Case Study Analysis: Midwifery Care in Ivy's Pregnancy - [Course Code]

This case study focuses on Ivy, a 22-year-old multigravida with a history of stillbirth and diagnosed with overweight. The assignment analyzes the importance of women-centered care, addressing Ivy's physical, psychological, and emotional needs, and her limited access to medical services. It explores decision-making factors, including emotional status, relationship, and social environment, and the use of counseling. The study examines the impact of lifestyle factors like obesity and smoking, recommending resources like Nutrition Australia and Medicare. It highlights relevant guidelines and plans like the Australian Pregnancy Care Guidelines and the National Maternity Services Plan, along with the Nursing and Midwifery Board of Australia's code of conduct and standards for practice. The case study also discusses the risks of smoking and alcohol during pregnancy, recommending cessation strategies like NRT, CBT, and counseling. The document emphasizes the importance of supporting the newborn during the postnatal period. This assignment is essential for understanding comprehensive midwifery care in complex cases.

Midwifery Case Study

Question 1:
Women-centred care involves women’s specific requirements, expectations and goals, her
self-determination and self-dignity for choice, initiation and continuity of care and focus and
address on her different needs like social, physical, emotional, psychological, spiritual and
cultural. It should be recognised that women and their unborn are not independent in terms of
social and emotional environment. This philosophy needs to be incorporated during
assessment and provision of care to the women (Wright, Pincombe, and McKellar, 2018).
Hence, stillbirth death in case of Ivy need to be kept central while providing care to her. Ivy
might have affected her physically, psychologically and emotionally. Hence, these factors
need to be incorporated while providing care to her. An individualised and women centred
care need to be provided to Ivy for every time rather than routine practice. Flexibility,
friendliness and non-threateningness need to be maintained while providing care to Ivy to
improve her accessibility to care. Accessibility of care for Ivy need to be improved because
her town is with limited access to medical services. Moreover, she is exploring alternative
and complementary services for her pregnancy. Every woman including Ivy has right of
antenatal and postnatal care considering her social and emotional needs. Decision making is
important aspect for planned pregnancy and decision making of women specifically depends
on the emotional status, relationship status and social environment (Chen, Hutchinson, Nagle,
and Bucknall 2018). In case of Ivy, her emotional status needs to be addressed effectively
through counselling because it is evident that she is expressing depression post stillbirth
death. Hence, she was administered with Sertraline (Lustral). It is evident that she has
positive relationship with Tony; hence, it can be efficiently utilised in her decision making.
Social environment is important aspects in the decision making. Social environment can be
obstructing factor for Ivy for effective decision making because she is residing in rural town
with limited accessibility of medical services. Addressing all the issues related to
environmental and occupational risk factors would be helpful in the understanding individual
women’s situation and environment for the development of baby (Nieuwenhuijsen, Dadvand,
Grellier, Martinez, and Vrijheid, 2013).
Ivy should be provided with the information related to the influence of obesity and smoking
on the pregnancy. It would be helpful in encouraging decision making in Ivy. It is necessary
to examine effective method of providing education and support to Ivy. Provided information
should be acceptable, easily understandable and accessible. Moreover, it is also necessary to
maintain respect and dignity of Ivy while providing information to her. It is necessary to

