnormalities. See malformations
developmental dysplasia of hips, 606–607, 661–662
diabetes mellitus, 165, 257–262
family history of, 186, 258
gestational. See gestational diabetes mellitus
induction of labour, 421
infant hypoglycaemia in, 690
macrosomia and, 618–619
maturity onset diabetes of the young (MODY), 259
secondary, 259
shoulder dystocia and, 479
type 1, 257–262
type 2, 254, 257, 259–262
diamniotic twins, 291
diamorphine (heroin)
abuse, 696
caesarean section, postoperative, 466
labour, 354
diaphragm (contraceptive), 579–581
diaphragmatic hernia, congenital, 654–655, 680–681
diarrhoea, neonatal, 672
diastolic murmur, 603–604
dichorionic twins, 288–294, 297
chorionic villus sampling, 292
premature expulsion of placenta, 299
ultrasound examination, 292
diclofenac (incl. Voltarol)
anal sphincter repair, postoperative, 320
perineal pain (postnatal), 508
diet
deficiency, pelvic anomalies, 70
at first antenatal visit, 186
in labour, 343–344. See also nutrition
digestive system. See gastrointestinal system
digit(s)
anomalies, 597–598
blood pressure-measuring devices, 245
dinoprostone inducing labour, 267, 423–424
disability
baby born with, 559
twin, 304
women with, 14–15
disadvantaged groups/women, 13–17
booking visit, 184
midwives meeting needs of, 17–18
discharge home in drug abuse, 697
discussion in antenatal education sessions, promoting, 131–132
disseminated intravascular coagulation (consumptive coagulopathy)
maternal, 273
in amniotic fluid embolism, 486
neonatal, 638–639
distress, psychological, 537
headache as precursor of, 523
diuretics in hypertension, 247
dizygotic (binovular/DZ) twins, 288, 292
monozygotic vs, 95–96, 288
DNA, free fetal, 214
documentation. See records and documentation
domestic abuse, 184, 509–510
dominant gene disorders, 648
dopamine agonists
lactation suppression, 723–724
prolactinoma, 264–265
Doppler assessment of fetal heart rate
labour, 344–345
multiple pregnancy, 295–296
double pumping, 719
double uterus, 75
doula, 336, 503–504
Down syndrome (trisomy 21), 208–210, 649–650
breastfeeding, 723
screening, 207–210, 213
drospirenone in combined oral contraceptive pill, 570–571
drug(s) (medical)
breastfeeding. See breastfeeding
lactation-suppressing, 723–724
placental transfer and risk to fetus, 105
anticonvulsants, 548
antipsychotics, 547
lithium, 548
SSRIs, 546–547
tricyclic antidepressants, 546
records in labour, 344
standards for management of, 35
toxicity, 492
treatment with. See medical management and specific (types of) drugs
drug abuse. See substance abuse
drying the baby, 611–612
Duchenne–Erb (Erb's) palsy, 632
ducts, lactiferous/milk, 705
blocked, 721
ductus arteriosus (arterial duct), 116–117
at birth, 117–118
patent persistent (PDA), maternal, uncorrected, 268
patent persistent (PDA), neonatal, 602, 645, 657–658
lesions dependent (for haemodynamic stability) on, 657–658
ductus venosus, 112, 116–117
at birth, 117
duodenal atresia, 652
duplications, uterine, 75
dural puncture-related headache, 356b, 357
duty of care, 32, 36, 39, 47
breach, 36–37
dyslipidaemia, atherogenic, 254
dysmenorrhoea, 94
dyspnoea (breathlessness), 158b
dystocia, 427
shoulder. See shoulder
E
ears
fetal, 115–116
neonatal, examination, 594
eating. See diet; nutrition
Ebstein's anomaly and lithium, 548
ecbolics. See uterotonics
eclampsia, 251–253
fulminant, 251
ectoderm (embryo), 97
neural tube development from, 115
ectopic (mainly tubal) pregnancy, 148–149, 225–226
education
maternal
antenatal. See antenatal education
diabetes, 261
midwife, ICM global standards, 4–8. See also information
Edwards' levels of ethics, 38b
Edwards' syndrome, 650
egg. See oocyte
ejaculatory ducts, 79
ejection murmur, 603
electrically-controlled breast pump, 719–720
electrolyte imbalances in newborns, 691–692
electronic fetal monitoring. See cardiotocography
elemental formulae, 727
ellaOne, 582
embolism
amniotic fluid, 485–486
pulmonary. See pulmonary embolism
embryo development, 97, 111
stem cells in. See stem cells
timescale, 111, 113
embryoblast, 97–99
emergency
contraception, 581–582
threat to health, 475–495
antepartum haemorrhage, 232, 234
breech presentation classed as, 356–357
communication in, 476
inborn errors of metabolism, 693
emesis. See vomiting
emotion(s)
in labour, 335, 535–536
midwives', 8–13
developing awareness of, 8, 12–13
managing, 11–12
postnatal, 526, 536
in pregnancy
antenatal screening impact on, 204–205
normal changes, 535–536. See also distress
emotion work, 9
sources, 9–11
emotional intelligence, 12
encephalopathy, neonatal, 672–674
end-of-life care with congenital malformations, 646–647
endocrine system (and activity)
adult female/maternal, 168–171
disorders, 257–265
kidney, 84
placenta, 104–105, 168–169
fetal, 115
neonatal, disorders, 694–695. See also hormones
endoderm (embryo), 97
endometrial cycle (menstrual cycle), 92f, 94–95
endometrium, 73, 144
combined oral contraceptive pill and cancer of, 572
implantation into. See implantation
in menstrual/endometrial cycle, 94–95
in pregnancy. See decidua
endorphins, 351
transcutaneous electrical nerve stimulation and, 353
endotracheal intubation in caesarean section, difficult/failed, 470–471
enemas, 343
engagement (fetal head descent into pelvic brim). See head
enkephalins, 351
enoxaparin, 266
enterocolitis, necrotizing (NEC), 672
Entonox. See nitrous oxide + oxygen
environment (physical)
in labour, 336
cleanliness, 336
position and, 372
LBW babies and optimization of, 625–626
environmental and genetic factors, disorders due to combination of, 648
epiblast, 97–98
epidermolysis bullosa, 669–670
epididymis, 78
epidural (regional) analgesia/anaesthesia, 354–356, 371b
caesarean section, 467–469
postoperative care after, 467
postoperative use, 466
technique, 469
cardiac disease patients, 267
complications, 356
multiple pregnancy, 296
spontaneous vaginal birth and, 371b
upper abdominal pressure (in labour) and, 369
epilepsy, 277–279
epinephrine. See adrenaline
episiotomy, 313
postpartum haemorrhage relating to, 407
repair, 318
in shoulder dystocia, 481
training (in performance and repair), 321
epithelial overgrowth (nipple), 721
Epstein's pearls, 595
epulis, pregnancy, 161
ERASMUS programme, 8
Erb–Duchenne (Erb's) palsy, 632
Erb–Klumpke palsy, 632
ergometrine, 400
cardiac disease and, 267
combined oxytocin and, 400
in postpartum haemorrhage treatment, 409
erythema, palmar, 168
erythrocytes. See red blood cells
erythropoietin, 84
Essure, 585
ethics, 37–39
frameworks and theories, 37–39
standards of, 34
ethnic minority women, 15–16
ethnocentrism, 16
eumenorrhoea, 94
European Action Scheme for the Mobility of University Students (ERASMUS)
programme, 8
European Convention for the Protection of Human Rights and Fundamental
Freedoms, 32
European Union Standards for Nursing and Midwifery, 4
evacuation of retained products of conception, 225
evidence-based research and practice, 3, 12
postnatal care, 509
EVRA (combined hormone patch), 574
examination, maternal (incl. physical)
abdominal. See abdomen
breech presentation, 357–358
in labour, 358–359
brow presentation, antenatal, 449
face presentation, intrapartum, 445
at initial assessment, 187–196
as indicator for referral for additional support, 183
midwife's, 189–196
recognition of problems, 668–672
in labour in 1st stage, 327, 340
breech presentation, 358–359
initial, 337
membranes. See membranes
occipitoanterior position
antenatal, 436–437
intrapartum, 438
placenta, 404–405
post-mortem (baby), 561
shoulder presentation
antenatal, 450
intrapartum, 450–451. See also observation; palpation
examination, neonatal
daily, 598–601
first, 592–598
NIPE (Newborn and Infant Physical Examination), 601–607
exchange transfusion in physiological jaundice, 684–685
excretion, fetal, 105
exercise
first antenatal visit and, 186–187
postnatal, 508–509
women's views at postnatal classes, 502
exomphalos, 650
expectant management
3rd stage of labour, 398–400, 403–404
prolonged pregnancy, 419
expected date of birth, determination, 184–185
experiences
midwife, of loss, 559
mother
in antenatal education groups, sharing, 130b
of childbirth. See childbirth
in fetal ultrasonography, 211–212
Expert Reference Group on antenatal education
Preparation for Birth and Beyond, 133–136, 138
systematic review, 129
on wants and needs of stakeholders, 138
expiratory grunting, 670
extension of fetal head, 374
left mentoanterior position, 445
right occipitoposterior position, 440
external cephalic version, 357, 450
external rotation of head, 371–372, 374, 375f, 378
breech presentation, 381
left mentoanterior position, 446
right occipitoposterior position, 441
extracorporeal membrane oxygenation in meconium aspiration syndrome, 679
eyes
fetal, 115–116
neonatal
first examination, 595
infections, 595, 605–606, 678
NIPE (Newborn and Infant Physical Examination), 605–606
F
face, fetal, 120
bruising with face presentation, 448
presentation, 121, 193–194, 444–448
causes, 444
complications, 448
labour management, 447–448
mentum as denominator with, 196
occipitoposterior position converted to, 442
primary vs secondary, 444
reversal, 447
trauma, 448, 631
face, neonatal
examination, 594–595
instrumental delivery-related trauma, 462–463
palsy (facial nerve damage), 462–463, 594f, 631–632
face to pubis presentation, undiagnosed, 442
facilities in Global Standards for Midwifery Education (2010), 7
faculty in Global Standards for Midwifery Education (2010), 6
faeces (stools)
maternal, incontinence (anal incontinence), 320, 507, 524
neonatal/infant, 601
bottle-fed baby, 729
breast-fed baby, 718
fallopian tubes (oviducts; salpinges; uterine tubes), 75–76
occlusion (for sterilization), 585–586
in pregnancy, 144
ectopic pregnancy in tubes, 148–149, 225–226
Fallot's tetralogy, 657
family
loss impacting on, 563
parenthood and relationship with other members of, 556
postpartum care centering on, 516
family history, 186
diabetes mellitus, 186, 258
Family–Nurse Partnership (FNP) programme, 138
postnatal care and, 502
fascia (pelvic), vagina, 72
fat(s)
body (in general), distribution related to disease, 254
breast, 704–705
in breastmilk, 707
wound healing and, 521t
fat-soluble vitamins, 708–709
fathers
in antenatal education
inclusion, 138–139
numbers, 139
in antenatal screening, unknown/unavailable/declining tests, 211
impact of loss, 563. See also parenthood; partner
fatigue/tiredness, postnatal, 508, 526
fatness, measures of, 254
fatty acids in breastmilk, 707
fatty liver, 253
fear
of giving birth, 533–534
in psychosis, 541. See also anxiety
feeding, infant, 703–736
complementary/supplementary to breastfeeding, 724–725
discussed at antenatal visit, 189
LBW babies, 624–625
poor, indicating bacterial infection, 675
twins, 299–301. See also breastfeeding; formula feeding
feet
in breech presentation, 357
in labour, 359
neonatal, examination, 597–598
female baby genitalia
examination, 597
male-looking, 664, 695
female genital mutilation (FGM/genital cutting/female circumcision), 314–317
personal account, 322b–323b
repair, 318. See also women
FemCap, 581
Femilis (and Femilis Slim), 578
feminization (under-virilization), male, 664
femoral fracture, 633
Ferguson reflex, 330, 368–369, 428
ferrous salts
antenatal, 274
postnatal, 524–525
fertilisation, 95–96
fertility
awareness (natural family planning), 582–585
future (after childbirth), 509
problems, 558
fetal haemoglobin, 114, 275
fetal membranes, 106
fetal surface of placenta, 104
feticide, 228
selective, 305
fetus, 111–123
adaptation to extrauterine life, 117–118, 670
amniotic fluid embolism effects, 486
antepartum haemorrhage and the
appraisal of fetus, 230
effects of haemorrhage, 230
asphyxia. See asphyxia
axis pressure, 333
blood sampling in labour, 347–348
death. See death
development and maturation, 112–116
timescales, 111, 113
diabetes and risk to, 260
diagnosis of abnormality. See antenatal diagnosis
distress or compromise, 296, 345, 456
excretion, 105
growth. See intrauterine growth
head. See head
heart. See heart
in instrumental delivery
as contraindicator, 457
as indicator, 456
intrauterine growth restriction related to factors in, 620
lie, 194
malformations. See malformations
movements. See movements
nutrition, 105
obesity and risk to, 255
position, 196
presentation. See presentation
prevention of rejection, 102
prolonged pregnancy and its impact on, 418–419
respiration, 105
rights, 36
screening, 189, 208–214
in shoulder dystocia, morbidity, 483
in shoulder presentation causation, 450
spontaneous/accidental loss. See miscarriage
teratogens. See teratogens
in unstable lie causation, 452
well-being. See health and well-being
fetus-in-fetus, 298
fever (pyrexia), neonatal, 599
fibrin, 234
breakdown (fibrinolysis), 234
deposits, HELPP syndrome, 253
fibroids (leiomyomas; fibromyomata)
degeneration, 227
postpartum haemorrhage relating to, 408
fits. See seizures
Five Rhythms method, 343
flexion (of fetus in labour), 373, 376
lateral, 374, 380
in occipitoposterior position, 440
failure, 441–442
in mentoanterior position (right), 446
ventouse extraction and point of, 459
floppy (hypotonic) baby, 612–614, 671
fluid balance
maternal, 166
labour, 341
neonatal overload, 691
fluid management
hypovolaemic shock, 490
septic shock, 492
fluoxetine, 547
focal (partial) neonatal convulsions/seizures, 640
folic acid
deficiency, 274–275
twin pregnancy and, 294
diabetic women, 261
supplements, 275
antiepileptic drugs and, 278–279
follicle(s), ovarian, 93–94. See also Graafian follicles
follicle-stimulating hormone (FSH)
females, 91–92
in ovarian cycle, 93–94
in pregnancy, 169
males, 80
follicular phase of ovarian cycle, 93–94
fontanelles, 116, 118–120
anterior, 120
posterior, 120
food cravings, 162. See also diet; feeding; nutrition
foot. See feet
footling breech, 357
foramen magnum, 118
