The Royal College of Obstetrics and Gynaecology estimate that 10-20% of known pregnancies result in spontaneous abortions (RCOG 2006). This statistic alone highlights the importance of the roles of midwives preconceptually and during the antenatal period, essentially being just as important as those in the intapartum and postnatal period.
Support and counselling pre-conceptually should be provided for all women with the intention of childbearing that suffer from pre-existing medical conditions; whether they are physical or psychological conditions which may be irritated by a pregnancy (CEMACH 2007). The role of the midwife preconceptually is to guarantee both parents are at the most favourable state physically and emotionally to manage pregnancy safely and happily (Wallace and Hurwitz 1998 PG 3).
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The role of the midwife in the pre-conceptual state is to obtain a history from the prospective parents and determine if any issues could affect the reproductive health of a woman/couple. They may also assess the holistic factors that may affect a pregnancy. The midwife is to advice where necessary; this must be handled with sensitivity to the individuals’ needs (Henderson and Macdonald 2004).
During an initial assessment there are a number of health issues that a Midwife must concern themselves with, including pre-existing medical conditions, environment and life style and maternal body weight, the optimal Body Mass Index (BMI) between 19.8 and 26 for highest fertility and positive pregnancy outcomes (Fraser and Cooper 2009). It is the midwifes role to advice with maternal dietary requirements and advise for pregnant women to eat 5 portions of fruit and vegetables a day, eat more starchy food and less fat, increase folic acid and folate intake and lower caffeine intake (Ramsay 2006, WHO 2009).A midwife must also inform parents about the dangers of smoking and alcohol consumption.
Pre-conceptionally the midwives role is to support a woman in getting her body at its optimal state for the physiological aspects of pregnancy. This could mean additional support for ladies with pre existing medical conditions, such as; diabetes mellitus, epilepsy, hypertension or heart disease.
With pre-existing medical conditions it is important to get the maternal body to an ideal state healthy enough to carry a foetus to term. For example with a diabetic woman the aim is to achieve normaglycaemia before pregnancy occurs. Women with type 2 diabetes should have insulin during the preconception period and throughout pregnancy (Jovanovic, Peterson and Fuhrmann 2008).
A midwife that cares for an epileptic women aims to keep her seizure-free while on the lowest form of anticonvulsants possible. Both oral medications to treat hypoglycaemia and anticonvulsants are known to have teratogenic effects (Chillemi and Vazquez 2008).
Preconception care is not widely accessed as not all pregnancies are planned. It is somewhat difficult to advice on care preconceptually once conception has occurred, however it is good practice for the midwife to offer advice to a postnatal woman for future pregnancies (Burden and Jones 2009). From my own experience I can note that the majority of women tend to attend their doctors surgeries for assistance preconceptually. This may be because it is easier to access a doctor through appointment; not many people are aware that you can contact midwives directly before pregnancy. The maternity act of 2010 hopes to change this. Many women discuss becoming pregnant and acquire advice at family planning centres if this is where they receive their contraception. I feel it would be more beneficial for families if midwives were able to offer more care pre-conceptually. This is because continuity of care would be greater if the same midwife gave care throughout the preconception, antenatal and postpartum stages.
Once a pregnancy has been established routine antenatal care should be implemented (NICE 2008). Antenatal care is defined as the care a pregnant woman and her family receive from conception until the beginning of labour (Vicars 2003). Families must be supported throughout pregnancy as a unit. It is important to establish how involved a family wishes to be and for the midwife to facilitate it. Many women hear of negative experiences others have during pregnancy and childbirth; it is vital to listen to the families and women’s worries to try to put them at ease. Pregnancy is supposed to be an enjoyable experience for all involved. The way in which care is usually given and the lifestyles families have tend to influence this. The physical and hormonal changes a woman is to experience may also cause distress if she or her family are not expecting it, for example morning sickness or other minor disorders of pregnancy can be somewhat worrying and have a great family impact. Midwives must support and assist when necessary, but still clarify the importance if something if is abnormal and in need of referral.
The first and advisable second appointment a woman receives is usually referred to as booking the woman. This is an important meeting with the woman as it is possible to provide her with helpful information about her pregnancy, birth and postnatal experience (NICE 2008). Within this booking period it is important to identify any women that may benefit from additional care (NICE 2008). This is because midwives are autonomous practitioners and are accountable for the safety of the women and unborn children in their care.
