Pregnancy Care

The Principles of Screening: Antenatal screening

Screening is the process of identifying healthy people who may be at increased risk of a disease or
condition, guiding whether a diagnostic test should be offered. Large numbers of asymptomatic are
screened. The screening provider offers information, further test, and treatment to reduce
associated risks or complications. Both the mother and the foetus is screened during antenatal
screening.

10 different reasons for a screening programme to be fit for purpose:

 Condition sought should be an important health problem

 Treatment for problem should be available.
 Facilities for diagnosis and treatments should be available.
 Recognisable latent or early symptomatic stage
 Available test or examination
 Test should be acceptable to population
 Natural history should be understood
 Agreed policy on whom to treat
 Case-finding should be a continuous project.

The Role of Healthcare Professionals

There are 3 types of healthcare professional associated with pregnancy:

 Midwives
 GPs
 Obstetricians

Different Types of Support Available

Instrumental social support: the various type of tangible support that others may provide, such as
help with housekeeping/childcare, or provision of transportation or money)

Emotional social support: having someone that shows empathy, compassion, and genuine concern –
active listening.

Esteemed social support: having people send you messages that help promote one’s abilities and
intrinsic values.

Informational support: supplying the pregnant mother with information – often from healthcare
professionals.

Social capital: the tangible assets that count for most in the daily lives of people: goodwill,
fellowship, and social intercourse among the individuals and families who make up a social unit.

Social comparison: this process involves people coming to know themselves by evaluating their own
attitudes, abilities, and traits in comparison with others.

Stress buffering hypothesis of social support: this refers to the perceived availability of social
support, which is assumed to eliminate or weaken the negative relationship between perceived
stress because of a chronic condition on health and quality of life. Essentially, social support protects
(or “buffers”) individuals from the harmful effects of stressful situations.

Support from healthcare:

 Genetic counselling
 Role of the antenatal clinic: the role of the antenatal clinic is to monitor the mother’s
health, the baby’s health, and support the parents to make plans which are right for them.
A series of appointments are offered with a midwife, GO, and sometimes an obstetrician.
During each antenatal visit, the aforementioned are monitored and guidance is given
appropriately.
 Role of the Miscarriage Clinic: the role of miscarriage clinics is diagnosing and treating
miscarriages and providing the mother the best chance of a successful pregnancy.

Pregnancy and Antenatal Care

Pregnancy is viable after 24 weeks, term is at 37-42 weeks, and then post term is 42 weeks.
Antenatal care: wellbeing of mother and baby, with community midwife/GP, and
obstetrician/hospital midwife providing multidisciplinary care. There are 10 appointments in total for
a first-time mother, and 7 for second or subsequent births (or more if the mother develops a medical
condition).

First trimester (0-12 weeks)

– booking (risk assessment, dating, and screening)

Second trimester (13-27 weeks):

– foetal anomaly assessment

Third trimester (27-40 weeks):

– foetal growth assessment, obstetric complication screening, delivery

Puerperium (delivery – 6 weeks):

– breast feeding, neonatal.

Most births are at hospital in either a consultant led unit, an alongside midwifery led unit, or
standalone midwifery unit. Different types of childbirth/delivery:

 Natural (home) birth: unrushed birth from home with less interference and invasive
monitoring. It means women do not have to worry about transport while in labour or getting
back home, all the comforts of being at home, recovery and transition to breastfeeding is
more comfortable, can yell louder, can invite whomever. However, special birthing
assistance is harder to acquire, may require transport to hospital if birth does not go
according to plan, dangerous not having the right treatment.
 Water birth: all stages in a portable tub of water. Pros: more relaxing and less painful. Cons:
mat increase risk of infection, logistics are a hassle (heating up tub, transport of tub etc.),
and may require hospital transfer if birth does not progress normally.
 Hospital delivery: ready access to emergency interventions such as a caesarean section,
advanced monitoring for high risk pregnancies, and more pain management options
 (including epidural anaesthesia). However, may rush through stages of labour, higher chance
of infection.
 Assisted Births – used when mother is too exhausted or if infant must be delivered more
quickly than is naturally occurring:
o Induced labour (29% of pregnancies)
o Caesarean sections (25-30% of pregnancies)
o Vaginal birth after C-section
o Instrumental (forceps/ventouse suction cup (vacuum)) delivery (10-15% of
pregnancies)