foramen ovale, 112, 116, 118
at birth, 118
closure, 117
forceps, 456, 460–463
breech presentation, 384, 456
characteristics, 460
classification, 460
complications, 462–463
neonatal trauma, 629–630
contraindications, 457
indications, 456
procedure, 460–461
types, 460. See also instrumental vaginal birth
forebrain, fetal, 115
foregut, 115
forehead region (fetal skull), 120
foremilk, 707, 716
forewaters, 332
rupture. See rupture of the membranes
formal carers in loss, 563–564
formula (bottle) feeding, 726–729
allergy and, 708
breastfeeding compared with, morbidity problems, 708, 726
choosing a feed, 727
as complementary or supplementary feeds to breastfeeding, 724–725
equipment, 728
sterilization, 728
intolerance to standard formulae, 727
preparation of feed, 727–728
technique, 728–729
twins, 299–300
preparation for, 293
types of milk, 726–727
‘framing’ effect, 207–208
frank breech, 357
Fraser competence, 35–36
frenotomy in tongue tie, 722
frontal bones, 118
frontal suture, 120
full blood count at booking visit, 188
functional vital capacity, 158
funeral, 561, 564
midwives at, 564. See also burial; cremation
funic souffle, 146
G
galactosaemia, 694
gall bladder in pregnancy, 163
disease, 236
GALT (gut-associated lymphoid tissue), 710
gametes. See oocyte; spermatozoon
gases, blood, in pregnancy, 159
Gaskin manoeuvre, 481
gastric…. See stomach
gastrointestinal (digestive) system
fetal, 115
maternal
changes, 161–164
shock affecting, 490
neonatal, 600–601
examination for problems, 672
malformations, 650–654
gastro-oesophageal junction in pregnancy, 162–163
gastroschisis, 650
gastrulation, 97
gate-control theory of pain, 351–352
general anaesthesia
caesarean section, 470–471
care following, 467
postpartum haemorrhage relating to, 407
general fluid pressure (in labour), 332
generalized neonatal seizures, 640
genetic disorders
congenital malformations due to, 648
cardiac, 266
family history of, 186
of metabolism, 692–694
genitalia. See female genital mutilation; reproductive system
genitourinary system (neonatal)
examination for disorders, 671–672
malformations, 81, 663–664
germ cells. See oocyte; spermatozoon
germinal matrix haemorrhage (GMH), 635–637
gestational age, 618
appropriate growth for, 618
assessment (at birth), 622–623
large for, 618
small for. See small for gestational age
gestational diabetes mellitus (GDM), 165, 260–262
shoulder dystocia and, 479
gestational hypertension, 246–247
gestational trophoblastic disease, 226–227, 249
gestodene in combined oral contraceptive pill, 570–571
Getting to Know Our Unborn Baby (theme in antenatal education programme), 134b
Gillick competence, 35–36, 337
Giving Birth and Meeting Our Baby (theme in antenatal education programme), 134
glandular tissue, breast, 704–705
Glasgow Coma Score, hypovolaemic shock, 491
globalization, 4–8
glomerulus, 83
filtration, 85
in pregnancy, 161
selective reabsorption in, 85–86
glucagon, 257
fetal, 115
glucocorticoids, adrenal, 695
glucose, maternal blood (glycaemia)
abnormal values. See hyperglycaemia; hypoglycaemia
assessment and management, 253, 261
intrapartum, 261
normal values, 165
glucose, neonatal blood (glycaemia), 689
abnormal levels, 689–691
homeostasis, 689
tests, 262, 690
glucose tolerance test (GTT), 256–257
glycaemia. See glucose
glycolysis, neonatal, 598–599
glyc(osyl)ated haemoglobin, 259–260
goat's milk formulae, 727
gonadotrophins
human chorionic. See human chorionic gonadotrophin
pituitary. See follicle-stimulating hormone; luteinizing hormone
gonorrhoea (N. gonorrhoeae infection)
maternal, 280
neonatal eye infection, 595, 605–606, 678
Goodell's sign, 148, 171
governance, clinical, 44–49
Graafian follicles, 93–94
rupture, 94
grandparents, impact of loss, 563
granular cells, 83
granuloma, pyogenic, 161
Graves' disease
maternal, 264
neonatal, 694–695
gravidity and attendance at antenatal sessions, 137–140
great arteries, transposition, 604b, 657
grief (in loss), 556–557
in multiple pregnancy/birth of one baby, 304
stages, 556–557
in termination of pregnancy, 558–559
group A streptococcus, 281
group B streptococcus (GBS), 281, 675–676
respiratory distress, 679
screening, 189, 215
growth
appropriate (for gestational age), 618
charts, LBW and preterm babies, 623
fetal. See intrauterine growth
undergrown. See small for gestational age
weight in assessment of, 618
growth factors in breastmilk, 710
growth hormone
human placental, 105
pituitary, deficiency, 695
grunting, expiratory, 670
guidelines (in clinical governance), 44–45
gut-associated lymphoid tissue, 710
Gygel, 581
gynaecoid pelvis, 68, 68t
GyneFix, 578
H
haem in pregnancy, 154, 275
haemangioma(ta), 593
capillary/strawberry, 662–663
haematemesis, 639
haematology
maternal/in pregnancy
disorders, 247
normal changes, 153–157
tests (compared with non-pregnant woman), 155t
neonatal, disorders, 688–689
haematoma, postpartum, 413
haematuria, 639
haemoglobin
fetal, 114, 275
glyc(osyl)ated (HbA1c), 259–260
postnatal levels and assessment, 524
in pregnancy, 154. See also anaemia
haemoglobin H disease, 275
haemoglobin S, 276–277
haemoglobinopathy, 275–277
screening for, 189, 210–211, 215–216
haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, 253
haemolytic disease of the newborn (HDN), 188, 216, 684–686
haemolytic jaundice, 685–686
haemophilia, 689
haemorrhage (baby), 633–639
cerebral (fetal), with face presentation, 448
conjunctival (neonatal), 595
support of parents, 641
haemorrhage (maternal), antenatal (and unspecified or in general), 229–235
arrest, 490. See also bleeding
haemorrhage (maternal), postpartum, 406
care after, 414
multiple pregnancy, 299, 407
primary, 406–412
causes, 406–408, 412, 487
maternal observation following, 412–413
prophylaxis, 408
signs, 408
treatment, 409–412
secondary, 413
timing of components of active management in relation to incidence of, 403
haemorrhoids, 164b
haemostasis (stopping bleeding)
endogenous
with placental separation and descent, 397–398
in wound healing, 520f
in postpartum haemorrhage, 409
hair growth, maternal, 167b
hand(s), neonatal
examination, 597–598
malformations, 660. See also manual techniques
handling the baby, 625–626
hands-free milk expression, 719
hands-off technique, 377
breech birth, 381, 385
hands-on-help from midwife in breastfeeding, 715–716
haploidy oocyte, 94
at fertilization (and haploid sperm), 95
Hashimoto's disease, 263
head (fetal)
attitude, 121, 194
birth of
in breech presentation, 381–384
in breech presentation, delay, 385
in face presentation, 447–448
normal, 377–378
in shoulder dystocia, reinsertion of head after, 482–483
circumference (HD) measurement
at birth, 593–594
ultrasound, 213
deflexion in occipitoanterior position, 437f–438f, 442–443, 451
descent into pelvic brim and engagement, 148, 193, 342f, 373, 376
breech birth, 382
extension. See extension
high, cord prolapse or presentation with, 477
moulding. See moulding
presentations (cephalic presentation), 121, 193–194, 373–374
assessment in 1st stage of labour, 341b
engagement with, 193
mechanism of labour in, 373–374
varieties, 195f
rotation. See external rotation; internal rotation
stations in relation to pelvic canal, 342f
head (neonatal)
examination, 593–594
feeding and support for, 624, 712
heat loss, 623
headache
dural puncture-related, 356b, 357
postnatal, 523
Health Act (1999), 28
Health and Social Care Act (2012), 27, 501–502
health and well-being/condition
fetal
in 1st stage of labour, 344–348
in 2nd stage of labour, 376
in diabetes, tests for, 261
indicators of, 196–198
multiple pregnancy, compromise, 296
maternal antenatal
in 1st stage of labour, assessment, 340–341
in 2nd stage of labour, 374–379
as indicator for referral for additional support, 183
indicators of, 196
maternal postnatal, 515–529
expectations, 508–509
future, 509
identifying deviation from normal, 517–525
immediate untoward events for mother, 516–517
life-threatening conditions and morbidity, 516
problems, 515–529
partner and other companions, in 2nd stage of labour, 375–376. See also medical
conditions/disorders; Our Health and Wellbeing; sexual health
Health Care and Associated Professions (Indemnity Arrangements) Order (2013), 37
Health Committee, 30
Healthy Start Initiative, 729
heart (fetal)
growth and development, 112
rate. See heart rate
heart (maternal)
anatomical changes, 149–153
failure, shock (=cardiogenic shock), 489
output, 152
in hypovolaemic shock, 489
output in labour
pain affecting, 352
positioning affecting, 267
heart (neonatal)
murmur. See murmur
NIPE (Newborn and Infant Physical Examination), 602
sounds, 603
heart disease (baby), congenital, 602, 656–658, 681
causes/risk factors, 656
lithium, 548
SSRIs, 547
postnatal detection (incl. examination), 602, 656
prenatal diagnosis/detection, 656
management with, 681
heart disease (maternal), 265–269
acquired, 268–269
congenital, 265, 268
care, 266–268
hypertension associated with, 248
preconception care and, 266
diagnosis, 265
heart rate (fetal)
auscultation. See auscultation
Doppler assessment. See Doppler assessment
electronic monitoring. See cardiotocography
in labour, 344–345
1st stage, 344–345
2nd stage, 376, 385
intermittent assessment, 344–345
normal, 346, 347b
overall classification of features, 346–347
pathological, 347, 347b, 348f
suspicious, 347, 347b, 348f, 376
multiple pregnancy, 294–296
heart rate (neonatal), 596
heartburn, 162–163
heat (baby)
loss, 598–599, 611–612
preterms, 623
overheating (hyperthermia), 599
Hegar's sign, 148, 171
help. See support and help
HELPERR acronym, 480
HELPP (haemolysis, elevated liver enzymes and low platelets) syndrome, 253
Henle's loop, 83
heparins (low molecular weight), 266
after caesarean section, 467
hepatic disorders, 235–236, 253
hepatitis, viral, 236
hepatitis A, 237, 280
hepatitis B, 237, 280
diagnosis/screening, 189, 214, 237
hepatitis C, 237, 280
diagnosis/screening, 189, 237
hepcidin, 154
hernia, congenital diaphragmatic, 654–655, 680–681
heroin. See diamorphine
herpes simplex, neonatal, 669
herpes zoster, 677
high assimilation pelvis, 69
hindbrain, fetal, 115
hindgut, 115
hindmilk, 707, 716
hindwaters, 332
rupture. See rupture of the membranes
hips (and hip bones), 62–63
developmental dysplasia, 606–607, 661–662
Hirschsprung's disease, 653, 672
histamine and blood pressure, 244
history (woman's), and its recording
at booking visit, 184–186
indicating referral for additional antenatal support, 183
in labour at onset, 337
HIV. See human immunodeficiency virus
home (or community setting)
antenatal visit, 199
birth at, 199, 335
breech, 360
option of, 182
cord prolapse management, 479
multiple births and their care at, 302
placental retention at, 412
postnatal haemorrhage, secondary, 413
postnatal visit, 503–504, 526–527
home-from-home, birthing rooms as, 336
Home Start, 305, 545–546
homeopathy and labour pain, 352
homosexual women, 17
HOOP (Hands-Off Hands-Poised) trial, 377–378
hormones
adrenal, 695
disorders relating to, 695
breast/lactation and, 705
in breastmilk, 710
contraception using, 570–575
emergency, 581–582
injectable, 574
long-acting reversible, 575–578, 586
oral. See oral contraceptive pill
skin patch, 574
vaginal ring, 574
kidney, 84
male, 80
maternal, 168–171
blood pressure and, 244
placental, 104–105, 168–169
in mental illness prophylaxis, 549
reproduction (in females) and, 91–100
HPV (human papilloma virus), 281
human chorionic gonadotrophin (hCG), 101, 105, 168–169
pregnancy loss, 224
pregnancy testing, 171
human chorionic somatomammotrophin hormone, 105
human immunodeficiency virus (HIV) and AIDS, 280–281
breastfeeding and, 723
postpartum haemorrhage and, 408
tests, 214
booking visit, 189
human papilloma virus, 281
human placental growth hormone, 105
human placental lactogen, 105, 169
Human Rights Act (1999), 32. See also rights
humeral fracture, 633
humoral immunity in pregnancy, 157
hyaline membrane disease (neonatal respiratory distress syndrome), 680
hydatidiform mole, 226–227
hydralazine, 247
hydramnios. See polyhydramnios
hydrocephalus, 660
hydrolysate formulae, 727
hydrostatic pressure in replacement of inverted uterus, 487
hydrotherapy, labour pain, 352–353
21-hydroxylase deficiency, 597, 664
hyperbilirubinaemia (neonatal), 681
late conjugated, 688
late unconjugated, 688
hypercoagulable state, 156, 266, 272
hyperemesis gravidarum, 228–229
hyperglycaemia
maternal, 257–258
neonatal, 690–691
hyperinsulinaemia
maternal, 164–165
neonatal, 623–624
hyperkalaemia, neonatal, 692
hyperlipidaemia (dyslipidaemia), atherogenic, 254
hypernatraemia, neonatal, 691–692
hypertension (and hypertensive disorders), 244–253, 522–523
chronic (benign/essential), 244–248, 523
superimposed pre-eclampsia, 248
combined oral contraceptive pill and, 279, 572
definitions, 246b
non-pregnant population, 246b
in pregnancy, 246b
gestational, 246–247
history of, 185–186
induction of labour, 248, 421
in labour, 341
postnatal, 522–523
in pregnancy, 244–253
complications, 247
management, 247b
secondary, 248–249
hyperthermia (overheating), 599, 671
hyperthyroidism
maternal, 263, 263t
neonatal, 694–695
hyperventilation in pregnancy, 159
hypervolaemia (increased blood volume) in pregnancy, 150–153, 272
hypoblast, 97–99
hypocalcaemia, neonatal, 692
in hypoparathyroidism, 695
hypogastric arteries, 116
at birth, 118
hypoglycaemia, 258
maternal (risk with insulin), 257–259, 261
severe, 258
neonatal, 262, 623–624, 689–691, 695
hypokalaemia, neonatal, 692
hyponatraemia, neonatal, 691
hypoparathyroidism, neonatal, 695
hypospadias, 596, 664
hypotension
in labour, 341
epidural analgesia-related, 356b
in supine position in pregnancy, 152b
hypothermia, neonatal, 671
hypothyroidism
maternal, 263–264
neonatal, 694
hypotonic (floppy) baby, 612–614, 671
hypovolaemic shock, 489–491
hypoxia
fetal, 457
healthy baby, 376
maternal response to, 244
