1. Care of the pregnant woman Year 2 Lent term

2. The Case 38 year old booked at 12 weeks gestation in the antenatal clinic Expecting her third baby 1 st baby 2.8kg (6lb 3oz) at term 2 nd baby 2.4 kg (5lb 6oz) at term Smokes 20/day BMI 25

3. What investigations are routinely offered in antenatal care?

4. Investigations: blood Standard at booking: Hb, Blood group, antibodies, rubella antibodies, serum test for syphilis. Optional at booking: triple test, tests for hepatitis B, HIV Varies with units: random blood sugar

5. Investigations: ultrasound Dating scan ?nuchal scan (under development nationally) Anomaly scan

6. Nuchal screening

7. What are the risk factors in this particular case?

8. Risk factors Maternal age Past obstetric history of small babies smoking

9. Maternal age >35y increased risk for: Chromosomal abnormality Miscarriage Twin pregnancy Stillbirth Maternal morbidity: thrombosis; hypertension; gestational diabetes; placental abruption

11. Risks of smoking in pregnancy Reduced fertility, ectopic pregnancy, miscarriage Preterm labour Placental abruption Stillbirth Intrauterine restriction: dose related Cot death, infant respiratory infection, lower IQ

12. Smoking: the single most preventable cause of adverse events in pregnancy

13. How would you manage this case?

14. Management of case Delivery in hospital unit with fetal monitoring and paediatric facilities Consider induction of labour with close fetal monitoring – timing may be decided from other parameters

16. How would you advise her if this was her baby’s growth chart?

17. Treatment plan Refer (if willing) to smoking-cessation programme Monitor fetal growth in third trimester using ultrasound- measure head circumference and abdominal circumference Biometric tests for fetal well-being: liqour volume, Doppler, cardiotocography

18. Despite your advise the patient requests to have her baby at home

19. She sees the midwife, who goes through the checklist with her:

20. Is the midwife obliged to deliver this patient at home?

21. Yes, if she insists. Second midwife recommended as back- up

22. Is the GP obliged to attend?

23. No unless in an emergency

24. Pain relief available at home?

25. Midwife can bring “Entonox” and give pethidine

26. Why is Syntometrine given?

27. Syntometrine 5U syntocinon 0.5mg ergometrine Given at delivery of anterior shoulder to constrict the uterus Helps prevent post-partum bleeding

28. Why is vitamin K given?

29. Vitamin K Given to the baby (usually IM) Helps prevent haemorrhagic disease of newborn from deficiency of clotting factors (immature liver)

30. Would you choose a home-birth? http://www.dh.gov.uk/assetRoot/04/14/29/48/04142948.pdf