It is the responsibility of the midwife to measure height and weight at the booking appointment and to calculate maternal BMI. Midwives must also measure blood pressure and test urine for anything abnormal such as proteinuria. This must be recorded accurately. Midwives are experts of the normal therefore it is their responsibility to determine and risk factors that may affect the pregnancy and its outcome. This includes risks such as pre-eclampsia, gestational diabetes or possibilities of a genetic condition. The midwife will then refer to the appropriate professionals. This complies with Rule 6 of the Midwifery Rules and Standards (NMC 2004). It is also important to obtain a clients family and personal medical history. This is to determine any particular risks the baby may have or the mother. We are also responsible to obtain any previous surgical history. This is to elicit any illnesses or operations that may complicate pregnancy (NICE 2008).
At the booking appointment it is essential to offer all relevant information regarding screening for any abnormalities. A midwife is a facilitator and an educator to pregnant women; it is important that the woman and her family have received all necessary information on any procedures or tests to enable them to make an informed choice (Baston and Hall 2009). It is the midwives responsibility to ensure this happens. Blood tests are offered to confirm blood groups and rhesus D status, hepatitis B status, HIV, rubella, asymptomatic bacteria or any other deviations of the norm for the mother. It is also important to identify any women who have had genital mutilation (NICE 2008).
The midwife must also offer screening for Down’s syndrome and offer early scans to establish gestational age and ultrasound screening for structural anomalies. (NICE 2008). Screening tests may be an emotional time for families particularly if they are aware of genetic disorders already within either family. Parents may be conscious that both carry a trait such as sickle cell anemia or thalassaemia, this may put huge stress on all members of the family. A midwife must be ethical in her advice and information. It is unethical for midwives to tell a family with trait that there baby is low risk or the same risk as families without the trait.
Information received from the booking visits is often used to establish whether the woman is at high or low risk of complications during pregnancy or labour. This allows the correct care to be given and the correct care pathway to be used (NICE 2008). Multi-vitamins and vitamin D are given if necessary. (NICE 2008). Information is to be given on vitamin K.
At each antenatal appointment it is essential to undertake urinalysis to detect abnormalities in urine. This is an important way of detecting any irregularities early on. Blood pressure and abdominal examinations are also to be conducted at each appointment. During the 1st and 2nd trimester this to determine the height of the fundus to ensure correct growth progress is being made (NICE 2008). From 28 weeks the measurements from the fundus to the symphysis pubis is to be recorded accurately by plotting on a graph. This is to ensure growth is noticeable. At this time also the lie and position of the baby is also to be noted. It is the midwives role to promote normal vaginal deliveries’ (Royal College of Midwives 2010).
It is also significant to determine whether any psychiatric or mental health treatment has been received, allowing midwives to implement the care needed for that particular woman and determine any risks for antenatal or postnatal depression. It is essential to provide information on the development of the baby throughout pregnancy and discuss feeding intentions along with antenatal classes. A midwife must empower their clients and facilitate them to make their own decisions’ relating to the care they receive. (NICE 2008).
It is at this early stage a midwife may advice on maternity benefits, this is due to the fact midwives play a large role in reducing health inequalities (Asthana and Halliday 2006). The Department of Health (2008) declare that healthy mothers have healthy babies. Infant mortality rates are lower among babies born to those of higher social classes (Acheson 1998). As midwives we are to offer smoking cessation sessions and promote healthy life styles. Along with this we are to recognise disadvantaged groups and try to reduce any equality that may be experienced. This is all intended to reduce mortality and morbidity in newborns and babies (Henderson 2005).
Nulliparous women are offered ten antenatal visits whilst multiparous women are offered 7 (NICE 2008). This is founded on the fact that the pregnancies have no variations of what we would class as normal. If a midwife was to feel a woman needed extra appointments for specific reasons her plan of care would implement what was needed. It is for the midwife to determine whether a woman needs extra attention for the safety of herself or that of the unborn baby (NICE 2008). I feel as though multiparous women should receive the same amount of appointments as nulliparous women; just because it is not a woman’s first child does not mean that the reservations of pregnancy and birth are eliminated, particularly on an emotional level if her previous experiences have been negative.
All appointments are to have a focus and structure. It is crucial for women to feel comfortable with their midwife; to allow them to receive the best care possible. If a woman does not feel the ability to trust her midwife she may withhold vital information through embarrassment or just through feeling uncomfortable sharing intimate details. This could put herself and the baby at high risk of complications (Baston and Hall 2009). It is essential for a midwife to have appropriate communication skills and have excellent listening skills (Nursing and Midwifery Council 2008).
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This is particularly relevant when discussing lifestyle advice with women and their families. It is beneficial for a woman to provide their midwife with the correct information; some women feel ashamed or embarrassed to admit situations such as smoking or alcohol consumption. This is why it is important that as midwifes we portray professionalism and not judge clients. It is valuable to build up positive relationships with women so they are empowered with their decisions’ although they have been provided with informed choice (NICE 2008).