hypoxic–ischaemia encephalopathy (HIE), neonatal, 672–673
I
identity, twins, 303
ileus, meconium, 653
iliococcygeus, 61
iliopectineal eminence, 65
iliopectineal line, 65
ilium, 62
imaging, fetal, new technologies, 214
immune system
neonate and, 105, 601, 675
breastmilk factors and, 710
in pregnancy, 156–157
preventing of fetal rejection, 102
immunization. See antibodies; vaccination
immunoglobulins. See antibodies
imperforate anus (anal atresia), 596, 652
implant, subdermal contraceptive, 576–577
implantation (trophoblast into endometrium), 97, 101–102
bleed, 222–226
incapacity. See capacity
incontinence
faecal/anal, 320, 507, 524
urinary. See urinary incontinence
indemnity insurance, professional, 37, 182
Indemnity Order (2013), 37
indicative sanctions, 30
individuality with twins, 303
induction of labour, 420–426
alternative (non-surgical or pharmacological) approaches to, 426
contraindications, 422b
indications, 421
cardiac disease, 267
hydramnios, 238
hypertensive women, 248, 421
multiple pregnancy, 294
pre-eclampsia, 251, 421
methods, 422–425
postpartum haemorrhage associated with, 407
ritual, 420
infants
feeding. See feeding
micturition, 89
mother's relationship with. See relationships
preterm. See preterm babies
sleeping, safety advice, 199, 626. See also neonates; sudden infant death syndrome
infections (maternal), 279–282
antibiotic prophylaxis for caesarean section, 464
healthcare-associated, 46
placenta as barrier to fetal infection, 105
in labour, 336–337
postnatal
breast, 721
caesarean section wound, 522
vulnerability to/potential causes/prevention, 519
testing/screening for, 214–215
at booking visit, 188–189. See also immune system; sepsis
infections (neonatal), 674–678
breastfed vs formula-fed babies, 726
breastmilk factors in protection from, 710
congenital. See congenital infections
eye, 595, 605–606, 678
hyperbilirubinaemia in, 688
respiratory distress due to, 679–681
urinary tract, 671–672
infertility, 558
infibulation, 316f. See also deinfibulation
inflammatory phase of wound healing, 520f
information (for women and parents), 17
in antenatal education groups, 139–140
sharing, 129–131
in antenatal screening, 207
amount needed, 207
on blood groups and red cell antibodies, 216
for haemoglobinopathies, pre-test, 211
at booking visit, 184. See also communication; education; knowledge
informed consent. See consent
infundibulum, fallopian, 76
inhalation anaesthesia in caesarean section, 470
inhalation analgesia. See nitrous oxide + oxygen
inhaler, asthma, 270
inherited disorders. See genetic disorders
inhibin, 93–94
injectable contraceptive, combined, 574
injury (trauma)
maternal
breast, affecting breastfeeding, 723
in epileptic seizure, 278
with face presentation, 448, 631
in instrumental delivery, 462
levator ani, 62
with occipitoposterior position, 443
pelvic deformation (following fracture), 70
pelvic floor, 523
perineal. See perineum
postpartum haemorrhage caused by, 412
neonatal, 593, 629–643
with face presentation, 448
haemorrhage due to, 633–635
in instrumental delivery, 462–463, 629–630
with occipitoposterior position, 443
skin, 593, 629–631
support of parents, 641
innervation. See nerve supply
innominate bones, 62–63
‘inside baby’, 559
inspection. See observation
instrumental vaginal birth, 456–457
complications, 462–463
neonatal trauma, 462–463, 629–630
contraindications, 457
failure, 463
indications, 456
insulin (fetal), 115
insulin (maternal), 164–165, 257, 261
administration, 258–259
hypoglycaemia risk. See hypoglycaemia
postnatal, 262
insulin-dependent (type 1) diabetes mellitus, 257–262
insulin growth factor (IGF), 105
insurance, professional indemnity, 37, 182
integumentary system, fetal, 116
intelligence
emotional, 12
kindness with, 10–11
intention to practice documentation, 39–40
intercostal recession, 670
interim conditions of practice order, 30
interim suspension order, 30
intermittent positive pressure ventilation, neonatal, 613
internal rotation of buttocks, 380
internal rotation of head, 373, 376
in left mentoanterior positions, 445
in occipitoposterior position, 440–441
long, 441
short, 441–442
in right sacro-anterior position, 381
internal rotation of shoulders, 374, 380–381
in left mentoanterior position, 446
in right occipitoposterior position, 441
International Code of Marketing of Breastmilk Substitutes, 729
International Confederation of Midwives, Global Midwifery Standards, 4–8
internationalization, 4–8
Internet, parental information, 137
interpretation services, 334
inter-pubic ligaments, 65
intestine. See bowel
intracranial haemorrhage, 634–637
with face presentation, 448
intraepithelial neoplasia, cervical, 223
intrahepatic cholestasis of pregnancy (obstetric cholestasis), 235–236, 257
intraparenchymal lesions (periventricular haemorrhagic infarction; IPL; PHI), 635–637
intrapartum period. See childbirth
intrathecal anaesthesia. See spinal anaesthesia
intrauterine growth (fetal growth), 112–116
restriction (IUGR), 618–621
asymmetrical growth in, 620–621
causes, 620b
symmetrical growth in, 619–620
timescales, 111, 113
intrauterine systems/devices
copper (non-medicated), 577–578
emergency use, 582
levonorgestrel-impregnated, 578
intravascular bleeding, bleeding associated with, 639
intraventricular haemorrhage (IVH), 635–637
intubation in caesarean section, difficult/failed, 470–471
Investigating Committee, 30
iodine
deficiency, 170, 263
requirements, 170
Ireland, Midwives (Ireland) Act (1918), 27, 39–40
iris (neonatal), examination, 595
iron (in pregnancy)
deficiency causing anaemia, 273–274
postnatal, 524–525
twin pregnancy, 294
metabolism, 154
tablets/supplements
antenatal, 274
postnatal, 524–525
iron (infant breastfeeding), 709
ischaemic heart disease, 269
ischioanal fossa, 61
ischiocavernosus muscle, 57
ischium, 62–63
islet cell transplants, 259
isoimmune thrombocytopenia, 667
isoimmunization
ABO, 687
Rhesus. See Rhesus status
itching. See pruritus
J
jaundice
maternal, 235–236
neonatal, 681–688
late, 687–688
pathological, 685–687
physiological, 682–685
jaw
breastfeeding and, 712–715
small/hypoplastic, 594–595, 654
thrust, 613–614
joints, pelvic, 64
judgements (in ethics), 38
justice, 38
juvenile-onset (type 1) diabetes mellitus, 257–262
juxtamedullary cells, 83
juxtamedullary nephrons, 83
K
Kali Carbonate, labour pain, 352
kangaroo care, 625–626, 719
ketones and ketoacidosis in diabetes, 257–258
ketosis and postpartum haemorrhage, 408
key performance indicators (KPI) of antenatal screening, 205
kidney (maternal), 81–84
disease
in diabetes, 260
hypertension in, 248
failure
with amniotic fluid embolism, 486
in shock, 490
filtration, 85
in pregnancy, 160
selective reabsorption, 85–86
kidney (neonatal), 600
examination for disorders, 671–672
malformations, 81, 663–664
Kielland's forceps, 460
kindness, intelligent, 10–11
Kiwi Omnicup™, 457–458
Klumpke's palsy, 632
knee–chest position, 478–479
breech birth, 382
knee presentation, 357
kneeling position, 371–372
in antenatal preparation, 437–438
vaginal breech birth, 382–385
knowledge
in antenatal education groups, sharing, 130b
on antenatal screening, 207
in The Code, 501b. See also information
L
labetalol, 247
pre-eclampsia, 250–251, 250t
labia
labia majora, 56
labia minora, 56
lacerations, 318
laboratory tests
cardiac disease, 265
disseminated intravascular coagulation, 638–639
inborn errors of metabolism, 693
physiological jaundice, 683. See also biochemistry; blood tests; haematology
labour, 311–325, 327–393, 395–433, 435–453, 455–473
1st stage, 327–366
cardiac disease patients, 267
duration/length, 330
face presentation, 447
initial meeting with midwife, 334–338
mechanical factors, 332–333
occipitoposterior position in, 439, 442
physiology, 330–333
recognition, 333–334
subsequent care, 338–344
2nd stage, 367–393
cardiac disease patients, 267
controversial areas, 368b
cord prolapse diagnosis in, 479
delay in, 429
maternal response, 370–373
mechanism, 373–374
midwifery care, 374–379
nature, 368–369
occipitoposterior position in, 439, 442
phases and duration, 370
recognition, 369–370
3rd stage, 395–416
active management, 400–404
cardiac disease patients, 267
care of women in, 398–404
completion, 404–406
complications, 406–414
expectant management, 398–400, 403–404
mismanagement as cause of postpartum haemorrhage, 407
physiology, 396–398
active phase, 328–329, 370
delay in, 427
asthma and, 270
cardiac disease and, 267
as continuous process, 328
defining, 328
emotions, 335, 535–536
epilepsy, 279
genital mutilation and, 317
hydramnios, 238
hypertensive women, 248
hyperthyroidism and, 264
induction. See induction
iron-deficiency anaemia, 274
latent phase, 328–329, 370
delay in, 426–427
malpositions/malpresentations and course and outcome of
face presentation, 446–447
occipitoanterior positions, 441–442
multiple pregnancy. See multiple pregnancy
myometrial preparation for, 144
obesity and, 256
obstructed (mechanically). See obstructed labour
onset (spontaneous physiological labour), 328–330
recognition, 329
pain. See pain
precipitate, 430
postpartum haemorrhage relating to, 407
pre-eclampsia, 251, 341
preparation (of mother) for, 198–199
preterm, causes, 621b
progress, assessment, 338–340, 428
partogram, 329, 338, 425
progress, failure, 426–429
prolonged, 426–429
left mentoanterior position, 446
postpartum haemorrhage relating to, 407
twin pregnancy, 288–292
psychological context. See psychological dimensions
rhythms, 328
sickle cell disease, 277
thalassaemia and, 276
thromboembolic disease risk, 271–272
transition/transitional phase, 328–330
controversial areas, 368b
maternal response to, 370–373
midwifery care, 374–379
nature, 368–369
urinary tract infection in, 282
lacerations and cuts, neonatal, 593, 629–630
lactase
deficiency, 722
simethicone and (‘over-the-counter’), 722
lactation, 705–707
amenorrhoea (method), 583–585
cessation, 723–724
combined oral contraceptive pill and, 573–574
mother and, 706–707
onset (lactogenesis), 705–706
twins, 300. See also breastfeeding
lactiferous ducts, 705
lactoferrin, 710
lactogen, human placental, 105, 169
lactose (in breastmilk), 707, 722
intolerance, 721–722
lacunar stage of implantation, 102
lambda (fontanelle), 120
lambdoidal suture, 118
lamotrigine, 548
language
of childbirth, 334
twins, development, 302
woman
difficulties, 16–17
interpretation services, 334
lanugo, 107, 116
large for gestational age, 618
laryngeal stridor, 656, 681
last menstrual period (LMP), 185, 418, 618
lateral flexion (of fetus), 374, 380
in left mentoanterior position, 446
lateral position in 2nd stage of labour, left, 371
law (legal issues), 32–37
abortion, 227–228, 227b
accountability under the law, 31–32
historical context, 27–28. See also medicolegal considerations; statutory regulation
learning disabilities/difficulties, 15
booking visit, 184
learning disability, 539
left lateral position in 2nd stage of labour, 371
left-to-right shunts, 657–658
leg(s)
fetal, in breech presentation, extended, 357, 359, 384
maternal
cramps, 167
oedema see oedema. See also limbs
legal issues. See law; medicolegal considerations
legislation, 32 see also specific Acts
leiomyoma. See fibroids
Leopold's manoeuvres, 438
lesbians, 17
let-down reflex, 705–706, 720–721
leucocytes
in breastmilk, 710
in pregnancy, 156–157
leucomalacia, periventricular, 636–637
leucorrhoea, 149, 189–190
levator ani muscle, 61, 89
Levonelle, 581–582
levonorgestrel-impregnated IUS, 578
liability, vicarious, 37
lidocaine, postnatal, perineal pain, 508
lie, fetal, 194
transverse. See transverse lie
unstable, 451–452
life support, basic, 487–489
life-threatening conditions
infant with cardiac malformations, 656
maternal, 45
antenatal bleeding, 232
postnatal, 516. See also death
lifestyle at first antenatal visit, 186–187
ligaments
bladder, 88
pelvic, 64–65
uterine, 72–73
in pregnancy, 144
light hazards (for baby), 626
lightening (feeling of baby dropping), 148
lignocaine (lidocaine), postnatal, perineal pain, 508
limbs, neonatal
examination, 597–598
reduction deficiencies, 660–661. See also arms; legs
linea alba, 167–168
linea nigra, 167–168, 190
lip, cleft palate and/or, 594–595, 653–654, 722
lipid metabolism, 165
listening after childbirth, 526–527
lithium, 548
prophylactic, 549
lithotomy, supported, in assessment of perineal trauma, 313–314
litigation, 35
NHS Litigation Authority (NHSLA), 35, 47, 321
liver
fetal, 115
maternal, 163–164
disorders, 235–236, 253, 257
shock effects, 490. See also HELPP syndrome
local action plan with supervisor (following LSA investigation), 48b
Local Supervising Authorities (LSA), 40–41, 49
Midwifery Officer, 41–42, 48–49
outcomes an investigation by, 48
location of birth. See place
lochia, 507
locked twins, 298
longitudinal layer of anal sphincters, 60
longitudinal lie, 194, 197f
loop of Henle, 83
loss, 555–567
accidental. See miscarriage
care, 560–564
forms, 557–559
grief in. See grief
in healthy childbearing, 559
meaning, 555–556. See also bereavement; death; grief
Løvset manoeuvre, 382, 384–385
low birth weight (LBW) babies, 617–628
environmental optimization, 625–626
instrumental delivery, 456
management, 622–625
maternal obesity and, 256
presentations, 618. See also preterm babies
lower limb. See leg
Lullaby Trust, 185
Lunelle, 574
lungs
at birth, 670
fetal, 114–115
maternal/in pregnancy
function, 158
gastric content aspiration into, in caesarean section, 470
shock effects, 490
meconium aspiration into, 679. See also respiratory system
luteal phase of ovarian cycle, 94
luteinizing hormone (LH)
females, 91–92
computer monitoring (contraceptive method), 584
in ovarian cycle, 93–94
in pregnancy, 169
males, 80
lying positions
mother lying on side for breastfeeding, 711
sleeping infant, 626
lymphatic drainage
anorectum, 60
bladder, 88
kidney, 83
ovaries, 77