establish effective communication among healthcare professional and Ivy. Moreover, Ivy’s
input is important in this process. It is important to document discussions and decisions
related to smoking and obesity in clear and consistent manner. Involvement of women in care
can be effectively improved through providing informed consent, giving responsibility and
improving accountability in decision making (Bar-Zeev, Bovill, Bonevski, Gruppetta, and
Reath, 2017).
Socio-cultural aspects and healthcare services are mainly responsible for the stress related to
pregnancy. Risks associated with maternal obesity like maternal and neonatal mortality,
congenital anomalies and gestational diabetes need to be informed to pregnant women with
obesity. Hence, pregnant women would take effective precaution for the management of
obesity. Different countries like United Kingdom, Ireland, United States of America, Canada
and Australia developed health-care guidelines for the effective management of maternal
obesity and gestational weight gain (Olander, Berg, McCourt, Carlström, and Dencker,
2015).
Nutrition Australia is a national, independent and none profit organisation which is useful in
inspiring healthy eating. Nutrition Australia delivers programmes and services throughout the
Australia. This programme is appropriate for Ivy because this programme is aimed to reduce
food-related lifestyle diseases and promotion of optimal health (Shrimpton et al., 2016).
Since, Ivy is associated with lifestyle disease like overweight; this programme would be
appropriate in her case. Medicare programme which is as insurance programme funded by
Australian Government would be appropriate for Ivy because it would be helpful in providing
certain types of medical care and hospital services to Ivy (Duckett, 2018). Provision of
medical care and hospital services are important in case of Ivy because her geographical
location is with limited medical services. Victoria State Government’s Better Health Channel
is a useful option for the pregnant women. Pregnant women should be aware of the different
pregnancy and birth care options available through Better Health Channel. According to this
channel, pregnant women have option of choosing their baby as public or private patient,
choosing carer like doctor, an obstetrician, a midwife, or a combination of these, choosing
birth place of baby like hospital, at a birth centre, or at home. Programmes like Better Health
Channel would be helpful for the pregnant women like Ivy because such programmes and
services would be helpful in relieving pregnancy burden on women, those who would not be
able to take appropriate decisions about care during pregnancy (Rodger et al., 2013).
Australian Government Department of Health published The Pregnancy Care Guidelines

Review Public Consultation Draft. These guidelines provide information related to the
maternity services to the pregnant women and those women planning for pregnancy.
Moreover, these guidelines provide information to healthcare professionals. These guidelines
would be helpful in pregnant women like IVY, because it would be helpful in participating
decision making of her own care. These guidelines also would be helpful for healthcare
professionals to persuade necessary maternity care for pregnant women like Ivy (Sinni,
Cross, Swanson, and Wallace, 2016). National Maternity Services Plan would be useful for
pregnant women like Ivy because it incorporates strategic framework to guide policy and
program for four priority areas like healthcare service access, service delivery, workforce and
infrastructure. Hence, National Maternity Services Plan is useful for Ivy because she has
limited access to healthcare services (Kildea, Tracy, Sherwood, Magick-Dennis, Barclay,
2016).
The Nursing and Midwifery Board of Australia (NMBA) regulate practice of nursing and
midwifery in Australia to protect the public health. Principle 2 of the code of conduct of
midwives would be appropriate for the care of Ivy because this principle is related to the
Women-centred practice under domain safe, effective and collaborative Midwifery practice.
Women-centred practice is appropriate in case of Ivy because Midwifery should address
physical, psychological and emotional issues associated with Ivy. Women-centred practice
under principle 2 of the Code of conduct for midwives is appropriate for Ivy because it
include Midwifery practice, decision making, informed consent and adverse events and open
disclosure. According to this principle Midwives deliver safe, women-centred and evidence-
based practice for improving health and well-being of the women. Midwives work in
collaboration with women and encourage women to participate in decision making for
effective care of women and baby. Standard 1 of the Midwife standards for practice is useful
for providing care to pregnant woman like Ivy. According to this standard, Midwives
promote health and wellbeing through evidence-based midwifery practice. Standard 1.5 of
practice states that midwives support improved accessibility of woman for the maternity care.
Hence, standard 1 is relevant in case of Ivy because she has limited access to the healthcare
services. Standard 3.5 is also relevant to the Ivy because she need consolation because she is
being experiencing depression. Standard 3.5 states that midwives engage in timely
consultation, referral and documentation. Midwives need to adopt competency 2.1 of
Midwifery competency standards. It states recognition and action within the knowledge base

