Medical Case Report: Senior Midwife Role in Pregnancy at Hospital

This medical case report centers on a 38-year-old woman, G4P3, presenting at 30 weeks of pregnancy with elevated blood pressure, mild abdominal pain, and a history of smoking. The report emphasizes the senior midwife's role in assessing the patient, considering potential diagnoses like hyperemesis gravidarum and hypertension, and outlining management strategies. It discusses the importance of physical assessments, investigations, and communication with the patient. The report also covers early pregnancy complications, the significance of EPAUs, and the need for collaborative decision-making, especially in a hospital without NICU facilities. The report highlights the importance of documentation and patient education, emphasizing the need for appropriate investigations and patient support.

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Introduction
The aim of assignment is to provision an evidenced based rationale in case of the patient and
present the collaborative management as a decision maker. The purpose is to well take into
consideration the history pertaining to the case and employ the various strategies that would
aid in the decision making as a senior mid wife associated with the medical case of Venessa.
As Venessa have the fourth pregnancy and the number of births pertaining to visible
offspring’s being three in the case. The intent to bring about the collaborative management
while having the support provisioned with the role of mid wife in the case. The various
activities that would form part of taking decisions and acting in a manner that the pre-
requisites are accordingly handled until the doctor is available. Early Pregnancy
complications are common in medical science, which include pregnancy loss, threatened
miscarriage, ectopic pregnancy, molar pregnancy and hyperemesis (NSW, 2017; Gillon et al.,
2014). Most of the early pregnancy complication cases women are assessed, diagnosed and
managed at early pregnancy assessment units (EPAUs). The manner in which the efficiencies
would be deployed to consider for the team of registered nurses and graduate mid wives is
crucial (AIHW, 2017). The decision making strategies which the assignment would cover
would include the steps which would be taken based on the roles and responsibility of the
senior mid wife.
History
Ms Vanessa Smith, a 38 year old G4 P3 presents takes her admission to the hospital. Since
the hospital has no facility for NICU or High dependency Unit it is primarily depends on the
emergency caesarean facility with on-call staff system. As the patient has already had
sporadic antennal case outside, there is no record available with the patient or the hospital and
even the patients cannot give any reference of the same (Magee et al., 2014). As documental
evidence, she carried during her time of admission only a copy of her morphology ultrasound
report. The report clearly indicate placenta was reported as situated in the upper anterior
quadrant and clear of the cervical with the confirmation in the report that she is
approximately 30 weeks pregnant. Her blood pressure been checked after thirty minutes from
her admission and found 164/112mmHg. According to the patient, her blood pressure has
always been normal. Some mild abdominal pain been reported, while investigating she
admitted that she used to smoke nearly ten cigarettes a day. Her heart rate has been checked

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and found 130bpm. The same has been conveyed to the GP and she has confirmed she will be
reaching hospital within four hours.
Observations
The patient is thirty weeks pregnant and of 38 years of age with 130bpm of heart rate, with
clear cervical os. Since there are not much of medical history records, the patients can be
advised for some physical activities as pr the guideline of the American College of
Obstetricians and Gynecologists (ACOG). The patient can adopt the prevalent Centers for
Disease Control and Prevention and recommendation of thirty minutes or more of moderate
considerable physical activity maximum on a regular basis, if not the entire week (Edwards et
al., 2014). Those Physical activities will have end number of positive associated with
pregnancy and delivery. She can get benefits which encompass shorter labor along with the
delivery time, reduced pregnancy-associated complications, and discomfort along with
recovery post-delivery (Shaffer, F. et al., 2014; Briley, A. L. et al., 2014; Mol, B. W. et al.,
2016). Routine physical activity will reduce the pertaining incidence of childhood obesity
along with the hypertension and gestational diabetes (Briley et al., 2014; Mol et al., 2016).
The cardiovascular system pertaining to fetal is responsive to a great extent to maternal
physical activity. Any physical activity linked to maternity at the times of gestation would
have an impact and lower fetal heart rate (HR) along with increased heart rate variability
(HRV).
Physical Assessments (Maternal And Fetal)
Higher intensity activity does associate to lower HR along with the greater overall HRV of
the fetus being developed. Since the guideline has not mentioned anything specific about
physical activities like continuous and non-continuous activities the patient can be advised to
take up certain activities like moderate Resistance training, tasks linked to weight lifting and
interspersed with certain periods of rest (Shaffer et al., 2014; Briley et al., 2014; Mol et al.,
2016). The fetal assessment could have been better judged with the ultrasound in this case.
Even with the consumption of smoking to a greater extent can have a negative impact. She
used to smoke 10 cigarettes a day, in order to assess all. Since we have no report on her
physical activities prior to pregnancy, it is difficult to recommend her anything specific.
However to be more ascertain she can be asked to fill up the Activity Questionnaire (MPAQ)