testes/scrotum, 78
ureters, 87
urethra, 89
uterine tube, 76
uterus, 74
vagina, 72
vulva, 56
lysozyme in breastmilk, 710
M
macerated fetus, shoulder presentation, 450
Mackenrodt's ligaments, 72
McRoberts manoeuvre, 480
macrosomia
diabetes and, 618–619
maternal obesity and, 256
postpartum haemorrhage incidence related to, 407
shoulder dystocia, 479
magnetic resonance imaging, fetal, 214
males
contraception
condoms, 579
pill, 586–587
sterilization, 586
genitalia/reproductive system, 77–80
female-looking, 664
neonatal, examination, 596–597
malformations, congenital fetal/neonatal (structural abnormalities/anomalies), 189,
211–214, 645–666
antenatal screening and diagnosis, 646
detailed anomaly scan, 211–214
detection rates, 212b
cardiac. See heart disease
CNS, 658–660
communicating the news, 646
definition and causes, 647–649
drugs causing. See teratogens
face presentation with, 444
gastrointestinal, 650–654
genitourinary, 81, 663–664
multiple pregnancy, 297
musculoskeletal, 660–662
palliative care, 646–647
respiratory system/tract, 654–656
skin, 645, 662–663
support for midwife, 665
vascular, 593, 662
malformations, congenital maternal (structural abnormalities/anomalies)
kidney, 81
heart. See heart
pelvis, 70
uterus, 74–75
malignancy. See cancer
malpositions, 435–443
as instrumental delivery indicator, 456
malpresentations, 444–452
breech considered as, 360
cord prolapse or presentation, 448, 451, 477
definition, 435
multiple pregnancy, 298
malrotation of bowel, 652–653
manic component of bipolar illness, 547–548
manual techniques
expression of breast milk
manual expression, 718–720
manually-operated pump, 719–720
removal of placenta, 411
rotation
from malpositions, 439–440
in shoulder dystocia, 481–483
Marfan syndrome, 268
Marmot Review, 14, 181–182
masculinization (virilization), female, 664, 695
mask of pregnancy, 167–168
massage
aromatherapy (in labour), 352
breast. See breast
fundal, 409
perineal, 198
mastitis, 721
maternal surface of placenta, 104. See also women
maternity care. See care
maternity services, obesity and, 255–256
maturity-onset (type 2) diabetes, 254, 257, 259–262
maturity-onset (type 2) diabetes of the young, 259
Mauriceau–Smellie–Veit manoeuvre, 383–384
mean cell volume (MCV), 154, 156
at booking visit, 188
in thalassemia, 275
meconium, 115, 596, 601, 613–614
in amniotic fluid (meconium staining), 376, 620–621
aspiration syndrome, 679
ileus, 653
passage, assessment, 672
medical conditions/disorders, 243–286
hepatic, 235–236, 253, 257
history-taking, 185–186
instrumental birth, 456
twin pregnancy and exacerbation of, 294. See also health
medical management (incl. drugs/pharmacotherapy)
abortion, 228
diabetes, 259, 261
drug abuse, 696–697
eclamptic seizure, 252
ectopic pregnancy, 226
hyperthyroidism, 264
labour induction, 267
miscarriage, 225
psychiatric disorders, 546–548 see also drugs and specific (types of) of drugs
Medical Officer of Health, 40
medicines. See drugs
medicolegal considerations, perineal injury, 321
mediolateral episiotomy, 313
continuous suturing, 319f
training, 321
medroxyprogesterone acetate, depot, 575–576
medulla oblongata, cardiovascular centre, 244
megaloblastic anaemia, 274–275
meiosis, 93, 95
melaena, 601, 639
melanocytic (pigmented) naevi, 593, 663
melasma, 167–168
membranes (chorioamnion), 106
cervical sweeping (CMS), 419–420, 422–423
delivery, 399, 402–403
examination
after delivery, 404–405
in labour, 341b
infection (chorioamnionitis), 239
retained, 407
rupture of. See rupture of the membranes
stretching and sweeping, 199
men. See males
menarche, 25
Mendelian inheritance, malformations associated with, 648
Mendelson's syndrome in caesarean section, 470
meningitis, neonatal, 676
meningocele, 659
meningomyelocele (myelomeningocele), 659
menopause, 91–92
menorrhagia, 94
menstrual cycle, 92f, 94–95
in natural family planning, 583–584
menstrual history at booking visit, 184–185
menstruation (menstrual phase; period), 94
disorders, 94
last (LMP), 185, 418, 618
onset in life (menarche), 91–92
mental capacity. See capacity
mental health, 531–553
problems. See distress; psychiatric/mental disorders
service provision, 548–549
vulnerability factors, 533f
mentoanterior positions, 446
left, 444f, 445–446
right, 444f
mentolateral positions, 444f
mentoposterior positions, 444f, 446–448
persistent, 447–448
mentovertical (MV) diameter, 120
mentum as denominator with face presentation, 196
MEOWS (Modified Early Obstetric Warning Scoring) system, 47, 267, 487–488
hypovolaemic shock, 491
meptazinol in labour, 354
mesoderm (embryo), 97
metabolic syndrome, 254
metabolism (maternal)
changes, 164–165
disorders, 253–257
metabolism (neonatal), disorders, 689–691
causing convulsions, 640t
genetic causes (inborn errors of metabolism), 692–694
metal ventouse cups, 457
metformin, 259, 261
methadone, 696
treatment using, 696–697
methicillin-resistant Staphylococcus aureus, 46
methotrexate, ectopic pregnancy, 226
methyldopa, 247
Michaelis' rhombus, 338–340, 369
microcephaly, 593–594, 660
microchimerism, 102
micrognathia (small/hypoplastic jaw), 594–595, 654
micropenis, 596
micturition (urination/voiding), 89
immediately after birth, encouraging, 405
in labour, 344
mid-stream urine testing, 215
midbrain, fetal, 115
midgut, 115
MIDIRS (MIDwives Information Resource Service), 131
midline episiotomy, 313
midwife
in congenital malformations, support for, 665
in contemporary practice, 3–23
definition and scope, 4
first meeting of woman with, 183
internationalization/globalization, 4–8
loss (incl. death) and the, 563–564
maternal, 564
midwife care, 560–564
midwife experiences, 559
professional issues, 25–52
public health role, 181–182
relationships. See partnership; relationships
roles and responsibilities in practice. See roles (midwives) and responsibilities
as ventouse practitioner, 460
midwife-led continuity of care, 336
midwifery
contemporary practice, 3–23
emotional context. See emotion
professional issues, 25–52
Midwifery Committee, 29
Midwifery Officer (of LSA), 41–42, 48–49
Midwives Act (1902), 27, 39–40
Midwives Act (1936), 40
Midwives Act (1951), 27, 40
MIDwives Information Resource Service (MIDIRS), 131
Midwives (Ireland) Act (1918), 27, 39–40
Midwives Rules and Standards, 32–35, 387–388
Midwives (Scotland) Act (1915), 27, 39–40
Midwives (Scotland) Act (1951), 27, 40
milia, 593
milk. See breastmilk; formula feeding
Millennium Development Goals, 8
mineral(s)
infant breastfeeding and, 709–710
maternal
deficiency, pelvic anomalies, 70
renal reabsorption, 86
wound healing and, 521t
mineralocorticoids, adrenal, 695
minor(s) (under-16s), consent issues for, 35–36
labour and, 337
minority groups, ethnic, 15–16
minute volume, 158
miscarriage (spontaneous pregnancy loss), 224–225, 558
combined oral contraceptive pill following, 574
complete, 224–225
incomplete, 224
inevitable, 224
IUCD and, 578
lactation and, 723–724
missed/silent, 224
repeated/recurrent, 225
history of, 185
threatened, 224–225
misoprostol (prostaglandin E1 analogue)
induction of labour, 267
prolonged pregnancy, 424
postpartum haemorrhage, 409
third stage of labour, 401
mitochondrial disorders, 648
mittelschmerz, 94, 569, 584
mobility. See movements and motions
Modified Early Obstetric Warning Scoring system. See MEOWS
molar pregnancy, 226–227, 249
Mongolian blue spots, 593
monoamniotic twins, 288, 291
monochorionic twins, 288–293, 297
labour onset, 294
malformations, 297
premature expulsion of placenta, 299
twin-to-twin transfusion syndrome, 297
ultrasound examination, 292
monophasic combined oral contraceptive pill, 570
monozygotic (uniovular/identical/MZ) twins, 288, 292
dizygotic vs, 95–96, 288
mons pubis, 56
mood stabilizers, 547–548
morning sickness, 162
Moro reflex, 608
mortalities. See deaths
morula, 96–97
mother. See women
motherhood. See parenthood
motions. See movements
moulding, 122
brow presentation, 449f
face presentation, 448, 448f
movements and motions (mobility)
fetal, 116
as indicators of well-being, 196–198
in normal labour, 373–374
quickening, 116, 171 see also specific movements
maternal
in labour, 343
postnatal, 525–526
neonatal, abnormal, 671, 674
MRSA (methicillin-resistant Staphylococcus aureus), 46
mucosa (and mucous membrane)
bladder, 88
rectal, button-hole tear, 312t, 314, 442
uterine endometrium, 73
vagina, 72
mucus plug
in ovulation, 583
in pregnancy (=show), 327, 332–333, 369
multidisciplinary team care
cardiac disease, 265–267
diabetes, 260–261
twin pregnancy, 293
ultrasound scans and, 212
multifactorial disorders, 648
multigravid women, attendance at antenatal sessions, 137–140
multiparity as risk factor for cord prolapse or presentation, 477
Multiple Births Foundation (MBF), 305
multiple pregnancy (incl. twins), 287–307
complications, 297–299
cord prolapse, 298, 477
postpartum haemorrhage, 299, 407
diagnosis, 292
missed, 299
incidence, 288
labour, 294–297
management, 295–296
onset, 294
postnatal period, 299–303
reduction, 305
selective feticide, 305
shoulder presentation, 450
sources of help, 305
types (of twin pregnancy), 288–292
UK statistics (1985–2011), 289t
multipotent stem cells, 99
multips os, 330
murmur, 603–604, 681
precordial, 603
muscle(s) (maternal)
abdominal, laxity as cause of shoulder presentation, 450
perineal, 57
uterus. See uterus
muscle(s) (neonatal)
assessment, 601, 612
tone, 612
blue skin and good tone, 613. See also hypotonic baby
trauma, 631
muscle layers/coats
bladder, 88
perineal, in suturing (after trauma), 319
ureters, 87
uterine tube, 76
vagina, 72
musculoskeletal system
fetal, 153
maternal, 167
neonatal, 601
deformities, 660–662
music therapy, labour pain, 353
myelomeningocele, 659
myocardium
enlargement (cardiomegaly), 269
infarction, 269
myoclonus and myoclonic seizures/convulsions
maternal, 278t
neonatal, 640
benign sleep myoclonus, 674
myometrium, 73–74, 144
in pregnancy, 144–146
myxoedema coma, 263
N
Naegele's pelvis, 70
Naegele's rule, 185
naevi (vascular), 662
pigmented, 593, 663
nasal…. See nose
nasogastric tube feeding of baby, 624
National Amniotic Fluid Embolism Register, 486
National Health Service (NHS)
Clinical Negligence Scheme for Trusts, 47
Litigation Authority (NHSLA), 35, 47, 321
outcomes framework relating to maternity care, 46b
National Institute for Health and Care Excellence (NICE) guidelines
antenatal visiting patterns, 180–181
breastfeeding, 730
caesarean section
indications, 463–464
reducing rates, 471–472
vaginal birth following, 466
for clinical practice (in general), 45
diabetes, 260
vitamin D supplementation, 708
National Screening Committee of the United Kingdom, 204–206, 208
on Down syndrome, 209
on haemoglobinopathies, 210–211
on infectious diseases, 214–215
on mental illness, 549
on ultrasound scans, 211
natural family planning, 582–585
nausea, 162, 228–229
neck
examination in neonate, 595–596
umbilical cord around (at birth), 378
neck reflex, asymmetric tonic, 608
necrotizing enterocolitis, 672
negligence, 36
voluntary risk-pooling scheme for claims, 47
Neisseria gonorrhoeae. See gonorrhoea
neonates (newborns; baby early after birth), 591–609, 611–615, 617–643, 645–701, 703–
736
adaptation to extrauterine life, 117–118, 670
breastfeeding difficulties related to, 721–723
contact with parent. See contact
deaths. See deaths
in diabetes
care, 262
risk to, 260
drug misuse and. See substance abuse
examination. See examination
feeding. See feeding
haemolytic disease (HDN), 188, 216, 684–686
healthy term baby
low birth weight. See low birth weight
recognition through screening assessment, 591–609
resuscitation, 611–615
immediate care, 405–406
immunity. See immune system
infections. See infections
injury. See injury
instrumentally-delivered, complications, 462–463
mother's relationship with. See attachment; relationships
obesity (maternal) risks to, 256
preterm. See preterm babies
prolonged pregnancy and its impact on, 418–419
safety and protection concerns, 510
significant problems causing illness, recognition, 667–701
zygosity determination, 292
neoplasms. See tumours
nephron, 82–83
nephropathy, diabetic, 260
nerve supply (innervation)
maternal
anal sphincters, 60
bladder, 88
kidney, 83–84
labour pain and its transmission and, 349–350
levator ani, 62
ovaries, 77
perineum, 57
testes/scrotum/spermatic cord, 78
ureters, 87
urethra, 89
uterine tube, 76
uterus, 74
vagina, 72
vulva, 56
neonatal, trauma, 631–633
nervous system
central. See central nervous system
fetal, 115–116
peripheral (neonatal), hypotonia relating to, 671
neural tube development, 115
defects in, 115, 658, 660
neurocranium, 116
neurogenic shock, 489
neurological assessment (baby), 671
neurological disorders
maternal, 279–282
neonatal
convulsions due to, 640t
examination for, 607
hypoglycaemia causing, 690. See also central nervous system; peripheral nervous
system
neuromuscular disorders, hypotonia, 671
neutral position, baby in, 612
neutrality, affective, 11–12
Neville–Barnes forceps, 460
Newborn and Infant Physical Examination (NIPE), 601–607. See also neonates
NHS. See National Health Service
NICE. See National Institute for Health and Care Excellence
nicotine replacement therapy, 187
nifedipine, 247
nipple, 705
in breastfeeding
anatomical variations affecting feeding, 720
attachment to. See attachment
ducts in nipple, 705
sore or damaged, 719–720
white spots/epithelial overgrowth (nipple), 721
stimulation inducing labour, 426
nitrous oxide + oxygen (Entonox), 353–354
cardiac disease patients, 267
nociceptors, 350–352
noise hazards (for baby), 626
non-insulin-dependent (type 2) diabetes mellitus, 254, 257, 259–262
non-maleficence, 38
nonoxinol-9, 581
non-steroidal anti-inflammatory drugs (NSAIDs)
afterpains, 506
caesarean section, postoperative, 466
norepinephrine and blood pressure, 244
norethisterone enathenate, injectable, 576
