Introduction:
The essay is focused in the woman’s needs and aims to explore the evidence related to the risks factors, as well as to support the advice we are giving.
In order to put the woman at the center of care, first we will provide her with evidence-based information about the risks and reassure her about her choices.
In addition, we will facilitate an open communication by providing a trusting environment and creating a good relationship with the woman. In order to achieve this we will consider her level of understanding so that we can provide the adequate information.
We will achieve this by a bi-directional communication, which means the woman and the midwife will share the care (RCN, 2015).
Following the tips of The Royal College of Nursing, 2015 about person centered care: We aim to promote autonomy about choices of care, respect opinions, support the person’s circumstances, and facilitate communication.
After, we will make an action plan according to her main needs and discuss our duty as midwives in the woman’s care.
Finally, we will be able to discuss the outcome and be critical about the care given.
Scenario:
The woman attends to her 20-week appointment for a routine antenatal check, she is 31 years old, currently 22 weeks and 1 day and is a Gravida 2 Para 1 with no relevant obstetric history, and her BMI at booking is 23.8 kg/m 2 and has 1 son, which was an uncomplicated pregnancy.
She also expressed her concerns about travelling to Africa for several weeks and missing her 26-week antenatal appointment.
During the routine checks, our findings happen to be the following: Blood Pressure of 113/70, Heart Rate of 87 and Urinalysis with no abnormalities detected. Good fetal movements were reported and felt, in addition, we offered to listen the baby’s heart rate for her reassurance and it was done with her consent (NICE, 2016), which we found it to be 150 bpm via sonicaid.
We find out that her weight gain is of 11 kg since last time it was checked, considering her BMI was normal at booking 23.8 kg/m 2, there has been a big increase. She also admitted having a diet rich in fats and eating very frequently during the day.
The healthy BMI parameters range between 18.5 – 24.9 kg/m 2 (CDC, 2015).
Despite there are no standard guidelines in weight management for the UK, there is a general consensus that women with a healthy BMI should normally put on between 11.5 kg – 16 kg during the whole pregnancy (NICE, 2010).
Health’s needs:
1. The risks on mother and foetus:
The woman would like to know the risks related to gaining excessive weight, therefore, we support our advice following evidence-based facts.
An adequate nutritional intake also means the diet should not be hypocaloric, as this is a cause of Intra-uterine growth restriction (NICE, 2010) but with the correct nutrients for optimal development of the fetus and mother’s wellbeing.
Antenatal:
Evidence suggests that there is a direct risk of developing thrombosis, pre-eclampsia and gestational diabetes (RCOG, 2011; NICE, 2010).
The pre-eclampsia signs and symptoms involve high blood pressure and proteinuria and may lead to further complications (Mol, 2016). Gestational diabetes mellitus (GDM) increases as well the chances of developing pre-eclampsia and the main risk factor is a BMI higher than 30 kg/m 2 (Stewart, 2014).
Other risks include postdates delivery (Denison, 2008), and in contrast, higher chances of pre-term elective deliveries associated with pre-eclampsia (Smith, 2007).
During pregnancy, there is a hypercoagulable state and increase in clotting factors (SIGN, 2014). A high BMI also increases the risk in the VTE (Venous Thrombosis) scale assessment; this would be explained by compromised coagulation factors and decreased physical activity, thus, travelling for prolonged hours increases this risk.
Local guidelines for the NHS prove the use of anti-embolism stockings, frequent mobilization and hydration to be the most effective prophylactic methods (SIGN, 2014).
Some studies have compared the gestational weight gain stated as 11.5-16 kg (NICE, 2010), within the pre-pregnancy BMI in population groups. Most of them have proven a relation within high BMI and the risks previously explained, however, they did not study the risks of increasing weight during pregnancy (Durst, 2016; Lucovnik, 2014; Bodnar, 2007).
The BMI is measured at booking, therefore, this explains that most studies do not measure a BMI change during gestation, studies would need to differentiate the factors that involve gestational weight; such as increasing extravascular fluid.
Lifestyle and dietary support during antenatal care also explains that the results on pre-eclampsia and GDM are less severe, when there is a gestational weight gain on a pre-existing normal BMI.
A more recent study has described the effects of gestational weight gain in the increase of GDM (Robitaille, 2015). Despite this, further studies are needed to give a clear relation between gestational weight gain and these adverse outcomes.
Intrapartum:
The local guidelines show evidence that a high BMI leads to increased risk of slower labour progression, caesarean section, post-partum haemorrhage (RCOG, 2011; NICE, 2010). However, these conditions are only described for a BMI equal or higher than 30 kg/m 2.