and scope pf practice. According to this competency, midwives recognises role and
responsibilities to understand, support, facilitate pregnancy, labor, birth and postnatal period.
Question 2 :
Smoking during pregnancy, lead to exposure of multiple harmful chemicals to the fetus.
Preterm birth is one of the major risk factors of the smoking; hence, these babies might not be
fully developed. These babies might also experience colic which demonstrate uncontrollable
crying and irritability. Babies of the smoker mother also are at the higher risk of sudden
infant death syndrome (SIDS). These babies might develop asthma and obesity. Nicotine
present in the smoke lead to blood vessel narrowing which results in the reduced supply of
oxygen and nutrients to the fetus. Nicotine also damage brain and lungs of fetus. Second hand
smoking also negatively affects babies. It has been established that babies exposed to second
hand smoking, born with birth weight approximately 20 % less as compared to the babies not
exposed to second hand smoking (Kim, Monteiro, Larson, and Derisier, 2017; Andriani and
Kuo, 2014). Alcohol consumption interfere with normal growth pattern of fetus and produce
birth defects in the baby. One of the most prominent risk factors of alcohol consumption is
fetal alcohol syndrome (FAS). FAS results in the growth problems, mental disability,
abnormal facial features and behavioural features. It has been reported that combined effect
of smoking and alcohol also produce multiple congenital abnormalities. Combined effect of
smoking and alcohol consumption increases risk of abruptio placentae, intrauterine growth
restriction, unexplained stillbirth and preterm labor (Gupta, Gupta, and Shirasaka, 2016).
Better health channel recommended that smoking need to be stopped without consumption of
smoking. However, pregnant woman is unable to quit smoking. Hence, use of nicotine
replacement therapy (NRT) is recommended. Nicotine replacement therapy comprises of use
of gums, loenges, mouth spray and inhaler. However, healthcare professionals should take
special precaution because this small amount of nicotine also can adversely affect baby (Bar-
Zeev, Lim, Bonevski, Gruppetta, and Gould, 2018). Combined implementation of CBT and
NRT proved cost effective because NRT alone is a costlier strategy. It has been reported that
counselling proved to be most effective strategy for stopping alcohol consumption and
smoking in pregnant women. Counselling along with provision of incentives, health
education and social support proved to be more advantageous as compared to the counselling
alone for reducing smoking and alcohol consumption. Cognitive behavioural therapy (CBT)
interventions including educational strategies and motivational interviewing proved

beneficial in reducing alcohol consumption and smoking in Australian pregnant women (Van
Lieshout, Yang, Haber, and Ferro 2017; Stotts et al, 2009). Telephone based support services
in addition to the face-to-face sessions proved helpful in cessation (Dennis and Kingston,
2008). Information provision through ultrasound appointments demonstrated significant
improvement in cessation. In Australia, quitlines extend care to the pregnant woman through
free call back service. Quitlines provide support during both pregnancy and postpartum. In a
randomised controlled trial, it has been established that Quitline is effective in quitting
smoking and maintaining abstinence postpartum (Tzelepis et al., 2017). Pre-conception
counselling model also proved to be effective in reducing risk of smoking and alcohol
consumption in pregnant woman. ‘Opt-out’ referral system proved to be effective as
compared to the ‘opt-in’ referral system. According to the ‘Opt-out’ referral system,
healthcare professional directs pregnant directly to the cessation support (Lam and East,
2015). It is essential to stop smoking and alcohol consumption abruptly during pregnancy;
however, research established that approximately 65 % woman in Australia prefer to stop
smoking and alcohol consumption gradually. Hence, integrated efforts through different
stakeholders need to be implemented to abruptly stop smoking and alcohol consumption in
Australian woman. Nearly less than 50 % pregnant woman smokers in Australia reported that
healthcare professionals discouraged them to smoke during pregnancy. This percentage need
to be improved through implementing cessation training programmes for healthcare
professionals. A survey carried out prior to and after implementation of the cessation
guidelines in Australia reported that approximately 50 % pregnant smokers did not receive
appropriate advice and support for smoking cessation. Specialist smoking cessation services
proved useful in smoking cessation; however, pregnant woman experienced lack of access as
the major barrier for these specialist smoking cessation services (Hutchinson, Moore, Breen,
Burns, and Mattick, 2013; Powers, McDermott, Loxton, and Chojenta, 2013).
Woman, who smoked during pregnancy, might go outside for smoking during postnatal
period. Hence, midwifery need to take care of newborn during this period. Newborn of the
smoker mother might be irritable and difficult to soothe. Hence, midwifery need to perform
neuro-behavioural assessment of the newborn to provide appropriate intervention. Moreover,
these babies might be with lower birth-weight; hence, midwifery need to report immediately
to physician to plan suitable intervention. Midwifery need to assess levels of nicotine in
saliva of infant. It would be helpful in planning preventive measures to minimise effects of
nicotine in newborn (Holbrook, 2016). Chances of fetus death are more in fetus of obese