It is imperative to discuss lifestyle choices such as smoking, alcohol consumption medication, drugs, domestic violence and sexual health in order to identify possible risk factors that may cause harm to the woman or her baby (Fraser and Nolan 2004).
Health can be considered is as a holistic concept; this refers to all dimensions of health (Dunkley 2000 A). It is essential for midwives to consider all aspects of health in relation to the care of their clients. Maslow (1954) portrays all dimensions of human requirements in his hierarchy of needs. This is what as midwives we must consider and ensure our clients are having all of their needs met.
It is particularly important to offer all women no matter of gravida or parity antenatal education.
Good midwifery care includes all members of the family actively in preparing for the birth of the baby. This is why antenatal education can be shared with all members of the family to initiate them in making informed choices and providing the skills to do this in the future relating to their newborn (Dunkley 2000 B).
A midwife must ensure that during the antenatal period the correct educational information is provided at the appropriate moment. NICE guidelines (2008) state that all women should be offered information on breastfeeding and support groups along with information on all newborn screening by 36 weeks gestation. It is also correct practice to offer advice preparing the client for labour and birth, including assistance on filling out a birth plan. It is important to provide women with information on how to recognise active labour and provide essential information regarding Vitamin K prophylaxis so an informed choice can be made. It is not acceptable to leave it until the woman is in labour before providing this information. By 36 weeks all midwives should offer advice on postnatal self-care and give information raising awareness of the ‘baby blues’ and postnatal depression. This is to prepare the women early as to know what to maybe expect (NICE 2008).
Through personal experience it has been noticed that most pregnant women are happy to accept antenatal education from a range of sources. It is common for health care professionals such as doctors, health visitors and physiotherapists to give educational advice to women as well as midwives. Pregnant women can also receive antenatal information from the National Childbirth Trust, hypnobirthing providers, peer groups, la leche and internet groups such as net mums. The midwife must be able to advice on reliable and accurate sources of accessible information.
It is important to acknowledge and respect the ability and life experience of a women and her family or support network. Each woman and pregnancy is different. I fell as though refresher parent craft classes would benefit multiparous women rather than the same classes’ nulliparous women attend.
The aim of childbirth education is to build up parents’ confidence and self esteem to enabling informed choices to be made. Childbirth education enables parents to communicate effectively with health professionals. (Nolan 2004). Women’s’ awareness of their own feelings, bodies and needs is something as midwives we are to support as well as prepare women, their partners and family of these needs. Antenatal education should encourage parents to take responsibility of their health care and the health of their baby. As midwives it is also important we create positive senses of identity so that parents’ experiences are of a positive nature (Nolan 2004).
Women’s families can be a great support network so it is essential to include them in all aspects of care that the woman feels comfortable and appropriate. Having a baby affects every member of a family; this is why it is essential to prepare everyone for the changes a newborn creates. Classes for fathers-to-be are a great way of preparing and helping them understand what their partner is going through. There have been persuasive cases implementing new ways to offer antenatal classes with an increased focus on fathers (Walsh 2006).
A midwife must be able to communicate with her clients in a professional and open manner. This must be the case for midwives communication with women’s family members as well as other members of the multidisciplinary team. A midwife must be sensitive towards her clients needs and communicate openly and freely allowing the woman to feel comfortable and able to form a supportive network with their clients. Midwives must also be able to assert the woman as an individual and provide individual care necessary to the woman’s unique needs (NICE 2008).
A midwife must also have a high-quality of intuition and be able to recognise when women may be showing signs of distress that may not be portrayed verbally (Henderson and Jones 1997). This is why I feel continuity of care is a positive aspect of midwifery practice. If a woman has the same midwife throughout her antenatal care a relationship is built meaning the midwife is more likely to notice if the client is feeling low or not herself. The woman is more likely to open up with her concerns with a midwife she knows and recognises. The tone and approach a midwife uses when communicating is essential, listening skills are critical also.
Midwives are to provide emotional and psychological support that co instates with the social circumstances of each family; this allows women and their families to share their experiences which may improve midwifery practice (Magill- Cuerden 2006).
This assignment has outlined the midwife’s responsibilities and roles in the provision of care preconceptually and during the antenatal period. It has demonstrated the uniqueness of each individual pregnancy and how the role of a midwife adapts to provide the care necessary. I have explained my feelings regarding the number of antenatal appointments offered, as well the way in which care is given preconceptually.
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