Midwives need to have skills to impart information about screening options with clarity, sensitivity and in a way that parents can
understand. How information is given and the language used can ease anxiety for parents. Parents are faced with having to make deci- sions about screening for abnormalities as developments in antena- tal care mean that there are ever-increasing ways to screen and detect abnormalities in the fetus. The majority of pregnancies will be normal, but for a minority some test results may come back positive, which means that parents face further decision-making about proceeding with more tests.
Referral to other health care professionals is needed if the tests detect an abnormality. Ultimately, the question of whether to con- tinue with the pregnancy may have to be faced. Many Trusts employ a midwife who specialises in screening and abnormalities, support- ing parents through their decision-making. If the woman is being cared for by an independent midwife she is still entitled to all the screening options provided by the NHS should she choose to have them. If abnormalities are found, the same options will be discussed and offered.
Screening tests
The following tests are offered to all women:
• Nuchal transclucency at 11–14 weeks to measure the thickness of the back of the fetus’s head in order to calculate a risk factor (many Trusts only offer this privately)
• Serum screening at 14–20 weeks for Down syndrome, giving a risk factor or probability of Down syndrome. For example, a 1 : 2800 risk would mean that if the woman was pregnant with the same baby 2800 times, there would be a risk of Down syn- drome occurring once
• Anomaly scan at 18–20 weeks (checking for abnormalities) for example, looking at the four chambers of the heart, kidneys, brain, face and limbs.
For women who may be at increased risk only:
• Chorionic villus sampling at 10–14 weeks. A fi ne bore needle is inserted into the uterus via the cervix and a small piece of devel- oping placenta is taken for analysis. The chromosomes in the cells are looked at to test for abnormalities and inherited disorders
• Amniocentesis at 16–20 weeks. A small sample of amniotic fl uid is obtained by inserting a fi ne bore needle through the abdomen into the amniotic sac via ultrasound guidance, looking for chro- mosomal abnormalities
Case Notes
Deborah, aged 32, was pregnant with her second child. Her daughter was a healthy seven year old and this was a much-wanted pregnancy with a new partner, Amir. Deborah decided to have the triple test at 16 weeks and thought of it as just another blood test. The results came back as positive.
Deborah was told this by phone on the Friday of a bank holiday weekend. Deborah and Amir had no idea what this meant for her or her baby and they spent three days desperately worried and frantically searching the Internet for clues. Deborah made an appointment on the Tuesday to see her community midwife who informed her that although the test was positive, it did not mean that her baby had an abnormality.
The test result of 1 : 100 meant that there was a higher probability that the baby had an abnormality, but this could only be confi rmed by amniocentesis.
Deborah and Amir were faced with a diffi cult decision as they knew there was a small chance that she could miscarry a healthy baby follow- ing an amniocentesis. Deborah felt philosophical and had a ‘what will be will be’ approach. She would want the baby regardless. Amir, on the other hand, believed that there was no way he could be a father to a child with an abnormality. This resulted in great confl ict and arguments. Even- tually they decided to go for the amniocentesis. It was stressful for Deborah as she was still uneasy about this choice, but felt she should do it for her partner. The results came back clear – there were no chromo- somal abnormalities. Deborah was relieved but also felt angry that she had been through this trauma. She was upset with Amir for persuading her to have such an invasive test that had put their baby at risk. Deborah decided that if she ever became pregnant again she would refuse any screening tests.
Antenatal Results and Choices, a national charity, provides non- directive support and information to parents throughout the ante- natal testing process. Visit their website: http://www.arc-uk.org.
Table 2.5 outlines key points that should be taken into account when assessing the women at each visit.
Midwifery wisdom
Ask about the baby’s movements whilst you are palpating, it will help you in defi ning the position.
Table 2.5 Key points to be taken into account when assessing at each visit At each appointment you should:
• Observe the woman’s appearance: Is she tired? pale? fl ushed?
• Assess the BP (a large woman may need a larger cuff)
• Undertake a urinalysis
• Observe for signs of oedema in the ankles, legs and hands
• Ask about (assess) gestation Perform palpation, noting:
• Abdominal appearance: Striae gravidarum? Linea nigra? Bruising?
• Fundal height – is this equal to dates? Give gestation
• Lie: is the baby lying oblique, longitudinal or transverse?
• Presentation: is the baby cephalic? breech?
• Deep palpation: is the presenting part free? How many fi fths palpable?
Assess:
• Fetal heart: what is the range? for example, 135–148 beats/min
• Fetal movements? Where? What do they feel like?
Do not forget:
• Date
• Time
• Signature
• Print your name by your signature.
Case Notes
I saw my midwife when I booked at the clinic when I was 12 weeks pregnant and saw another midwife when I was 16 weeks. I had my 20- week scan yesterday and the sonographer said I had a low-lying pla- centa. My next visit with the midwife is not for eight weeks! Eight weeks!
I was told by the receptionist that because this is my second pregnancy, I am entitled to fewer visits than the fi rst time around. How am I sup- posed to wait until I am 28 weeks pregnant? I have been on the Internet to look at low-lying placentas and am now pretty scared. My friend had a placental abruption last year and her baby died. I just wish I could have a midwife to talk to.