Ultrasounds
Ultrasounds are carried out in the first trimester because they are a safe way of visualising
pregnancy, they are also a good means of checking the development of the foetus. Ultrasound
scanning uses a high frequency pulse of sound that is reflected at tissue interfaces – reflection
depends on tissue density (e.g. fluid or fat). Used for screening, diagnosis, and surveillance. 2D, 3D,
and 4D (3D with movement) is available. Ultrasounds at 12 weeks are conducted to:

 check if the pregnancy is in the right place (ectopic?)

 check if the pregnancy is viable (right size and heartbeat)
 check for the number of foetuses
 give an indication of the date of the pregnancy
 check for any defects in the cardiovascular system (mainly defects with the heart, such as
the formation of the septum)

Ultrasounds at 20 weeks (anomaly scan) are conducted to: check for any structural defects, and to
check if the ventral wall has closed properly (intestines should be pushed back into belly by week
11). A full bladder creates a reservoir of fluid that enhances the movement of sound waves through
the abdominal cavity, creating a clearer view of the structures that need to be observed.

Signs of pregnancy from an ultrasound scan: thickened endometrium, the gestation sac (black circle
of ultrasound scan), the yolk sac (a lighter ring in the gestation sac on the ultrasound scan), and the
foetal heartbeat (the best prognostic sign).

Common Birth Defects

- Cleft lip
- Down’s syndrome
- Omphalocele (liver, stomach, and intestines herniated at the abdominal wall - exomphalos)
- Gastroschisis
- Spina bifida (risk can be lowered by taking to folic acid).

Pregnancy Tests and Screening

Screening tests
Detects potential disease indicators. Used on large numbers of asymptomatic but potentially at-risk
individuals. Inexpensive, and generally simple and acceptable. Positive results only indicate
suspicion of disease that warrant confirmation. Generally chosen towards high sensitivity to not
miss a disease. Large numbers of people will ned to be screened to identify a small number of cases.
Antenatal/prenatal screening for Down’s syndrome: this is a way of assessing the likelihood of a
baby developing, or already having developed, an abnormality during a pregnancy. It cannot
diagnose conditions like Down’s syndrome but helps make the decision to have pre-natal diagnostic
tests. Antenatal screening for DS should have been carried out by the end of the first trimester.
There are two screening tests:

 The combined test: Most women are screened between 11 and 13 weeks. It is a screening
test for Down’s syndrome, Edward’s syndrome, and Patau’s syndrome. It combines a blood
test (9-13 weeks of gestation), and an ultrasound scan (11-13 weeks). A special type of
ultrasound scan, known as a nuchal translucency scan, is used, it measures the pocket of
fluid behind the baby’s neck as babies with Down’s syndrome usually have more fluid in
their neck than normal. The blood test checks for levels of free beta-hCG (human chorionic
gonadotropin), and placenta associated plasma protein A (PAPP-A) hormones that might
indicate the possibility of Down’s syndrome.
 The quadruple test: it is possible to have screening up to 20 weeks into pregnancy using the
‘quadruple test’ (14th-20th week but optimally the 15th-19th week. It is a blood test testing for
hCG, uE3 (oestriol), AFP (alpha-fetoprotein), and inhibin A. Neither this nor the combined
test very sensitive so only shows the risk, warranting the antenatal/prenatal test if the
mother so chooses.

Diagnostic testing
Establishes presence/absence of disease. Used to establish diagnosis in symptomatic individuals or
used on asymptomatic individuals with a positive screening test. Expensive and can sometimes be
invasive. Chosen towards a high specificity, so more weight is given to accuracy and precision than
to patient acceptability. Result provides definite diagnosis. Higher costs associated with it but might
be justifiable to establish diagnosis.