mother. Hence, midwifery needs to make arrangements to shift fetus to the neonatal intensive
care unit. Maternal obesity produces cardiovascular alterations in the fetus. Hence, there
would be more oxygen requirement, alteration in cardiac and vascular functions. Hence,
accurate assessment needs to be performed in fetus for planning effective intervention.
Hypoglycemia, jaundice, and respiratory distress are the other complications associated with
fetus; hence, effective corrective measures need to be taken to address these complications in
fetus. Cesarean section is difficult in obese pregnant woman; hence, vigilant precautions
need to be taken considering individual circumstances (Odibo, Zamudio, Young, Magann,
and Williams, 2015; Kareli et al., 2014).
Drugs are not the common causes of birth defects; however, it has been reported that certain
drugs are most likely to cause birth defects. Evidence reported that approximately 70 – 90
women, consume minimum one prescription drug during pregnancy. Approximately, 70 % of
these women consume medications during first trimester which is an organogenesis period.
Each woman consume on an average 3 medications and approximately 50 % women
consume four or more medications (Lupattelli et al., 2014).
Certain prescribed drugs to the pregnant mother; could produce adverse effect to fetus. Drugs
would interfere with the normal development of fetus, damage baby’s organs, damage
placenta and put baby’s life at risk, augment chances of miscarriage and premature labor and
newborn birth. Baby’s with premature birth are always associated with physical and
psychological abnormalities. Angiotensin converting enzyme (ACE) inhibitors, angiotensin II
antagonists, isotretinoin, cocaine, certain antibiotics, anticonvulsants, anticancer drugs,
warfarin and anti-rheumatic drugs are responsible for the defects in the developing fetus.
These drugs are termed as teratogenic drugs. Ivy was consuming sertraline for for the
treatment of depression. Previous studies demonstrated that Sertraline consumption lead to
birth defects like heart defects. These baby’s also might lead to pulmonary hypertension and
serious lug problems. Birth defects are more in sertraline consuming pregnancies’ in
comparison to the pregnancies’ not consuming sertraline. Sertraline also affect pregnancy in
third trimester low birth weight and premature delivery. Education need to be provided to the
pregnant woman related to the ill effects of medication on mother and fetus. However,
evidence suggested that pregnant women are less sceptical about non-consumption of
medications during pregnancy. In most of the studies, it has been demonstrated that most of
the pregnant woman consume analgesic medications followed by medications for cough and
cold. Other studies reported that most of the preganant women consume anlagesics along

with antibiotics. Certain medications need to be administered during pregnancy to manage
certain complications; however, such medications exhibit other pregnancy related
complications. Aspirin being used during pregnancy to prevent intrauterine growth
restrictions in pre-eclampsia. However, aspirin augment risk of maternal and fetal
haemorrhage during first trimester and fetal ductus arteriosus constriction leading to
pulmonary hypertension during third trimester. Hence, it is worthwhile to consume 50 to 150
mg aspirin during pregnancy (Demailly, Escolano, Quantin, Tubert-Bitter, and Ahmed, 2017;
Lupattelli et al., 2015).
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