norgestimate in combined oral contraceptive pill, 570–571
nose, neonatal
blocked, 722
examination, 594
flaring of nostrils, 670. See also nasogastric tube feeding
notochord, 98
nuchal fold thickness, 213
nuchal translucency, 209
increased, dealing with, 212–213
Nurses, Midwives and Health Visitors Act (1979), 27
repeal, 28
review, 27
Nursing and Midwifery Council (NMC), 29–32
committees, 29–30
consensual panel determination (NMC), 30–31
functions, 29
membership, 29
referral to (following an LSA investigation), 48b
Register. See Register
responsibility and accountability and the, 26–27
Nursing and Midwifery Order 2001: SI 2002 No: 253, 29–32, 40–41
nutrition (baby)
fetal, 105
infant. See feeding
nutrition (woman/mother)
breastfeeding and, 706
breastmilk composition and, 707
in labour, 343–344
pelvic anomalies due to dietary deficiency, 70
in pregnancy, needs, 254–255
in puerperium, 505
wound healing and, 521t. See also diet
NuvaRing, 574
O
obesity, maternal, 253–257
oblique diameter of pelvic inlet, 66–67
oblique lie, 194, 197f
observation and inspection (maternal)
abdominal (in pregnancy), 190
hydramnios, 238
multiple pregnancy, 293–294
occipitoanterior position, 436
oligohydramnios, 238–239
hypovolaemic shock, 491
in labour
in 1st stage, 340–341
in 2nd stage, 376
pain control and, 355–356
prolonged labour, 428
placenta and membranes, 404–405
postpartum, 504–509
haemorrhage, 412–413
observation and inspection (neonatal)
cardiovascular function, 602
eye, 605
obsessive–compulsive symptoms, postnatal, 543
obstetric history, previous, 185
as indicator
for caesarean section, 464
for referral for additional antenatal support, 183
obstructed labour, 331–332, 429–430
face presentation, 448
occipitoposterior position, 443
obstruction (blockage)
cardiac defect causing, 658
lactiferous ducts, 721
neonatal upper airway, 681, 722
occipital bone, 118
protuberance, 118, 120
occipitoanterior positions
direct, 198b
left and right, 198b, 198f, 373
positions other than, 435–443
occipitofrontal (OF) diameter, 120, 440
occipitolateral positions
instrumental delivery, 456
left and right, 198b, 198f
occipitoposterior positions, 436–443
antenatal diagnosis, 436–437
antenatal preparation, 437–438
birth in. See childbirth
causes, 436
complications, 442–443
direct, 198b
instrumental delivery, 456
left, 198b, 198f, 437f
midwifery care, 439
persistent, 441, 443, 443f
right, 198b, 198f, 437f, 439f
mechanisms, 440–441
occipitotransverse position, manual rotation from, 439
occiput denominator with vertex presentation, 196
occiput region (fetal skull), 120
malpositions, 435–443
posterior rotation, 385
oedema (maternal), 190
lower leg, 166
postnatal, 522–523
in pre-eclampsia, 249
oedema (neonatal), buttocks, 631
oesophageal atresia, 650–652
oesophagogastric (gastro-oesophageal) junction in pregnancy, 162–163
oestradiol, 104, 169
oestriol, 104, 169
oestrogens
in combined oral contraceptive pill, 570
dominance, 571f, 572
mode of action, 571
in labour, 328–329
in ovarian and menstrual cycle, 93–95
placental, 104, 169
oestrone, 104, 169
oestrone-3-gluronide females, computer monitoring (contraceptive method), 584
olanzapine, 547
oligohydramnios, 81, 238–239
omphalocele, 650
oocyte (egg; female gamete; ovum), 91
fertilisation, 95–96
formation, 93
release. See ovulation
oogonia formation (oogenesis), 93
operative births, 455–473
prerequisites, 457
puerperium after
practical skills for care, 525–526
uterus and vaginal loss, 519–520
techniques for lowering rate of, 456b. See also caesarean section; forceps; ventouse
ophthalmia neonatorum (neonatal conjunctivitis), 596f, 605–606, 678
ophthalmoscopy, neonatal, 605
opiates/opioids
abuse, 696
pharmacological treatment, 696–697
caesarean section, postoperative, 466
labour, 354
continuous epidural infusion, 355
oral changes in pregnancy, 161–162
oral contraceptive pill
combined. See combined hormonal contraceptives
male, 586–587
missed/forgotten, 573, 575
progestogen-only, 574–575
Order, the (Nursing and Midwifery Order 2001): SI 2002 No: 253, 29–32, 40–41
organ. See systems and organs
organization and administration
Global Standards for Midwifery Education (2010), 6b–7b
maternity care, 11
orogastric tube feeding of baby, 624
Ortolani manoeuvres, 606–607
Osiander's sign, 171
ossification of skull, 118
osteogenesis imperfecta, 662
osteomalacic pelvis, 70
Our Health and Wellbeing (theme in antenatal education programme), 134–136
outcomes
from Local Supervisory Authority investigation, 48
NHS outcomes framework relating to maternity care, 46b
ovarian artery, 74
ovarian cycle, 92–94
ovarian hyperstimulation syndrome, 228
ovarian ligaments, 73
ovaries, 76–77
cancer, combined oral contraceptive pill and, 572
cysts, progestogen-only pill and, 574
overheating (hyperthermia), 599, 671
oviducts. See fallopian tubes
ovulation, 94
in natural family planning methods, 583–584
pain (mittelschmerz), 94, 569, 584
oxygen
maternal, arterial partial pressure, 159
neonatal, blown onto face, 613. See also extracorporeal membrane
oxygenation; nitrous oxide + oxygen
oxytocin, 128, 169
in childbirth, administration (incl. Syntocinon) for induction or augmentation of
labour, 251, 267, 296, 299, 424–425
cardiac disease patients, 267
with ergometrine. See ergometrine
postpartum haemorrhage and, 403, 407
postnatal release causing uterine contractions, 505
in breastfeeding, 398, 405–406
oxytoxics. See uterotonics
P
pain, 349–356
abdominal. See abdomen
acute vs chronic, 350
back, 167
breast, deep (breastfeeding mother), 720–721
labour-related, 349–356
physiology, 349–351
relief. See analgesia
stimulus and sensation, 349
transmission, 349–350
pelvic girdle, 229
perineal, postpartum, 507–508, 520–521
theories, 351–352. See also afterpains; backache; colic; headache
palate, cleft lip and/or, 594–595, 653–654, 722
palliative care with congenital malformations, 646–647
pallor, neonatal, 592, 668–669
palmar erythema, 168
palmar reflex, 608
palpation (cervical) as natural family planning method, 583
palpation (maternal abdominal)
breech presentation, 357–358
in labour, 358–359
in labour and childbirth, 340
breech presentation, 358–359
brow presentation, 449
face presentation, 445
postnatal, 505, 518
in pregnancy, 191–193
hydramnios, 238
multiple pregnancy, 294
occipitoanterior position, 436–437
oligohydramnios, 239
in placenta praevia, 231
uterus, 190–191
palpation (neonatal), cardiovascular function, 602–603
pancreas, artificial, 259
Papanicolaou (Pap) smear, 148, 223
parathyroid gland disorders, neonatal, 695
paraurethral glands, 89
parent(s)
antenatal education. See antenatal education
communication to. See communication
contact (physical) with. See contact
information for. See information
at labour, care of, 374–376
of mother, relationship changes, 539
of newborn
resuscitation and communication with, 614
in trauma/haemorrhages/convulsions, support for, 641
parenthood and parenting (and motherhood)
antenatal education for. See antenatal education
ideology, 534–535
social context, 13–18
transition to, 509–510, 534–535
parietal bones, 118
parity and risk of cord prolapse or presentation, 477
paroxetine, 547
partial (focal) neonatal convulsions/seizures, 640
partner
multiple births and mother's relationship with, 302
red cell antibody testing, 217
sleep disturbances after birth of baby, 526
support from, 134–136
support in 2nd stage of labour for, 375–376. See
also companion; father; lesbians; parenthood
partnership
supervisors and midwives (supervisees) in, 43
women and midwives in, 10, 12, 18
postnatal care, 500. See also Family–Nurse Partnership programme
partogram/partograph, 329, 338, 427
passages (in the 3 ‘Ps’), 427–428
passenger (in the 3 ‘Ps’), 427
Patau syndrome, 650
patch contraceptive, 574
patient-controlled analgesia (PCA)
caesarean section, 469
postoperative, 466
labour, 354
patient focus, 44
Pavlik harness, 661–662
Pawlik's manoeuvre, 193
peak expiratory flow, asthma, 270
PEGASUS (Professional Education for Genetic Assessment and Screening), 211
pelvic inflammatory disease, copper IUCD and, 578
pelvis (pelvic region), 62–69
diameters, 66–67
false pelvis, 66
joints, 64
ligaments, 64–65
orientation, 67
pelvic brim, 65
in asynclitism, 69b
diverging dimensions, 68
fetal head descent into. See head
pelvic canal
axis, 67
measurements, 66f
stations of fetal heard in relation to, 342f
pelvic cavity, 65
diameters, 67
pelvic floor, 61–62
damage, urinary continence problems, 523
pelvic girdle (bony pelvis), 61–62
pain, 229
pelvic inlet diameter, 66–67
pelvic outlet, 65–66
diameters, 67
planes, 67
in pregnancy (and childbirth), 65, 451
palpation, 192–193
soft tissue, displacement in 2nd stage of labour, 369
true pelvis, 65–66
types (size and shapes) incl. contracted pelvis and unusual or abnormal
types/shapes, 68–69
face presentation and, 444
occipitoanterior position and, 436
shoulder presentation, 450
penis, 79
neonatal
examination, 596
urethra opening on undersurface (hypospadias), 596, 664
performance, standards of, 34
perimetrium, 74, 144
in pregnancy, 144
perinatal loss, 557–558
perineum, 56–61
central point (perineal body), 61
infiltration anaesthesia caesarean section, 468
massage, 198
postpartum pain and discomfort, 507–508, 520–521
shaving, 343
trauma, 312, 520–521
1st degree, 312t, 318
2nd degree, 312t, 318
3rd degree, 312t, 315f
4th degree, 312t, 315f
button-hole tear, 312t, 314, 442
definition, 312
medicolegal considerations, 321
minimization factors and strategies, 312
postpartum care, 507
trauma, repair, 318–319, 507
postpartum haemorrhage and, 407
training, 321
period. See menstruation
peripheral nervous system disorders, hypotonia, 671
periventricular haemorrhagic infarction (PHI), 635–637
periventricular leucomalacia, 636–637
pernicious anaemia, 274–275
Persona, 584
personal information at booking visit, 184
personal liability, 37
personal protective equipment, 337
personal responsibility, 31
personality disorders, 539
petechiae, 669
pethidine (in labour), 354
cardiac disease patients, 267
phaeochromocytoma, 248
pharmacological agents. See drugs; medical management
phenylketonuria, 693
phobia of giving birth, 533–534
photographs of lost/dead baby, 561
phototherapy, physiological jaundice, 684
phylloquinone. See vitamin K
physical examination. See examination
physiological care in 3rd stage of labour, 398–400
phytomenadione/phytonadione. See vitamin K
pica, 162
Pierre Robin sequence, 594–595, 654
pigmented birth marks, 593, 663
Pinard stethoscope, fetal heart, 194
labour
1st stage, 337, 344–345
2nd stage, 376
pituitary gland (and its hormones)
fetal, 115
maternal, 169
tumours, 264–265
neonatal, disorders, 695
place (location) of birth, options, 182
breech presentation and, 360
forceps and, 461
placenta, 101–110, 166, 168–169
abruption, 109, 230, 231t, 233–234
postpartum haemorrhage, 407
adherent
morbidly (placenta accreta), 102, 232, 412
partially, 411
wholly, 411
anatomical variations, 108–109
circulation/blood flow, 106, 146
delivery/birthing, 400–403
cardiac disease and, 267
postpartum haemorrhage treatment before/without, 411
postpartum haemorrhage treatment following, 409–411
descent, 396–398
signs, 399
drug passage across. See drugs
early development, 101–103
examination, 404–405
hormones/endocrine activity, 104–105, 168–169
intrauterine growth restriction related to, 620
manual removal, 411
retained (of whole or part), 407
at home, 412
previous history of, as cause of postpartum haemorrhage, 407–408
treatment of postpartum haemorrhage with, 411–412
separation, 396–398
incomplete, 407
signs, 399
at term, 103–109
twin/multiple pregnancy
examination (after delivery), 297
premature expulsion, 299
types, 288–292
placenta accreta (morbidly adherent), 102, 232, 412
placenta praevia, 230–233
degrees, 230–231
incidence, 231
management, 231–232
postpartum haemorrhage, 407
shoulder presentation, 450
placental souffle, 146
placing reflex, 608
plantar reflex, 608
plasma protein in pregnancy, 154
platelets, low. See HELPP syndrome; thrombocytopenia
platypelloid pelvis, 68t, 69
plethora, 669
pluripotent stem cells, 99
pneumothorax, neonatal, 680
polarity (uterus in 1st stage of labour), 330
policies
in antenatal education, 127–129
in clinical governance, 44–45
polycystic kidney disease, 663–664
polycythaemia, neonatal, 623, 669
polydactyly, 597, 660
polyhydramnios (hydramnios), 238
cord prolapse, 477
face presentation, 444
multiple pregnancy, 294, 297
postpartum haemorrhage relating to, 407
shoulder presentation, 450
polyps, cervical neck, 223
popliteal fossa pressure in breech birth, 384
port wine stain, 593, 662
position/posture
fetal, 196
breech presentation and, 357, 381
other than occipitoanterior (=malpositions), 435–443
infant
breastfeeding, 712
sleeping, 626
maternal in breastfeeding, 711–712
maternal in labour
in 1st stage (with normal presentation), 343
in 2nd stage (with normal presentation), 371–373
in breech presentation, 360
cardiac output influenced by, 267
in multiple pregnancy, 296
in occipitoposterior position, 439
in perineal trauma minimization, 312b
in prolapsed cord management, 478–479
in shoulder dystocia, 480
positive pressure ventilation, neonatal intermittent, 613
Post Registration Education and Practice (PREP) Standards, 34–35, 43
posterior rotation of occiput, 385
post-mortem examination of baby, 561
postnatal period (postpartum period; puerperium), 499–529, 531–553, 555–567, 569–588
breech birth and examination of mother in, 385
cardiac disease and, 267–268
care during
family-centred, 516
framework and regulation for, 501
midwives in, 501–504
provision and need for, 502–503
self-care and recovery, 526
contraception, 570
basal body temperature measurement, 583
cervical palpation method, 583
cervical secretions method, 583
combined hormone patch, 574