Alternatively, there are recent studies, which prove that excessive gestational weight gain above the NICE guidelines parameters (11.5-16 kg) during pregnancy, have shown an increase on the amount of cesarean rates in every BMI category (Trojner-Bregar, 2016). Such results are also found in the incidence for PPH (Gollop, 2014; Fyfe, 2012), this risk is as well aggravated when there is an emergency caesarean section. A slower progress of labour is also related to PPH due to the loss of uterine tone found in high BMI women (Zhang, 2007).
The main advantages of these studies and reviews are that they are quite new; they have been done in large populations, studying women with different BMI’s, based in up to date evidence.
Risks for the baby:
The chances of having a large baby are increased to 14% and the risk of stillbirth to 1% compared to women whose BMI is between normal ranges (RCOG, 2011).
Other studies (Joergensen, 2014; Poel 2012), also describe the relation between a higher BMI, the chances of shoulder dystocia and babies born having vitamin D deficiency (related to GDM).
Large for gestational age is been proven to be related to excessive weight gain during pregnancy and specifically of GDM (Most, 2012); as described previously in several studies.
In relation to the stillbirth risk, it has also been identified when there is a BMI increase between the 1st and 2nd pregnancy. Even when the increase is minimal, this can mean big potential adverse effects on the baby.
The strengths of the studies (McCowan, 2016; Whiteman, 2011; Villamor, 2006) are that they have been done in large cohorts; weight gain during pregnancy has been considered as a main risk factor and studied the BMI changes in the 2nd pregnancy (relevant to this case). Despite this, the studies do not state the causes of the stillbirth consistently due to the diversity of factors in the studied populations.
Postnatal:
The risk of thrombosis is still present after birth (RCOG, 2011), as described previously.
In addition, a complete systematic review has shown that overweight/obese women are less likely to start and maintain breastfeeding their babies (Turcksin, 2014). Nevertheless, other studies (Hauff, 2014; McGuire, 2013) found that the previous knowledge and belief about breastfeeding also takes an important role on this.
This difference aims to demonstrate that women in every BMI category would be able to breastfeed, providing that they have good antenatal and postnatal care.
It is likely that the weight gained will be maintained or increased later after pregnancy (NICE, 2010); therefore, the woman should be advised on diet and lifestyle, as explained below.
2. Lifestyle recommendations:
There are no local guidelines about lifestyle or weight management (NICE, 2010), however, the British Nutrition Foundation (2006) and the Royal College of Obstetricians & Gynecologists (2011) published some tips for a healthy diet and exercises in pregnancy (“not eating for two”, eating more fiber, fruits and vegetables, maintaining an active life…). They do not provide a list of foods but there are some foods to avoid in pregnancy that should be explained to every woman antenatally.
Also, highlight the importance of vitamin supplementation in pregnant women. Vitamin D and folic acid play a crucial role as the absorption may be compromised in GDM (Joergensen, 2014; Poel, 2012), considering the risk-related of a high BMI.
3. The relevance of the antenatal visits:
Antenatal care is the key of the basic care in order to maintain the mother and fetus wellbeing and to detect crucial complications that may occur later in pregnancy (Hofmeyr, 2015).
Receiving continuity of antenatal care reduced maternal deaths from conditions such as pre-eclampsia, thrombosis, diabetes and sepsis (MBRRACE, 2014). Poor antenatal resources have also been associated with higher maternal mortality rates, about a 60% in the sub-Saharan Africa (WHO, 2010).
Therefore, we advised the woman to access antenatal care for her 26-week appointment but we considered personal circumstances that might prevent her from being able to do so (personal life, accessibility of the services in the visiting country…).
The Role of the Midwife in Antenatal Care:
Trusting relationship
Firstly, the midwife and I built a trusting relationship with the woman, providing an open environment to express herself and her needs. To achieve this, we introduced ourselves, listened openly, explained the tasks we were going to do and gained her consent (NMC, 2015).
The communication was bilateral (RCN, 2015), where we both exchanged information, also, we encouraged her to take decisions about her health (NMC, 2015) by sharing our knowledge; this means we facilitated an informed choice.
Consent
We monitored the weight with the woman’s consent and reported that she gained weight in a sensitive manner (NMC, 2015).
Also, we must ensure that we use carefully our words to describe the woman as a “high risk” and other conditions. Research has shown that this creates unnecessary feelings of stigma and anxiety and might lead to more adverse outcomes later in pregnancy and labour (Davies, 2013).
We might consider that in many cases the woman could be self-conscious about her weight, however, our woman recognized this fact and was open and honest about her diet and lifestyle.
A women-centered care approach
After, we prioritized her health and psychological needs, working in partnership with her as stated by the NMC Code of Conduct, 2015 “…in order to deliver the care more effectively”.
We had given her diet and lifestyle advice always with the available evidence (NMC, 2015), due to the weight gain and she expressed her choice to travel at her own risk.
In addition, we discussed the importance of having antenatal care abroad (MBRRACE 2014; WHO, 2010).
