Reflection of working with women during pregnancy and in the postnatal period
I first met Ashley at the Nepean antenatal clinic. At the time, she was 30+1 gestational weeks. I established from her history that this was her third pregnancy. Her first pregnancy had been in the year 2001. She had not carried the pregnancy to term because she had had a miscarriage. Her second pregnancy was in 2010. For this pregnancy, she had a normal vaginal delivery at 37+1 weeks. She had given birth to a live female infant, Isobel, who weighed 3140 grams. She had attended the visit with Isobel who is now 2 yrs old. A UA was performed during this visit because Ashley has a history of recurrent UTI but the results came back NAD. The usual antenatal screening was also done. Her BP was 98/60. On palpation, her fundal height was 29 weeks and the position LOL. Ashley complained of heart burn after eating large meals. I informed her that heart burn is common during pregnancy because progesterone relaxes the valve that separates the esophagus from the stomach allowing gastric acid to seep back up the pipe. I explained to her that heart burn is a result of irritation of the esophagus by gastric acid. I advised her to take an anti-acid that can be purchased from the chemist. I informed her that her next appointment would be on the 3rd of April 2012. I asked her if she would like to take part in the CCP care program, she agreed and i gave her a brochure containing the details of the program. The registered midwife then signed the ethics form.
Ashley attended this visit with her 2 year old daughter Isobel. Her gestation by dates was 34+1 weeks. She had presented to my duty hospital on the 20/3/12 with complains of flu like symptoms and disseminated muscle pain. She said they had done blood works and the results had come back NAD. She had then be treated for a viral illness and discharged. She reported that she had recovered quickly and was now feeling well. The routine antenatal check up was done, her BP was found to be 139/60 mmHg, fundal height 33 weeks, and position LOL. I asked Ashley if she had cut down on her smoking. She said she was taking on average ten cigarettes a day.
Example of prenatal health promotion
During her first antenatal visit at Nepean Hospital antenatal clinic, she had been counselled on the potential harm of smoking during pregnancy. In line with the Sydney west area health service policy, a smoke-free assessment and support document was provided to Ashley during this visit. She was informed of the multiple benefits of smoking cessation to not only her own but also to her baby’s health. These benefits include reduced risk of cancer, cardiac, and respiratory diseases, as well as reduced financial burden. The reduction in cost was particulary pertinent to Ashley because she had money problems. She acknowledged that saving the money she used on cigarettes would be particulary beneficial because her family was struggling financially at the time.The potential benefits of smoking cessation to her unborn child discussed with Ashley included increase in oxygen and nutrient levels, better chances of the baby having a healthy birth weight, reduced risk of premature birth, and a decreased risk of complicated delivery. In response to this information, Ashley stated that she had not been aware that her smoking may harm her unborn child and she had in fact, smoked throughout her first pregnancy.
She had been hesitant about quitting smoking until she was informed of the potential complications her baby may face in the future such as increased risk of SIDs and respiratory diseases such as asthma. Her 3 year old daughter had recently been diagnosed with asthma following a severe attack which had required hospitalisation. She said that she had experienced numbing fear when Isobel had had that first attack and she would not like to go through such an experience again. She said that she felt guilty that her smoking had in some way being responsible for her daughter’s condition. The midwife reassured her that there was no definite way of knowing what had really caused the attack and the important thing then was for her to consider quitting smoking for the sake of her health and that of her family. Ashley said that she would like to quit but she did not know how best to go about it. She was given a quit pack and informed of the free nicotine replacement therapy offered by Nepean Hospital. We offered to book for her an appointment with a clinical psychologist so that she could discuss with him/her any negative feelings she had in relation to her child being diagnosed with asthma or any other issues or concerns. She declined the offer but took a quit pack. Her next routine antenatal visit was scheduled after three weeks. This visit was also to be used to determine her progress in smoking cessation and if further services were required to help her through this difficult process.
During this visit, her gestation was 36+4 weeks by dates. Her BP was 110/60 mmHg, fundal height was 35 weeks, presentation cephalic, and position LOL. When asked about her general health, she stated that she had been well although she had been getting some Braxton hicks. She reported that she had also felt them during her first pregnancy. I advised her to have a warm bath or to use a heat pack. I also informed her to take paracetamol for pain relief if she felt the need because it is the safest drug to take in pregnancy. An LVS swab was taken for strep B test. Ashley was educated on the reasons for the test and what to expect if the results were positive. Its Nepean hospital policy for all expectant mothers to be tested at 36 weeks except for those who had already been found to be GBS positive who are presumed to be positive. Just like the WHO, I do not support this policy. I enquired from the midwife i was working with after Ashley had left why this practice is part of Napean’s hospital policy, she said that she did not know why because the procedure is not evidence-based and it is not recommended by the WHO guidelines. She also said that she hoped that the hospital would change its policy.
On this visit, her gestation by dates was 38+1 weeks.