Antenatal/prenatal Tests: only carried out if screening shows that the baby may have an increased
risk of developing an abnormality. Re-sensitisation can occur for the following tests so antibodies
may be produced by the mother, attacking the baby’s blood – this is rhesus disease. There are two
tests that are commonly used:

 Chorionic Villus Sampling (CVS): invasive procedure in which the placental tissue (chorionic
villi) is aspirated (drawn up/in using a sucking motion to obtain a fluid, air, or bone fragment
sample) through the cervix (via a tube) or through the abdominal wall (via a needle) under
ultrasound visualisation: this is performed after 10 weeks of gestation. The foetal cells
obtained are karyotyped. However, there is a risk of heavy bleeding and miscarriage (1 in
100).
 Amniocentesis: an invasive procedure in which amniotic fluid is removed and the foetal
cells that it contains are analysed. The needle is inserted through the abdomen or vaginal
canal to obtain a fluid sample, it is guided by an ultrasound. This is only performed when
there is a known risk because of the potential threat to the health of the foetus and the
mother. The volume of fluid needs to be large enough, but not so that it may harm the
foetus. Usually performed between 14-15 weeks and the results take several weeks to come
back, by which time therapeutic abortion may not be available. 1% chance of miscarriage.
Lowers amniotic fluid level, may cause limb reduction, as well as hypoplastic lungs so baby
might not be able to breathe on birth.
Non-Invasive Prenatal Test (also known as cfDNA screening, or cell free DNA screening): It is the
analysis of maternal blood using a blood test that analyses the cell free foetal DNA (cffDNA), as the
DNA gets into the bloodstream as DNA from the placental cells go into the blood. High sensitivity
and high specificity but it’s more expensive. It can determine chromosomal abnormalities
(specifically sex-linked disorders – such as DMD (Duchenne Muscular Dystrophy and for some
skeletal dysplasia, such as achondroplasia) and the sex of the baby. Can not be used to diagnose
Down’s syndrome but it does show the risk, it does this as there is slightly more chromosome 21
specific DNA in maternal circulation. It is done in early pregnancy (~9 weeks) to refine T21/T18/T13
risk, reducing need for invasive testing (chorionic villus biopsy or amniocentesis). Can be affected by
BMI, multiple pregnancies, adequate pre-test counselling and achieving fully informed consent, NOT
“just a blood test”, test could become routine (women feeling unable to decline), impact on the
disabled community (creates a stigma around it).

Pregnancy and blood pressure

During pregnancy, a woman’s body accommodates for foetal growth and development. The
circulation of the mother expands due to the addition of the passage of blood to the foetus, this,
coupled with hormonal changes, cause the blood vessels to dilate, leading to a drop in blood
pressure as a result of lower pressure against the arterial walls. Blood pressure is the force of your
blood pushing against the walls of your arteries, and is recorded as two types of numbers: the
systolic number (the numerator) indicates the amount of pressure in your arteries when your heart
beats, and the diastolic number is the denominator, which indicates the amount of pressure in the
arteries between heartbeats. Preeclampsia is a condition characterised by high blood pressure and
possibly protein in your urine during pregnancy or after delivery. It generally happens after the 20 th
week of pregnancy, and can sometimes progress to eclampsia, which is a severe progression of the
disease – with this, high blood pressure can even result in seizures. Causes can include genetic
factors, blood vessel problems, autoimmune disorders. Hypotension – very low blood pressure – is
also a common occurrence in pregnant women.

Miscarriage
Recurrent miscarriages are defined as three or more miscarriages - at this point, karyotyping to
check for chromosomal abnormalities, ultrasound scan (a transvaginal USS can be used to check the
structure of the womb for abnormalities), and blood testing can be done. Reasons for miscarriage
are often unknown, but risk factors (such as age, smoking, alcohol, drug use, and obesity) can
increase chance of miscarrying.