combined oral contraceptive pill, 573–574
diaphragm, 580–581
fertility monitoring device, 584
progestogen-impregnated IUS, 578
progestogen injections, 576
progestogen-only pill, 575
progestogen subdermal implants, 577
rhythm (calendar) method, 584
defining, 499–500
diabetes management, 262
eclampsia management, 252–253
epilepsy, 279
haemorrhage. See haemorrhage (maternal), postpartum
health and health problems after. See health
historical background, 500
hypertension management, 248
hyperthyroidism, 264
hypothyroidism, 263–264
iron-deficiency anaemia, 274
multiple birth and, 299–303
obesity, 256b
observations. See observation
operative birth and. See operative birth
physiological changes, 504–509
pre-eclampsia management, 251
prolactinoma, 265
psychological context, 532–537
disorders. See psychiatric/mental disorders
emotions, 526, 536
sickle cell disease, 277
talking and listening, 526–527
thalassaemia, 276
thromboembolic disease prevention, 271–273, 522
women-focused, 516
postnatal ward after caesarean section, care in, 467–468
postoperative care
anal sphincter repair, 319–320
caesarean section, 466–468
postpartum period. See postnatal period
post-traumatic stress disorder, 537
posture. See position
potassium (and its imbalances), 692
Potter sequence/syndrome, 81, 238, 663
poverty, 15
powers (in the 3 ‘Ps’), 427
practical skills work in antenatal education sessions, 132–133
practice
best. See best practice
conditions of. See conditions of practice
intention to practice documentation, 39–40
LSA practice programme (following an LSA investigation), 48b
obligations of, 33b
requirements for, 33b
scope of, 33–34, 33b
standard, 35
Practice Committees, 29–30
pre-conception period
antiepileptic drugs, 278
cardiac disease, 266
diabetes, 260
epilepsy and antiepileptic drugs, 278
hormonal contraception
combined oral contraceptive pill, 573
injectable progestogens, 576
progestogen-only pill, 575
subdermal progestogen implant, 577
sickle cell disease, 277
thalassaemia, 276
precordial murmur, 603
pre-eclampsia, 246, 249–251
labour, 251, 341
induction, 251, 421
management, 249–251
severe, 246, 251
superimposed (in chronic hypertension), 248
pre-embryonic period, 96–99
pregnancy, 127–177, 179–219, 221–307
breastfeeding preparation and promotion in, 189, 711, 730
changes/adaptations (anatomical and physiological) in, 143–177
common disorders arising from, 171–173
discussed at antenatal visit, 189
pelvis, 65, 167
urinary tract, 89–90, 159–161
dating by ultrasonography, 418
diagnosis/tests, 171
drugs in. See drugs; substance abuse
early (before 24th week), 92f
common problems, 222–226
placenta in, 101–103
thalassaemia and diagnostic tests in, 276
ectopic, 148–149, 225–226
education in. See antenatal education
history (previous). See obstetric history
with IUCD, miscarriage risk, 578
later (after 24th week), common problems, 229–235
medical condition. See medical conditions
midwife–woman relationships and, 10–11
molar, 226–227, 249
multiple. See multiple pregnancy
prolonged. See prolonged pregnancy
psychological context, 532–537
disorders, 539–541
emotions, 535
risk factors arising in, 199b
social context, 13–18
‘tentative’, 204
termination (induced or spontaneous). See abortion; miscarriage
prelabour (premature) rupture of the membranes (PROM), 333, 360–361
induction of labour, 421
preterm. See preterm prelabour rupture of the membranes
prelacunar stage of implantation, 102
premature babies. See preterm babies
premature expulsion of placenta, twin pregnancy, 299
premature labour, causes, 621b
premature rupture of the membranes, preterm. See preterm prelabour (preterm
premature) rupture of the membranes
prenatal…. See entries under antenatal
Preparation for Birth and Beyond (Expert Reference Group's), 133–136, 138
presentations (fetal), 121, 193–194
abnormal. See malpresentations
appearance of presenting part, 369–370
assessment in 1st stage of labour, 341b
compound, 452, 477
denominators, 196
engagement and, 193
multiple pregnancy, 295f
malpresentations, 298
normal. See vertex presentation
pressure
bimanual. See bimanual compression/pressure
blood. See blood pressure
cord, release (with prolapsed cord), 478–479
cricoid, in caesarean section in Mendelson's syndrome prevention, 470
fundal, gentle, 411
hydrostatic, in replacement of inverted uterus, 487
suprapubic, in shoulder dystocia, 480–481
upper abdominal (in labour), epidural analgesia and, 369
vacuum, for ventouse extraction, 459
pressure symptoms, multiple pregnancy, 294
pressure ulcer prevention in labour, 343
preterm babies (premature babies), 621–622
breastfeeding, 723
characteristics, 621–622
cord prolapse or presentation, 477
delayed cord clamping, 402
infection, vulnerability, 675
shoulder presentation, 450
small for gestational age, 618. See also low birth weight babies
preterm labour, causes, 621b
preterm prelabour (preterm premature) rupture of the membranes (PPROM), 239–
240, 361
multiple pregnancy, 298
primitive reflexes (neonatal), 607
breastfeeding-related, 608, 712
primitive streak, 97
principles (in ethics), 38
procedural rules, 38
Professional Education for Genetic Assessment and Screening (PEGASUS), 211
professional issues (for midwives), 25–52
professional accountability, 31–32
professional detachment (affective neutrality), 11–12
professional indemnity insurance, 37, 182
Professional Standards Authority, 27
progesterone
blood pressure and, 244
in labour, 328–329
in ovarian and menstrual cycle, 94–95
placental, 104–105, 169
selective receptor modulators, 582
progestogen (contraceptive use)
alone
emergency use, 581–582
injectable, 575–576
IUCD impregnated with, 578
oral, 574–575
combined oral contraceptive pill, 570
in 1st/2nd/3rd generation pills, 570–571
dominance, 571f
mode of action, 571
prolactin, maternal, 169
lactation and, 706
pituitary tumour secreting (prolactinoma), 264–265
proliferation, vascular, 593
proliferative phase
menstrual cycle, 94–95
myometrial development in pregnancy, 144
wound healing, 520f
prolonged labour. See labour
prolonged pregnancy, 418
incidence, 418–419
induction of labour, 421
prone sleeping position, warning, 626
prostaglandin(s) (in general)
3rd stage of labour, 401
postpartum haemorrhage treatment, 409
in duct-dependent disease, infusion, 657
endogenous, cervical ripening and, 424
prostaglandin E1 analogue. See misoprostol
prostaglandin E2 inducing labour, 267, 418–419
prostate gland, 79
protective role of placenta, 105
protein
breastmilk, 707–708
cow's milk, intolerance, 727
plasma, in pregnancy, 154
wound healing and, 521t
protein hormones, placental, 105
proteinuria (in pre-eclampsia), 249
labour and, 341
tests/determination, 250b, 250t
prothrombin, 156, 234
prothrombotic state in metabolic syndrome, 254
protocols (in clinical governance), 44–45
pruritus, 168, 236
in cholestasis, 257
psoas major muscle, 86
psychiatric/mental disorders, 538–550
definition, 538b
mild to moderate, 538–540, 544–545
postnatal, 136, 526, 541–545
headache as precursor of, 523
in pregnancy, 539–541
prevention/prophylaxis, 549–550
serious/severe, 532, 538, 540–541
treatment, 545–549
types, 532–533. See also bereavement; grief
psychological dimensions, 531–553
caesarean section, midwife's role in psychological support, 465
female genital mutilation, 323
labour and birth, 335, 532–537
fear, 533–534
impact on partner, 375–376
pain, 349
personal account of psychological trauma, 388
prolonged labour, 428
multiple births
identity and individuality, 303
isolation at home of new mother, 302
mother–baby, 301
mother–partner, 301
siblings of multiples, 303
triplets (and higher order births), 303
pregnancy (in general) see pregnancy. See
also bereavement; distress; emotions; grief; loss; psychiatric/mental
disorders; stress; support
psychological treatments, 545
psychosis
in pregnancy, 540
prevention, 549
puerperal, 541–542. See also antipsychotics
psychosocial impact of antenatal screening, 204–205
ptyalism, 162b
pubis (pubic bones), 63
face to (presentation), undiagnosed, 442
symphysis. See symphysis pubis
public
involvement, 44
self-regulation and the, 26–27
trust, 34
public health care
postpartum period and, 501–502
role of midwife, 181–182
pubocervical ligaments, 73
pubococcygeus, 61
puborectal muscle, 61
pubovesical ligament, 88
pudendal nerve, 62
anal triangle, 57, 60
perineum, 57
vulva, 56
pudendal nerve block
caesarean section, 468
ventouse extraction, 458
puerperium. See postnatal period
pulmonary embolism, 272–273
amniotic fluid, 485
postnatal, 522. See also lung
pulse monitoring
maternal, intrapartum, 340–341, 345
maternal postnatal, 504, 517
neonatal, 602–603
purple (anal cleft) line, 338–340, 369
purpura
maternal idiopathic thrombocytopenic, 667
neonatal, 669
pushing (active), 370–371
avoiding, 370–371
in breech birth, 382
checking cervical dilatation before encouragement of, 385
pyogenic granuloma, 161
pyrexia, neonatal, 599
Q
Qlaira, 570, 572–573
quadruple pregnancy, UK statistics (1985–2011), 289t
quadruple testing, 209
quality standards, antenatal, 181
quickening, 116, 171
quins, UK statistics (1985–2011), 289t
R
rachitic pelvis, 70
radiology (imaging), fetal, new technologies, 214
randomized controlled trials, 18–19
rashes, 669–670
Raynaud's phenomenon, 264
realization (awareness) of loss, 556
recessive gene disorders, 648
records and documentation
antenatal screening, 205–206
intention to practice, 39–40
labour and birth, 338, 387–388, 406
breech, 385
medicines, 344
loss (incl. death), 564
neonatal examination, 598
developmental dysplasia of hip, 607
in Rules and Standards, 34, 387–388
rectum, 57
trauma (in childbirth), 312t
button-hole tear of mucosa, 312t, 314, 442
examination for, 314. See also anorectum
red blood cells (erythrocytes)
fetal, formation, 114
maternal
antibodies. See antibodies
mass/size/shape changes, 153–154. See also mean cell volume
red reflex, 605
referral for additional antenatal support, 183b
pre-eclampsia, 249–250
red cell antibodies, 217
reflexes (neonatal)
primitive/primary. See primitive reflexes
red, 605
refugees, 16
regional analgesia/anaesthesia
in caesarean section, 468–470
care following, 467
epidural. See epidural analgesia
Register, 26, 28
removal from, 30
striking off order. See striking off order
voluntary, 31
restoration (following striking off order), 31
regulation, statutory. See statutory regulation
regurgitant murmur, 603
relationships
midwife–colleague, 11
midwife–mother/woman, 10–11
postnatal, 526. See also partnership
mother–baby/neonate/infant
in depressive illness, 544–545
in multiple births, 301
in psychosis, 542. See also attachment
mother–parents of mother, changes, 534
mother–partner (couples')
in antenatal education, 134–136
lesbians, 17
in multiple births, 302
relaxation, postnatal, 508–509
relaxin, 94, 158, 167–168
REM sleep, fetal, 116
remodelling phase of wound healing, 520f
Remuneration Committee, 29
renal pelvis, 82
renal system. See kidney; urinary tract
renin, 83–84, 170–171
renin–angiotensin–aldosterone system (RAAS), 150–151, 166
reporting (in Rules and Standards), 33b
reproductive capacity. See fertility
reproductive cycle, 91–100
reproductive system (genitalia)
females
baby, examination, 597
changes in pregnancy, 144–149
external, 55–56
infections in pregnancy, 279
internal, 70–77
fetal, 115
males. See males
neonatal, 601
ambiguous genitalia, 597, 664, 695
first examination, 596–597
NIPE (Newborn and Infant Physical Examination), 607. See also genitourinary
system
rescue breaths, 488–489
research, 18
antenatal education, 127–129
evidence-based. See evidence-based research and practice
resolution (in grief for loss), 556–557
resources in Global Standards for Midwifery Education (2010), 7
respiration
fetal, 105
neonatal, malformations relating to, 654–656
respiratory distress, neonatal, 598–599, 678–681
causes, 678–681
initial management, 679
signs, 598–599, 670
respiratory distress syndrome
adult (ARDS), 490
neonatal, 680
respiratory rate
labour pain and, 352
neonatal, observation, 596
respiratory status assessment
in hypovolaemic shock, 491
postnatal, 504, 517
respiratory system
amniotic fluid embolism signs and symptoms, 485
fetal, 114–115
neonatal, 670–671
disorders/problems, 678–681
initial examination and recognition of problems, 670–671
malformations, 654–656
in pregnancy, 157–159
disorders, 269–270
responsibilities. See roles (midwives) and responsibilities
rest, postnatal, 508–509
restitution (fetal movement in labour), 374, 378
buttocks, 380
in left mentoanterior position, 446
in right occipitoanterior position, 441
resuscitation (cardiopulmonary)
baby, 611–615
recognition of problems at time of, 672–674
mother, 488, 592–598
postpartum haemorrhage, 409. See also ABC(DE) protocol
retained products of conception, evacuation, 225
retraction ring, 331–332
return to practice programme, 35
return to work and lactation cessation, 724
Rhesus status (and isoimmunization and subsequent disease), 105, 685–686
assessment, 216
booking visit, 188
partner testing, 217
causes, 105, 686
management of isoimmunization, 686
prevention of isoimmunization with anti-D prophylaxis. See anti-D prophylaxis
rheumatic heart disease, 268–269
rhombus of Michaelis, 338–340, 369
rhythm (calendar) method, 583–584
ribs (and rib cage)
neonatal, 670
in pregnancy, 158
rickets, pelvic deformation, 70
rights (human), 32
fetus and, 36
risk (in general)
in antenatal screening
biases in interpreting information on, 207
explaining, 207–208
assessment at booking visit, 187
management, 44, 47–49
Robert's pelvis, 70
roles (midwives) and responsibilities
antenatal screening, 205–208, 212
with associated problems in pregnancy, 222
breastfeeding, 715–716, 726
in caesarean section, psychological support, 465
contraception, 570
disseminated intravascular coagulation, 235