On the other hand, we respected her choice of travelling and informed her about the risks according to this fact (NMC, 2015).
Advocacy
Discussed her options about diet and lifestyle, respected her choice to travel and promoted her right to access antenatal care abroad.
We highlighted the importance of attending to any Hospital if an emergency occurs, such as bleeding, abdominal pain or waters are broken, we advised to contact the Maternity Helpline in last instance, however, we understood she might be unable to do so due the high cost of an international call.
Continuity of care
Women who receive continuity of care reports higher overall satisfaction with the midwifery services (RCM, 2014). Concerning women with higher BMI, it has also been proven to show results are less likely of having an instrumental delivery (Davies, 2013), thus the importance of giving care involving respectful views towards the women.
Our role in the Antenatal clinic is not to caseload the woman; however, we are able to develop a trusting relationship, manage her needs by working in partnership with the other professionals, as well as develop an environment where the woman will express her concerns more openly.
Action Plan:
The action plan has been developed considering the risk of a weight increase, however, following the NHS Trust Policy (2016), the management will be in a midwifery led setting, providing that the woman’s BMI is less than 35 kg/m 2. Changes in the woman’s risk status will be managed differently.
Antenatal Care:
Focused on promoting lifestyle changes to minimize the adverse outcomes, undertaken in the midwifery led antenatal clinic.
A recent systematic review has shown that excessive gestational weight gain can be successfully prevented antenatally with diet and exercise (Muktabhant, 2015).
On the other hand, there has been disparity in the results of weight management effectiveness over the adverse outcomes during the antenatal period in overweight women.
While there is a clear relation between high BMI pre-eclampsia and GDM (RCOG, 2011; NICE 2010), other studies (Dodd, 2014; Saunders, 2012) showed no results in antenatal weight management in women whose BMI is equal or more than 26 kg/m 2. However, one found a reduction in the risk of large for gestational age (Dodd, 2014).
The difference is due once again to the diversity in the cohorts; the pregnancy stage where the women were included in the study, which resulted in being unable to monitor them for a period long enough to show a positive result.
As stated previously by the NICE guidelines, there is a need to establish more specific values in the gestational weight gain. This could be solved by individualizing the interventions (McGiveron, 2014), which proved a reduction in gestational hypertension.
While there is a clear relation between high BMI pre-eclampsia and GDM (RCOG, 2011; NICE 2010), other studies (Dodd, 2014; Saunders, 2012) showed no results in antenatal weight management in women whose BMI is equal or more than 26 kg/m 2. However, one found a reduction in the risk of large for gestational age (Dodd, 2014).
Other studies support that diet and vitamin supplementation may prevent pre-eclampsia and gestational diabetes (Joergensen, 2014; Poel 2012). This is explained because a diet low in calcium leads to low concentration levels in blood associated with pre-eclampsia and GDM (Mol, 2016).
Intrapartum Care:
The aim is to promote natural birth, providing that this is the woman’s 2nd pregnancy and the 1st pregnancy was uncomplicated. High-risk obstetric ward will only be considered if the woman’s BMI were higher than 35 kg/m2, or should other complications be present (NHS Trust, 2016), therefore, the place to give birth will be entirely the woman’s choice.
We will provide the woman with a ‘sense of control’ and support her in her decisions through labour (NICE, 2014); in order to do so we will communicate with the woman continuously about what events are occurring, seek for her expectations and encourage to participate in the care. According to a review (Davies, 2013); all this actions have been proven to have a positive effect on the women’s labour experience and on minimizing the risk of having instrumental deliveries and caesarean sections, particularly in women with a high BMI.
The use of therapeutic water, mobilization, privacy to stimulate oxytocin and avoidance of continued fetal heart monitoring also proved to minimize adverse outcomes (Davies, 2013). These recommendations are also approved by the NICE guideline (2014) during Intrapartum care; however, they do not state that these measures fully prevent women from having instrumental deliveries in the end, as more specific studies are needed.
Nevertheless, the choice of pain relief, labour positions and management would be explained; should the woman request an epidural, she would be advised to go to the high-risk obstetric ward (NHS Trust, 2016).
Postnatal Care:
This comprehends a risky period when most women also might increase their weight (NICE, 2010). Nevertheless, at the same time appropriate to promote lifestyle changes in order to achieve a healthy BMI change, without the complications of the pregnancy.
Breastfeeding is found to aid the return to pre-pregnancy weight (NICE, 2010)
Referrals to other professionals in order to help the women adequately in her needs; GP for lifestyle advise and breastfeeding support (NOT IN GP)
The baby’s wellbeing and needs will also be considered in this period, depending on the outcome, as well as the postnatal checks (NICE, 2015).
Encouraging mobilization after birth and preventing the risk of DVT by the use of thromboembolism stockings is approved by the local guidelines (NICE, 2015; SIGN, 2014).