Feature / Maternity matters

Our series giving managers an understanding of clinical activities continues with a look at maternity care. Seamus Ward reports.

MOST women, particularly those having their first child, will go to their GP in the first instance. But there is no clinical reason to do so; they can go direct to the community midwife or even a hospital midwife.

Whichever route they choose, the accuracy of over-the-counter pregnancy tests means expectant mothers tend to present early – at six to seven weeks, sometimes even at five weeks. Midwife and Royal College of Midwives (RCM) special adviser for education Gail Johnson says early contact is good as it helps clinicians minimise risk and ensure better outcomes.

At eight to 11 weeks, the pregnant woman should see the community midwife in a booking appointment. The midwife will take a blood sample and discuss the woman’s health. Risk factors such as smoking, alcohol and poor diet during pregnancy, as well as the importance of taking folic acid and vitamin D supplements will be discussed. Blood will be tested for anaemia and infections such as rubella, syphilis, HIV and hepatitis.

The mother’s blood group and rhesus (Rh) factor, which can be positive or negative, are also determined. If the mother is Rh-, extra care may be needed to reduce risk of Rhesus disease, which can affect future pregnancies. These tests are repeated at 30 to 32 weeks.

The booking appointment is a prelude to the first ultrasound scan, which should be before 13 weeks. This confirms the pregnancy and ensures it is viable. It is known as the dating scan as the date of delivery is estimated here.

A further scan is offered at about 20 weeks – this is known as the anomaly scan at which conditions such as spina bifida, Downs syndrome and heart defects can be spotted and further tests offered, including amniocentesis. If the parents wish, the sonographer can also indicate the likely sex of the foetus.

The mother-to-be will see the community midwife every four to six weeks, but this will become more frequent as the pregnancy progresses. At each visit, the woman will provide a urine sample and have their blood pressure taken. The urine is tested for proteins, blood and ketones – presence of the latter may be an indication that she is not eating well.

Pre-eclampsia

Protein in the urine could be a sign of pre-eclampsia, which is more common in the later stages of pregnancy. Pre-eclampsia affects about 10% of first-time pregnancies, usually from 20 weeks, and if it develops into eclampsia can be life-threatening for mother and child – this affects 1% of pregnancies.

Pre-eclampsia can be treated by taking steps to lower blood pressure or inducing labour (depending on how far along the pregnancy is).

The urine is also tested for glucose, which could indicate the woman has diabetes or gestational diabetes – a temporary form of the disease, which usually disappears after giving birth. It occurs because women are less tolerant of sugar surges during pregnancy.

Diabetes concerns

Ms Johnson says those with pre-existing diabetes should already be under the care of specialists, while those with gestational diabetes must be seen by a specialist. In many areas, obstetricians work with diabetologists and dieticians to ensure blood sugar remains within the normal range. Whatever type of diabetes, antenatal sessions will be longer and more frequent as there is risk of complications.

Antenatal classes, which provide support and information, are provided by the NHS and bodies such as the National Childbirth Trust (which may charge a fee). They usually start eight to 10 weeks before the baby is due.

Ms Johnson says women with low risk should be offered all choices of birth settings – home birth, midwife-led unit or obstetrician-led care in a hospital. Those with high risk will be offered the latter option and are cared for by a specialist team. She adds that where facilities exist, a water birth should also be a possibility.

‘Caesarean section is only used to save the life of the mother or baby or where it is in the best interests of the mother. If the baby is distressed and it’s the quickest way of getting it out and sometimes if it is in breach position, caesarean section might be the best option, depending on the size of the baby,’ she says.

A caesarean is a major abdominal surgery that should not be taken lightly, she adds, especially as the mother would be expected to look after a baby shortly after the procedure.

Gestation normally lasts 37 to 42 weeks and babies are considered to have gone to term if they are born after 36 weeks. Most babies born before 24 weeks cannot survive as the lungs and other organs are insufficiently developed.

When the woman goes into labour they will have a named midwife regardless of setting. Ms Johnson says that, ideally, the midwife looks after just one woman in labour, which helps build a relationship and ensures the mother feels supported, as recommended by the RCM and the National Institute for Health and Clinical Excellence (NICE). However, given the demand pressures on maternity units, this is not always possible. When the baby is about to be born, another midwife may come into the birthing suite to assist with the birth.

While hydrotherapy (being in water) and gas and air (entonox) may be used for pain relief, the woman may opt for an epidural – a drip-fed dose of local anaesthetic that numbs the lower body. The epidural is set up by an anaesthetist so is not available for home births. Once set up, the midwife or mother-to-be can top up the amount of anaesthetic received. Since an epidural is an intervention that could affect both mother and child, a monitor is fixed around the woman’s abdomen to monitor contractions and the foetal heartbeat. The mother’s blood pressure is taken every 15 minutes. Epidurals can prolong the labour

and increase the chances that an assisted or instrumental delivery (using forceps, for example) will be needed.

Labour usually takes between five and 18 hours. Once born, the child is examined to ensure there are no major problems. Within three days, a more detailed examination is performed, including heart, hips and eyes – this can be performed in hospital or in the community. Vitamin K is offered to prevent a rare bleeding disorder called haemorrhagic disease of the newborn.

When to discharge

If the birth has gone smoothly, the mother and child can be discharged in as little as two hours, though it can be up to 48 hours. Children with complications may take longer – for example, if they are premature, have low birth weight or are born with a heart defect that can be corrected by surgery.

Mother and child are discharged into the care of the community midwife team, who run a seven-day-a-week service, and then to the health visitors. Midwives will support mother and child in the early days, promote breastfeeding and carry out a number of checks, including weight. When the child is between five and eight days old, the midwife will ask to take a blood sample from the heel to test for rare but potentially serious illnesses, including cystic fibrosis and sickle cell disorders.

Despite a clear pathway and guidelines, Ms Johnson says the rate of stillbirth is higher in the UK than in the rest of Europe. She says maternity services must ask why, particularly as countries such as Norway have reduced the stillbirth rate by adopting NICE guidelines.

Facts and figures

• Deliveries in hospital remained stable at about 669,000 in 2011/12 compared with the previous year.
• About 25% of deliveries are by caesarean section – again similar to 2010/11.
• The number of induced deliveries increased by 0.8% to 12%.
• The number of instrumental deliveries increased by 0.4% to 13%.
• Almost 70% of deliveries had a length of stay of two days or less (44% one day or less) and 10% five days or more. The longest stays were associated with caesarean deliveries.

Source: hospital episode statistics for 2011/12, NHS Information Centre