female genital mutilation, 317
in labour and childbirth, 361, 374–379
breech, 387
confidence concerning birthing position, 372
in induction of labour, 425–426
initial examination of woman, 337
initial meeting with, 334–338
pain control and, 355–356
in prolonged labour, 428–429
NMC and, 31–32
occipitoposterior position, 439
postnatal care, 501–504
prolonged pregnancy, 420
psychiatric disorders, 545
sexual health, 570
roles (parenting), change and conflict, 534
rooting reflex, 608, 712
rotation
external. See external rotation
internal. See internal rotation
manual therapeutic manoeuvres. See manual techniques
posterior, of occiput, 385
round ligaments, 73
in pregnancy, 144
rub up a contraction, 409
rubella
congenital, 676–677
immune status assessment, 215
booking visit, 189
Rubin manoeuvre, 481
rule(s), ethics and, 38
rule utilitarianism, 38–39
Rules and Standards, Midwives, 32–35, 387–388
rupture of the membranes/waters breaking (forewaters and/or hindwaters), 369
artificial, 267, 296, 333, 424
failure (in labour), 333
prelabour and preterm. See prelabour rupture of the membranes; preterm prelabour
rupture of the membranes
S
sacral dimple, 598
sacro-anterior position, right, 380–381
sacrococcygeal joint, 64
sacrococcygeal ligaments, 65
sacrocotyloid dimension (pelvic inlet), 67
sacroiliac joints, 64
sacroiliac ligaments, 64
sacrospinous ligaments, 64
sacrotuberous ligaments, 64
sacrum, 63
as denominator with breech presentation, 196
safety
fetal ultrasonography, 211
infant sleeping, advice, 199, 626
sagittal suture, 118
saliva in pregnancy, 161–162
excess (ptyalism), 162b
salmon patch haemangioma, 593
salpinges. See fallopian tubes
sanctions (by NMC), 30
sarcomeres of respiratory muscle in pregnancy, 158
Saving Mothers' Lives, 538, 550b
SBAR tool, 476
schizophrenia, 539
postnatal symptoms of, 541
sclera (neonatal)
first examination, 595
NIPE (Newborn and Infant Physical Examination), 605
scope of practice (=Rule 5), 33–34, 33b
Scotland. See Midwives (Scotland) Act
screening
antenatal. See antenatal screening
neonatal, 591–609
principles, 592b
scrotum, 78
neonatal, examination, 597
Seasonale and Seasonique, 586–587
secretory phase of menstrual cycle, 95
seizures/convulsions/fits
maternal
eclamptic, 251–252
epileptic, 277–279
neonatal, 639–641, 674
causes, 674
support of parents, 641
selective progesterone receptor modulators, 582
selective serotonin reuptake inhibitors, 546–547
self-care, postnatal, 526
self-regulation, 26–27
seminal vesicles, 79
seminiferous tubules, 78, 80
semi-recumbent positions (for labour and birth), 360, 371
breech birth, 381–384
and delayed birth of head, 385
sense organs, fetal, 115–116
sensory (afferent) pathways and labour pain, 350–351
sepsis
postnatal, 516
shock due to, 489–492
serious adverse incidents, 48–49
sertraline, 547
services
in Global Standards for Midwifery Education (2010), 7
maternity, obesity and, 255–256
mental health, 548–549
sexual health, future, 586
sex chromosomes, 95, 115
conditions linked to gene defects on, 648
sex determination, 95, 115
sex development, disorders, 597, 664, 695
sex hormones, adrenal, 695
sextuplets, UK statistics (1985–2011), 289t
sexual development, indifferent state of, 115
sexual health
role of midwife, 570
services, future, 586
shingles, 677
shivering (baby), inability, 598–599, 623
shock (circulatory failure), 489–492
classification, 489
shock (psychological) with loss, 556
shoulders
birth, 378–379
dystocia, 479–483
incidence, 479
management and manoeuvres, 480–483
outcomes, 483
risk factors, 479–480
warning signs and diagnosis, 480
internal rotation. See internal rotation
presentation, 193–194, 449–451, 477
show (mucus plug), 327, 332–333, 369
shower in labour, 343
shunts, left-to-right, 657–658
siblings
impact of loss, 563
of multiples, 303
sickle cell disease, 276–277
depot medroxyprogesterone acetate and, 576
screening for, 189, 210
signposting parents, 136
silicone (soft/silicone) ventouse cups, 457, 463
simethicone and lactase, 722
Simpson's forceps, 460
Sims' position, exaggerated
1st stage of labour, 439
prolapsed cord, 478–479
sinciput region (fetal skull), 118, 120
sinus rhythm,, neonatal, 602–603
sitting positions
for breastfeeding, 711–712
for labour and birth, 371
supported, 371–372, 374
skeleto-muscular system. See musculoskeletal system
Skene's ducts, 89
skimmed milk in formula feeds, 726
skin (fetal), 116
skin (maternal)
disorders, 236
perineal, suturing (after trauma), 319
postnatal, 505
pregnancy-related changes, 167–168
inspecting for, 190
preparation for caesarean section, 464
pressure ulcer prevention in labour, 343
skin (neonatal), 592–593
care, 599–600
colour. See colour
examination (for problems), 592–593, 668–670
lesions, 593, 600, 668–670
traumatic, 593, 629–631
vascular malformations/birth marks, 593, 662–663
rashes, 669–670
skin patch contraceptive, 574
skin-to-skin contact (woman–baby), 296, 299, 398, 465, 499–500, 599–600, 622, 711
skull, fetal, 116, 118–122
in breech birth, vault born slowly, 385
diameters, 120–121
divisions, 118–120
fracture at birth, 633
moulding, 122
sleep
fetal, 116
infant
benign sleep myoclonus, 674
safety advice, 199, 626
maternal, disturbances, 159
postnatal (and partner), 526
‘sleepy’ babies, feeding, 724b
small for gestational age, 618–621
hypoglycaemia, 623
preterm and, 618
small intestine in pregnancy, 163
smoking
combined oral contraceptive pill and, 572
first antenatal visit and, 187
sniffing position, 613
social circumstances established at booking visit, 184
social contact with baby, 625
social context of pregnancy/childbirth/motherhood, 13–18
social impact of antenatal screening, 204–205
social mode of (postnatal) care, 503
social support. See support
socioeconomic disadvantage (incl. poverty), 15
sodium, neonatal, 691–692
depletion, 691
excess intake, 692
imbalances, 691–692
sodium valproate, 548
soft tissue displacement in 2nd stage of labour, 369
soft ventouse cups (silicone/silastic cups), 457, 463
somatic syndrome in depressive illness, 543
somatosensory function and pain, 350–351
somersault manoeuvre, 378
soya-based formulae, 727
spermatic cord, 78
spermatozoon, 91
formation (spermatogenesis), 80
oocyte fertilisation by, 95–96
spermicides, 581
sphygmomanometer, 245
spina bifida, 659
occult, 598, 659–660
spinal (intrathecal) anaesthesia for caesarean section, 469
postoperative care, 467
spine
maternal, deformation with concurrent pelvic deformation, 70
neonatal, examination, 598
spiral arteries, 106, 146
remodelling/modification, 106, 146
failure, 145
spirometry, asthma, 270
squatting position, 371–372
SSRIs (selective serotonin reuptake inhibitors), 546–547
standards
antenatal quality, 181
Global Standards for Midwifery Education (2010), 6
for medicines management, 35
Midwives Rules and Standards, 32–35, 387–388
for preparation and practice of supervisors of midwives, 42
Staphylococcus
postnatal infection, 519
s. aureus, methicillin-resistant, 37
startle reflex, 608
status asthmaticus, 270
status epilepticus, 278
statutory regulation, 26
abortion, 227–228, 227b
postnatal care, 501
statutory instruments, 28
statutory supervision, 39–43, 47–48
stem cells (in embryonic development), 99
harvesting, 99
sterilization (microbial), feeding equipment, 728
sterilization (reproductive), 585–586
feeding equipment, 728
female, 585–586
male, 586
steroid hormones, placental, 104–105. See
also corticosteroids; glucocorticoids; mineralocorticoids
stethoscope, fetal heart, 194
labour
1st stage, 337, 344–345
2nd stage, 376
stillbirths, 557–558
lactation and, 723–724
multiple vs singleton, 304f
stomach
maternal, 163
content aspiration into lungs, in caesarean section, 470
neonatal, 600–601
tube feeding, 624
stools. See faeces
strawberry haemangioma, 593, 662–663
streptococcus
group A, 281
group B. See group B streptococcus
postnatal infection, 519
stress (psychological), 532–533. See also distress
stretch marks (stretch marks), 167–168, 190
stretching the membranes, 199
striae gravidarum (stretch marks), 167–168, 190
stridor, upper airway (incl. larynx), 656, 681
striking off order, 30–31
restoration to Register following, 31
student body in Global Standards for Midwifery Education (2010), 6–7
Sturge–Weber syndrome, 593, 662
subaponeurotic haemorrhage, 634
subarachnoid space, catheter misplaced in, 469–470
subcutaneous (superficial) tissue injuries, 630
subdermal contraceptive implants, 576–577
subdural haemorrhage, 634–635
subgaleal haemorrhage, 634
sub-mentobregmatic (SMB) diameter, 120
sub-mentovertical (SMV) diameter, 120
sub-occipitobregmatic (SOB) diameter, 120, 373
sub-occipitofrontal (SOF) diameter, 120, 373
substance (illicit drug) abuse, 187, 539, 550, 696–697
discharge and long-term effects, 697
overdose, 492, 550
signs of withdrawal, 696
treatment, 696–697
substance P, 350–351
substantive rules, 38
succenturiate placental lobe, 108–109
sucking reflex, 608, 713–716
LBW and preterm babies, 624, 723
sudden infant death syndrome, previous occurrence (woman or in family), 185
sudden unexpected death in epilepsy, 278
suicide, maternal, 550
superficial (subcutaneous) tissue injuries, 630
superficial transverse perineal muscle, 57
supervision, statutory, 39–43, 47–48
supervisor
local action plan with (following LSA investigation), 48b
roles and responsibilities, 42
selection and preparation, 42
supine hypotensive syndrome, 152b
supine sleeping position, 626
supplementary feeds (to breastfeeding), 724–725
support and help (incl. social and psychological support), 535
in caesarean section, 465
in labour
continuous, 336
for partner in 2nd stage, 375–376
in loss, 562–563
for midwife in congenital malformation, 665
in multiple pregnancy, 305
for breastfeeding, 293b
of parents in neonatal trauma/haemorrhages/convulsions, 641
from partner, 134–136
in psychiatric disorders, 545–546
supported lithotomy in assessment of perineal trauma, 313–314
supported sitting position, 371–372, 374
suprapubic pressure in shoulder dystocia, 480–481
Sure Start, 501, 545–546
Children's Centres, 138, 501–502, 510
surfactant (fetal lung), 114–115, 680
exogenous, administration, 680
lack/deficiency, 115, 671, 680
surgery
ectopic pregnancy, 226
maternal
of breast, affecting breastfeeding, 723
history of, 185–186
neonatal, affecting breastfeeding, 723
pregnancy loss
miscarriage, 225
termination of pregnancy, 228. See also operative births; postoperative care
surveillance for red cell antibodies and related disease, 217
suspension order, 30
interim, 30
sutures (fetal skull), 116, 118–120
suturing in perineal injury
muscle layer, 319
postpartum haemorrhage relating to, 407
skin, 319
vagina, 318–319
swallowing (swallow reflex), 716, 718
LBW babies, 624
preterm infants, 723
sweeping the membranes, 199
symphysis pubis, 64
pain, 229
surgical separation in shoulder dystocia, 483
symptothermal method, 584
syncytiotrophoblast, 97, 102–103, 168–169
syndactyly, 597, 660
Syntocinon. See oxytocin
syphilis (Treponema pallidum infection), 281
testing for, 188, 215
systemic causes of hypotonia, 671
systems and organs
postpartum changes, 504–509
pregnancy-related changes. See pregnancy
shock and its effects on, 490
systolic murmur, 603–604
T
tachypnoea of newborn, 670
transient, 679–680
talipes calcaneo-valgus, 598
talipes equinovarus, 597–598
congenital, 597, 661
talking
after childbirth, 526–527
after loss, 561. See also communication
TAMBA (Twins and Multiple Births Association), 305
teacher in Global Standards for Midwifery Education (2010), 6
teat
bottles, 728
breast/nipple, 712–713
teenage (young) mothers, 14
under 16 years see minors
teeth in pregnancy, 161–162
temperature
control. See thermoregulation
instability in neonates, 675
measurement
natural family planning methods using, 583–584
postnatal, 504. See
also cooling; heat; hyperthermia; hypothermia; pyrexia; warming
temporal bone, 118
TENS (transcutaneous electrical nerve stimulation), 353
teratogens/potential teratogens (causing fetal/congenital defects/malformations), 648,
664–665
alcohol, 664–665
anticonvulsants, 548
antipsychotics, 547
heart defects due to, 656
lithium, 548
preconception care and, 260, 277–278
SSRIs, 547
warfarin, 266
terminal care with congenital malformations, 646–647
termination of pregnancy (induced or spontaneous). See abortion; miscarriage
testes/testicles, 78
neonatal
examination, 597
undescended, 664
testosterone, 80
tetralogy of Fallot, 657
thalassaemia, 275–276
screening for, 189, 210–211
α-thalassaemia, 275
β-thalassaemia, 275–276
sickle cell and, 243
thermoregulation (temperature control), neonatal, 598–599, 670–671
LBW babies, 623
twin babies, 299
three-dimensional ultrasonography, 214
thrombin, 234
thrombocytopenia (low platelets)
maternal, 638. See also HELPP syndrome
neonatal, 638, 688
thrombocytopenic purpura, maternal idiopathic, 667
thromboembolic disease (venous thromboembolism), 270–273
combined oral contraceptive pill and risk of, 572
prevention (thromboprophylaxis), 270–271
in caesarean section, 465
postnatal, 271–273, 522
thromboembolic-deterrent (TED) compression support stockings, 266–268, 271,
277, 467, 522, 525–526
thromboplastin, 234
thrombosis, 266
deep vein, 190, 229, 271–273, 522
disposition in metabolic syndrome, 254
history of, 185
management, 266
thrush. See Candida albicans
thyroid
disease
maternal, 262–264
neonatal, 694–695
function, maternal, 169–170
thyrotoxicosis (hyperthyroidism), 263, 263t
thyroxine (T4), maternal, 170, 262
administration in hypothyroidism, 263–264
excess, 262–263
tiredness, postnatal, 508, 526
tocolytics in preterm prelabour rupture of the membranes, 240
tocophobia, 533–534
tongue tie, 722
tonic-clonic seizures, maternal, 278t
tonic neck reflex, asymmetric, 608
tonic seizures/convulsions
maternal, 278t
neonatal, 640
top-up (complementary) feeds, 724–725