Prenatal example of detection of obstetric emergencies
Ashley presented for the antenatal appointment with her daughter. When I asked her how she had been feeling, she stated she had not being feeling so well because she had been getting a lot of abdominal pain. I asked for the location of the pain and its duration. She replied that the pain was in her lower pubic area and she had had it for two days. I asked if she had been getting any vaginal discharge, she reported that she had not had any. I enquired whether she had been feeling the normal fetal movements. She reported that she had not felt the baby move since the prior night and she was worried because her baby usually moves alot. I told her that i would send her for a CTG at the hospital so that her baby could be checked out. She said she had to take her daughter for swimming lessons thus she could only go later in the afternoon. I explained to her the importance of going to the hospital immediately as i did not have the equipment to do a full assessment on the baby at the community center. The community center does not have a CTG. I did the routine antenatal check up. Her BP was 110/70 mmHg and fundal height 38 weeks. The fetal heart rate was 135-145bpm and irregular. When i was palpating her abdomen, i felt the bay move severally. I called the hospital and informed the midwife-in-charge that i would be sending Ashley for a CTG and review by the O&G team. Unfortunately, i was unable to take Ashley to the hospital because i had to finish my work at the clinic. Ashley went to the hospital and a CTG was performed which showed that her baby was normal. She was then allowed to go home.
Delivery (8/5/12)
On the 8th of May 2012, I received a call at 4 am from the birth suite. The caller informed me that Ashley had presented there in labour. A VE had been done and her cervical Os had been found to be 4 cm dilated. She was getting moderate contractions at a rate of 3:10. When I arrived, Ashley was in the delivery room with her husband and mother. She was lying on the bed and using gas No.3 + O2 mixed at a ratio of 50:50. Ashley told me between contractions that she had started getting them at about 11pm and they has been increasing in strength and intensity. Since her husband Tony had been working then, she had called her mother Susan to come help her. Susan had dropped their daughter at her grandpa’s place and then brought Ashley to the birth suite. Tony had been able to leave work soon after they had arrived at the birth suite and had just gotten there.
At 4.30 am, Ashley’s BP was 121/71 mmHg,her MHR was 87bpm, and temp 36.80C. The FHR was 125-130bpm on doppler and contractions were 4:10 and moderate in tone. She seemed to be coping well with the situation and she was using the gas during contractions .
At 5.45 am, I advised Ashley to shower because the contractions were getting more intense. She used the N03 +02 (60:40) as she showered.
At 6 am, Tony was massaging Ashely’s back. Ashley, on the other hand, was becoming more irritable. The midwife asked Ashely for permission to do another VE to assess her progress. Ashley consented verbally and laid on the bed in lithotomy position. The midwife did the VE and reported she was 8cm dilated and the membranes were buldging. She asked for permission from Ashley to rapture the membranes. Ashley gave the go ahead and the midwife raptured the membranes with her hook.
Not long after the artificial rapture of membranes, Ashley stated she felt like pushing. I wore gloves and encouraged her to push with each contraction. A female baby was born in the first 15 minutes of 2nd stage thus it was a fast delivery. I placed the baby on the mother’s abdomen skin to skin. I then did active management of 3rd stage. IM syntocinon was given after the birth of the baby because the delivery was quick. The placenta was delivered via controlled cord traction. It was examined and found to be complete. The cord had 3 vessels and was centrally placed. Examination for tears revealed that Ashley had a 2nd degree tear that needed suturing. She was sutured by one of the doctors. The baby was breastfeed within 30 minutesand both the mother and baby looked calm.
I visited Ashley in the postnatal ward. I asked her thoughts about the delivery. She said it had been better than her first child's birth because it had been shorter and less painful. She attributed the positive change to the fact that she knew what to expect. In addition, she appreciated that she had being able to move around and to have a shower something she had not being permitted to do during her previous delivery because she had been induced. When i asked her about breastfeeding, she said that baby sally was breastfeeding well and she would continue breastfeeding her.
I visited Ashley in the postnatal ward. She was being discharged on that day and was just about to leave when I arrived. She said she was really looking forward to going home as she had not slept well because the patient on the bed next to hers had been unwell all night. I did a postnatal check up and after establishing that all was well, I informed her that I would call her after two weeks to find out how she was doing.
I called Ashley at home. She said she was doing well but was very tired because her 3 year old daughter had had gastroeneteritis and she was still caring for her new born baby. I asked her how baby sally was doing. She said that the baby was a little Angel and she could not ask for a better baby. She said that although she was tired, she loved having a new born baby again. I asked if she was still breast feeding to which she replied in the affirmative. She said she was hoping she would be able to breastfeed her until she was 6months. She also told me that she had given up smoking completely. I congratulated her for the efforts she was making. I ended the call by thanking her for the fantastic opportunity she had given me. She said I would make a good midwife and if she ever wished to have more children, she would love to have me as her midwife. I felt touched by this and thanked her and wished her the best with motherhood.