Chromosomal causes of miscarriage:

 Aneuploidy: one or more chromosomes are lost or gained, most aneuploidies arise from
errors in maternal meiosis I, for example, spindle fibres might not work or join properly. 3
copies of a chromosome, maternal age is a risk factor for most human trisomies;
monosomy, 1 copy of a chromosome.
 (Unbalanced) chromosomal translocations: can be identified when someone is sub fertile
(they have a balanced chromosome arrangement), when there is a raised risk from the
combined test, when parental testing is carried out after child is found to have an
unbalanced chromosomal pattern, and when it is found to be the case incidentally
antenatally from amniocentesis.
Translocation increases the chance of miscarriage because many of the zygotes formed from the
gametes with an abnormal chromosomal arrangement will have an unbalanced chromosomal
arrangement. For example, with Robertsonian translocations, the carrier of the balanced
chromosomal arrangement may have a whole 21 and 14 chromosome but the homologous
chromosomes of each may have joined together to form one chromosome, this may lead to zygotes
with a single 21 chromosome and another with the 14 and 21/14, leading to monosomy 14 and
trisomy (as they will both receive a 14 and 21 chromosome from the sperm). These both will result
in miscarriages.

Abortion
Abortion is the loss/termination/end of a pregnancy before viability (i.e. being able to live or
develop independently). The most common complication of a termination is infection.

Methods of Termination
Abortion pill: breaks down lining of womb and can take place in the hospital or at home, dependent
on gestation. Uses anti-progesterone drugs and prostaglandins.

Surgical termination: under sedation, local or general anaesthetic, cervix is dilated, and pregnancy is
removed by vacuum or forceps. After 21 weeks, it may be necessary to inject the foetus with
potassium chloride (KCl) to ensure foetal asystole (the cessation of electrical and mechanical
activity of the heart) before labour is induced (feticide).

First trimester pregnancies can be terminated by means of a suction curettage (i.e. vacuum
aspiration performed through the cervix), and in even earlier pregnancies, they can be terminated
using anti-progesterone drugs and prostaglandins. Second trimester pregnancies can be terminated
by suction through the cervix or using destructive forceps – prostaglandins can be administered by
injection into the amnion or via vaginal suppositories.

Ethical Considerations
Religious views are the largest set of values that disagree with abortion, because they feel that
abortion is playing God, and that life begins at conception so it would be murder to abort a baby.
There are many arguments for both for and against abortion:

Against
Human life begins at conception – abortion is
murder
Right of life must be protected
Abortion is morally wrong
Abortion can lead to medical complications
later in life
Medical care can ensure that female does not
get pregnant
Intense psychological pain and stress
For
A woman has control over her body
Personhood at conception is a religious belief,
not a proven biological fact
If pregnancy was the result of rape
Some countries have a one child policy
Mother’s life may be at risk
It’s a safe medical procedure
The mother might not be able to support the
child (teenager etc.).
Personhood – a moral term meaning to matter morally, and to be a part of our moral community.
It questions at what point someone becomes a person. Some religious rules say it’s at the point of
“quickening” or ensoulment – when the baby starts moving.

Legality
It first became legal with the Abortion Act 1967. It says that when two medical practitioners are of
the opinion that: the pregnancy has not exceeded 24 weeks; the pregnancy would cause greater risk
to the physical or mental health of the woman or any existing children if it were to continue; the
termination is necessary to prevent grave permanent injury to the physical and mental health of the
woman or any existing children; the pregnancy involves the risk to life of the pregnant woman; there
is substantial risk that if the child were to be born it would suffer from physical or mental
abnormalities as to be seriously handicapped. An abortion is the elective choice if it is the mother’s
decision based on a non-medical reason. The final decision is made by a registered medical
practitioner if two registered medical practitioners are of the opinion based on the previous
criteria. The Supreme Court, in 1976, said that when a husband and wife or parents disagree, only
the view of the pregnant woman prevails because she “physically bears the child and is more
directly affected by the pregnancy”. Overall, abortion is no longer legal after 24 weeks except in
cases where it was necessary to save the life of the woman, there was evidence of extreme foetal
abnormality, or there was a grave risk of physical and mental injury to the woman. The Abortion Act
requires evidence and records to be kept.