TORCH, 676, 688
torticollis, 631
totipotent stem cells, 99
touch, mother–baby, 625–626
toxic chemicals, placenta transfer, 105
toxic (septic) shock, 489–492
toxicity, drug, 492
toxoplasmosis, 677–678
screening, 189
tracheal intubation in caesarean section, difficult/failed, 470–471
traction
controlled (on umbilical cord). See umbilical cord
in forceps birth, 461
in ventouse birth, 457, 459
adverse effects, 462–463
training
NIPE (Newborn and Infant Physical Examination), 607
perineal repair, 321
transcutaneous electrical nerve stimulation (TENS), 353
transitional epithelium
bladder, 88
ureter, 87
urethra, 88
transport mechanisms, placental, 106
transposition of the great arteries, 604b, 657
transverse cervical ligaments, 72
transverse diameter of pelvic inlet, 66–67
transverse lie, 194, 197f, 477
shoulder presentation, 451
trauma. See injury
travelling families, 17
Trendelenburg posture, prolapsed cord management, 478–479
Treponema pallidum. See syphilis
trials, randomized controlled, 18–19
tricyclic antidepressants, 546
tri-iodothyronine (T3), maternal, 170, 262
excess, 262–263
tripartite placenta, 109
triphasic combined oral contraceptive pill, 570
triplets (and higher orders pregnancies/births), 303
UK statistics, 289t, 303f
trisomy 13, 650
trisomy 18, 650
trisomy 21. See Down syndrome
trophoblast, 97, 146
implantation. See implantation
trophoblastic disease, gestational, 226–227, 249
trunk diameters, 121
trust, public, 34
tube feeding of baby, 624
tubules (renal), secretion by, 86
tumours (neoplasms)
adrenal gland, 248
malignant. See cancer
pituitary, 264–265
tunica albuginea, 78
tunica vaginalis, 78
tunica vasculosa, 78
Turner syndrome, 650
twin pregnancy. See multiple pregnancy
twin reversed arterial perfusion, 298
twin-to-twin transfusion syndrome, 297
Twins and Multiple Births Association (TAMBA), 305
U
ulipristal acetate, 582
ultrasonography (abdominal/fetal)
dating of pregnancy, 418
diabetic women, 261
hydramnios, 238
in hypertensive disorders, 248
oligohydramnios, 239
for screening, 211–214
1st trimester, 212–213
2nd trimester (incl. 18+0 to 20+6 weeks), 213
safety, 211
three-dimensional, 214
twin pregnancy, 292
women's experiences, 211–212. See also Doppler assessment
umbilical arteries, 112
umbilical cord, 107
anatomical variations, 108–109
around neck (at birth), 378
blood sampling, 404
breaking, 411
clamping and cutting, 379, 399, 401–402
with cord around neck, 378
early, 401
late/delayed, 402
timing in relation to postpartum haemorrhage incidence, 403
controlled traction, 399, 402–403
and counter-traction, 403
timing in relation to postpartum haemorrhage incidence, 403
loosening gently (in breech), 385
presentation, 478
definition, 477
predisposing factors, 477
prolapse, 385, 477–479
definition, 477
diagnosis, 478
in malpresentations, 448, 451, 477
management, 478–479
in multiple pregnancy, 298, 477
in occipitoposterior position, 438
occult, 477
predisposing factors, 477
stump. See umbilicus
umbilical veins, 112
at birth, 117
umbilicus (and umbilical stump)
bleeding from, 639
bowel protruding through (omphalocele), 650
examination, 637
infections, 675
UNICEF
Baby Friendly Hospital Initiative (with WHO), 718–719, 727, 729–730
International Code of Marketing of Breastmilk Substitutes and, 729
uniovular twins. See monozygotic twins
unsettled babies, feeding, 725b
upper limb. See arm
upright birth positions, 343, 371–372
breech birth, 360, 381–385
urachus, 88
urea measurements in pregnancy, 155t, 161
ureters, 82, 86–87
in pregnancy and childbirth, 156, 160
urethra
females, 88–89
males
opening on penis undersurface (hypospadias), 596, 664
orifice, 56
posterior, valves, 663
urinalysis. See urine
urinary incontinence (and other urinary problems)
antenatal, 161b
postnatal, 507, 523–524
urinary tract (baby)
fetal, 115
infection, 671–672
malformations, 663–664. See also genitourinary system
urinary tract (female), 81–90
catheterization in caesarean section, 464
in pregnancy and childbirth, 89–90, 159–161
infection, 281–282
urination. See micturition
urine, 84–86
characteristics, 84
production/output, breastfed baby, 718
production/output, maternal, 85–86
in pregnancy and childbirth, 90
tests (incl. urinalysis from mid-stream specimens), 215, 282
at booking visit, 188
in labour, 341
in proteinuria, 250
urogenital system. See genitourinary system; reproductive system; urinary tract
urogenital triangle, 56–57
uterine souffle, 146
uterine tubes. See fallopian tubes
uterosacral ligaments, 73
uterotonics (oxytoxics; ecbolics) in 3rd stage of labour, 399
breech birth and, 382
caesarean section, 465
postpartum haemorrhage (PH) and
timing of administration in relation to incidence of PH, 403
in treatment of PH, 409
uterus, 72–74
anterior obliquity, 444
atonic, 406, 409
bimanual compression in postpartum haemorrhage treatment, 409–411
emptying, in postpartum haemorrhage treatment, 409
fundus, 73
dominance (first stage of labour), 330
eclamptic seizure and, 252
massage, 409
measuring height (in pregnancy ), 191
palpation (in pregnancy), 191
pressure (gentle), 411
inversion, 486–487
acute, 486–487
classification by severity, 486
subacute and chronic, 486
involution, 505–507, 518
in labour
in 1st stage, actions, 330–332
in 2nd stage, actions, 368–369
contractions see subheading above
at onset of labour, 329
malformations, 74–75
muscles
contractions. See contractions
laxity causing shoulder presentation, 441–442
retraction see subheading below
neck. See cervix
postnatal
changes, 505
deviation from normal physiology and potential morbidity, 518f
morbidity after operative birth, 519–520
morbidity after vaginal birth, 518–519
in pregnancy, 144–148
apoplexy, 233
divisions, 148
fibroids. See fibroids
glands, 102
palpation. See palpation
shape and size change, 147–148
resting tone (in labour), 331
retraction (in labour), 331
in 3rd stage of labour, 397
retraction ring, 331–332
rupture, 484–485
segments (upper and lower in labour)
formation, 331
lower uterine segment technique for caesarean section, 465
utilitarianism, 38–39
V
vaccination
HPV, 281
rubella, 189, 676–677
VACTERL spectrum, 650–651, 660
vacuum extraction. See ventouse
vagina (maternal), 70–72
blood loss from. See bleeding; haemorrhage
in labour and childbirth, examination, 340
brow presentation, 449
face presentation, 445
indications, 340
initial, 337
occipitoposterior position, 438
shoulder presentation, 450–451
misoprostol, for induction of labour, 424
orifice/introitus, 56
in perineal injury, suturing, 318–319
in pregnancy, 149
leucorrhoea (white discharge), 149, 189–190
vagina (neonatal), bleeding, 639
vaginal birth/delivery
assisted. See instrumental vaginal birth
breech presentation, 356–360, 380–387
1st stage of labour, 356–360
2nd stage of labour, 380–387
assisting manoeuvres, 384–385
checklist, 385b
facilitation, 382–385
instrument-assisted, 384, 456
brow presentation, unlikeliness, 449
epidural analgesia and, 371b
multiple pregnancy, 294
previous caesarean section and, 466
uterus and vaginal loss after, 518–519
vaginal ring, combined hormonal, 574
valproate (sodium), 548
Valsalva manoeuvre in 2nd stage of labour, 371
cardiac disease and, 267
valvular rheumatic heart disease, 268–269
Vancouver wrap, 712
varicella. See chickenpox
varicella zoster virus, 677
varicose veins in pregnancy, 153, 190
vasa praevia, 109, 476–477
vascular birth marks, 593, 662–663
vascular endothelial growth factor (VEGF), 105
vasculature. See blood supply; blood vessels
vasectomy, 579
vasodilation in pregnancy, 150–151
vasopressin. See antidiuretic hormone
veins
central venous pressure monitoring in shock, 491
fetal development, 112–114
supply to female reproductive organs. See blood supply
thrombosis. See thromboembolic disease; thrombosis
varicose, in pregnancy, 153, 190
velamentous insertion of cord, 109
Venereal disease research laboratory (VDRL) test, 188
venlafaxine, 547
venous sinuses, 122
ventilation, neonatal intermittent positive pressure, 613
ventilatory breaths for babies, 613
ventouse (vacuum extractor), 457–460
complications, 462
contraindications, 462–463
neonatal trauma, 629–630, 639
failure, 463
indications, 456
procedure, 458–459
types, 457–458
use, 458
precautions, 459. See also instrumental vaginal birth
ventricles (brain), haemorrhage from (IVH), 635–637
ventricles (heart)
ejection murmur, 603
septal defect (VSD)
maternal, 268
neonatal, 602, 658
verbal consent, 36
vernix caseosa, 107, 116
vertex presentation, 121, 193–194
occiput as denominator with, 196
positions in, 198b, 198f see also specific types of vertex presentation
vertex region of fetal skull, 120
vesicular rash, 669
vestibular glands, greater, 56
vestibule, vulval, 56
bulbs, 56
vicarious liability, 37
viral infections, neonatal, 676–677
Virchow's triad, 271–272
virilization (masculinization), female, 664, 695
visceral pain, 351
visits. See antenatal care; booking visit; home
vital capacity, 158
vital signs, postnatal, 504–505, 517
vitamin(s) (in general)
breastmilk, 708–709
deficiency, pelvic anomalies, 70
wound healing and, 521t
vitamin A, breastmilk, 708
vitamin B complex, breastmilk, 709
vitamin C, breastmilk, 709
vitamin D, 708
breastmilk, 708
deficiency, 674, 708
supplementation, 165, 708
vitamin E, breastmilk, 708
vitamin K (phytomenadione/phytonadione/phylloquinone), 708–709
neonatal/infant
administration and supplementation, 600, 637–638, 688, 709
breastmilk source, 709
deficiency (and associated bleeding), 637–638, 688, 709
in obstetric cholestasis, supplements, 236
vitelline arteries, 112
vitelline duct, 98–99
vitelline veins, 112
Voltarol. See diclofenac
voluntary removal from Register, 31
voluntary risk-pooling scheme for negligence claims, 47
volvulus, 652–653
vomiting (emesis)
maternal, 162, 228–229
neonatal
bile-stained, 672
blood-stained (haematemesis), 639
vulnerable women, 13, 184
vulva, 55–56
W
Wales, All Wales Clinical Pathway for Normal Labour, 388
warfarin, 266
warming in hypovolaemic shock, 490
warts, genital, 281
water, body
maternal, 166
neonatal depletion, 691–692
water birth. See birth pool
water-soluble vitamins, 709
water supply for infant feed preparation, 728
waters breaking. See rupture of the membranes
weaning from breast, 724
weight, maternal, 165–166
at booking visit, 187–188
gain in pregnancy, 254–255
postnatal difficulties in losing weight after, 256–257. See also obesity
weight, neonatal, 617–618
classification, 617–618
loss followed by gain, 601, 718. See also low birth weight
Welfare Food Scheme, 729
well-being. See health and well-being
Wharton's jelly, 107
whey
in breastmilk, whey-dominance, 708
in formula feeds, 726
hydrolysates, 727
whey-dominant formulae, 726
white blood cells in pregnancy, 156–157
white spots (nipple surface), 721
WHO. See World Health Organization
Who Is There for Us? People and Resources (theme in antenatal education
programme), 136
Why Mothers Die in the UK, 538
Winterton Report (1992), 500
withdrawal (in drug abuse), babies, 696
pharmacological treatment, 696–697
signs, 696
withdrawal method (coitus interruptus), 582
women (as users/clients/mothers)
amniotic fluid embolism morbidity, 486
in antepartum haemorrhage
effects on woman, 230
initial appraisal of woman, 230
attachment to baby, 556
caesarean section requested by, 465
care of or centred on, 13
immediate care after birthing, 405–406
in induction of labour, 425–426
in loss, 561–563
in multiple births, 302
postnatal, 516
in second stage of labour, 398–404
communication with. See communication
contact with baby. See contact
counselling. See counselling
death. See death
disadvantaged. See disadvantaged groups
examination. See examination
experiences. See experiences
information for. See information
injury. See injury
in instrumental delivery
complications, 462
as forceps delivery indicator, 456
intrauterine growth restriction related to, 620
in loss
care of, 561–563
contact with baby, 560–561
milk production and, 706–707
numbers in antenatal education group, 139
obesity risks to, 255
postnatal, 256
in partnership with midwives. See partnership
in postnatal period
care focused on, 516
contact with/visits by midwife, 503–504
immediate untoward events, 516–517
potentially life-threatening conditions, 516
views of, 502b
in postpartum haemorrhage
observation, 412–413
resuscitation, 409
prolonged pregnancy and its impact on, 418–419
psychosocial impact of antenatal screening, 204–205
puerperium. See postnatal period
relationships with others. See relationships
screening for disorders, 214–217
in shoulder dystocia, morbidity, 483
in shoulder presentation causation, 449–450
in transition and third stage of labour, response, 370–373
in unstable lie causation, 451. See also female baby genitalia; female genital
mutilation
Woods manoeuvre, 481
work, lactation cessation with return to, 724
workshops, postnatal, women's views, 502
World Health Organization (WH)
Baby Friendly Hospital Initiative (with UNICEF), 718–719, 727, 729–730
breastfeeding promotion initiative, 729–730
formula feeding, 728–729
labour defined by, 328
wound, postnatal, 520–522
care after caesarean section, 467
deviation from normal physiology and potential morbidity, 518f
healing, phases, 520f
problems, 520–522
Wrigley's forceps, 460
written consent, 36
X
X chromosomes, 95, 115
conditions linked to defects on, 648
XO (Turner) syndrome, 650
Y
Y chromosome, 95, 115
young mothers see minors; teenage mothers
Z
Zavanelli manoeuvre, 482–483
zinc, infant breastfeeding, 709–710
zona pellucida
penetration by sperm, 95
in pre-embryonic period, 96–97
zygosity of twins, 95–96, 288
determination, 288–292
after birth, 292
relationship between chorionicity and, 291t
zygote
development, 96–99
formation (by fertilisation), 95–96
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