Summary of terms of the Abortion Act 1967:

 Must be carried out in a licensed hospital or clinic.

 Allows practitioner to opt out if they conscientiously object (unless women’s lives are at
risk)
 Requires certain records to be kept
 Must not exceed 24 weeks gestation and the pregnancy continuation would involve g
 reater risk to woman, or children’s mental or physical health than continuation. It was
actually limited to 28 weeks at first, but the Human Fertilisation and Embryology Act 1990
brought it down to 24.
 Termination is necessary to prevent grave permanent injury.
 Pregnancy continuation involves risk to life of pregnant woman, greater than if pregnancy
was terminated.
 Allowed if there is substantial risk that the child would suffer from physical or mental
abnormalities as to be seriously handicapped.
 The abortion must be done by a registered medical practitioner if two registered medical
practitioners are of the opinion, formed in good faith.

The act does not enshrine a ‘right to choose’, nor does it require a service to be provided, or even
permit abortion on demand. It also does not give full protection to either maternal or foetal rights,
and takes choice away and puts it in terms of medical need – unacceptable paternalism (or patient’s
best interest but against their will – refers to a physician’s authority). Some grey areas: What
constitutes seriously handicapped? What if there’s no doctor to perform? How much risk is needed?
How can it be determined that 24 weeks gestation has been reached? Coronavirus Act 2020 has
made it acceptable to take the tablets from home.

Litigation (the process if taking legal action):

  Criminal Law – the Crown (prosecution) attempts to prove that the defendant is guilty of a
crime e.g. gross negligence manslaughter. The courts can give a verdict of guilty and impose
a sentence.
 Civil Law – common law where the claimant tries to prove that the defendant has breached
a legal duty e.g. negligence. The verdict of the case is some remedy is owed.

The law tells us what is legally permissible – but might not necessarily be morally justifiable. 3 legal
systems that make up UK law: Northern Ireland, Scotland, and England and Wales (common law
system).

Sources of law:

- Acts of Parliament made by the government

- Case law (law made by judge in court when hearing to certain cases)
- Other conventions and national treaties that the UK has agreed to (e.g. the European
Convention on Human Rights)

There is a hierarchy of courts, with The Supreme Court sitting at the top.

Available Support for Mothers Having an Abortion

Role of the specialist midwife: these are midwives who are specialised in a certain field of medicine,
such as in diabetes or termination of pregnancies. They can provide the mother with more detailed
knowledge about the matter in hand. With regards to termination of pregnancies, the specialist
midwife would discuss legal and clinical criteria for the termination of a pregnancy. The patient
would also be given information regarding who makes the final decision.

The NHS provides a support programme that provides pregnant mothers free health care through
their GP/midwife and prenatal care. Nutritional, lifestyle, and childbirth advice are available at local
parenting/social classes, as well as pregnancy alternatives for those who wish to terminate their
pregnancy and have an abortion or those wishing to give their baby up for adoption. These services
are used to assist the mother in making the right choices for her and her unborn baby based on
living environment, education, and physical well-being.

Assistance at prenatal appointments includes pregnancy scans and pelvic examinations, so that they
can learn how to take care of their bodies as well as their child’s health in utero.

Counselling should be given to mothers terminating their pregnancy so that they can make the best
decision possible for themselves. It should also be provided at all times from the first visit to the last
prenatal clinic and through their personally assigned GP/midwife – assuring that the mother is
served evidence-based information and educated on how to deal with the physical and emotional
changes involving pregnancy and the long-term consequences of the decision she is making.
Adoption resources should be given for those relinquishing the rights to their child