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based on which she can be recommended for continuous (e.g., walking, jogging) or non-
continuous (e.g., weight lifting, yoga) (May et al., 2014; Briley et al., 2014; Mol et al., 2016)
. We can recommend her for tests to determine if she is suffering from any of those. Nausea
in pregnancy, hyperemesis gravidarium, end of the first trimester with the symptoms -
Wernicke’s encephalopathy - resulting from a nutritional imbalance of reduced thiamine,
intravenous rehydration, electrolyte monitoring and restitution, anti-emetics, thiamine
supplementation, non-resolving cases steroid therapy (Serin et al., 2017; May et al., 2014;
Briley et al., 2014; Mol et al., 2016).
The Possible Diagnoses
Many women, almost over 50% suffer from nausea in pregnancy. It is called Hyperemesis
gravidarium which is the inability to maintain hydration and leads to complication like
dehydration and ketonuria. The symptom is nausea and vomiting in pregnancy (Serin et al.,
2017; May et al., 2014; Briley et al., 2014; Mol et al., 2016). Though the percentage is low
among pregnancy however it is something that makes a patient dehydrated, ketonuric,
developing an electrolyte imbalance, (hyponatraemia and hypokalaemia). Those symptoms
developed within the 8 weeks, and are directly associated with the levels of HCG, which tend
to be evident at the end of the 1st trimester earlier to the settlement of second trimester (Serin
et al., 2017; May et al., 2014; Briley et al., 2014; Mol et al., 2016). Patients who have nausea
or associated weakness along with the symptoms of vomiting have greater discomfort in
swallowing. The morning sickness along with the nausea at the pregnancy tends to be
harmless. The extremity of morning sickness Hyperemesis Gravidarum pertains to the
extreme form of morning sickness that is accompanied with severe vomiting (Serin et al.,
2017; May et al., 2014; Briley et al., 2014; Mol et al., 2016). The diagnosis is based on the
medical history of the patient. The physical examination is considered significant in the case.
The signs of HG with great prominence are monitored with the examination done. the
additional tests would also be needed in case to rule the problems associated with
gastrointestinal concerns. The appropriate medication with the drugs - Promethazine or
meclizine can be best resort (Garland et al., 2015; Serin et al., 2017; May et al., 2014; Briley
et al., 2014; Mol et al., 2016). The patient can be proposed for pathophysiological tests to
determine hyperemesis. It is related to the HCG (human chorionic gonadotrophin).

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There is a very rare case of complication called Molar pregnancies. This case is found among
one out of seven hundred (1:700). This complication happens does take place in case of an
abnormal conception as the case may be (Denno et al., 2015; Serin et al., 2017; May et al.,
2014). (Jurkovic et al., 2015; Gillon et al., 2014).
Investigations
Motherhood is a dream for every woman and for that they take all possible means to ensure
the birth of a healthy baby. Unfortunately there are cases where a women need to face some
unexpected complications. It is advisable in general for every woman to go through active
follow-ups and undergo necessary medical investigation when they receive the report
confirming pregnant. It is even advised to take up necessary steps during the planning phase
of family expansion (Heitmann et al., 2016; Jurkovic et al., 2013). It is very important to
remember that each case is individual, all circumstances are different and proper information
about the risk and benefits needs to be conveyed to the patients in advance with proper
guidance with all available treatment options (Heitmann et al., 2016; Jurkovic et al., 2013).
The role pertaining to EPAU along with open access does tend to aid in terms of regular
scanning being conducted. Open access and choice in care options has also been advocated as
helping women to feel more in control of their treatment and reducing post-treatment rates of
anxiety and depression (Mitchell et al., 2017; Cirillo & Cohn, 2015; Fan et al., 2014). The
baby along with the parent mother has to take care of her health. It is also crucial that for
patients who have a case of an ectopic pregnancy, the relevance of ultrasound in subsequent
pregnancies is important as it would in turn aid to exclude a recurrence. There are cases
where pregnancy complications are found. Early pregnancy of complication during the
advance stages of pregnancy (Cirillo & Cohn, 2015; Fan et al., 2014). The units provide a
detail report with specialist investigations (scan, HCG), on the nature of complication and a
guideline on how to co-ordination and dealing. The EPAU does enable to a greater extent, the
continuity of care along with the needed medical administrative coverage.

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The early pregnancy assessment has the risk of heavy bleeding from vagina. The abdominal
pain also shoots up and the visual examinations hold greater significance (Cirillo & Cohn,
2015; Fan et al., 2014; Creanga et al., 2015). The examination done by the nurse has to be
recorded along with other medical conditions. The internal scans done are of great help too.
Along with the ultrasound done, the blood test also might be needed to rule out any further
complication and risk factors associated with infections (Smolowitz et al., 2015; Lavin et al.,
2015). This is accepted by the medical science globally as the most cost effective while
streamlining investigations. For the females who have the case of previous pregnancy being
complicated, this service tends to be significant too for ongoing support in the case of future
pregnancy (Cirillo & Cohn, 2015; Fan et al., 2014). Unfortunately there are the healthcare
services that fall under ever increasing pressure just in order to reduce costs the open access
would not be deemed to a greater extent as a financially viable service. It is crucial that viable
investigations do take place and results are well explained (Creanga et al., 2015; Cirillo &
Cohn, 2015; Fan et al., 2014). It is considered significant that patients are given appropriate
education along with the efforts from support groups.
Management
Prioritizing patient care is essential as there can be the risk of unexpected that always
prevails. With the appropriate patient care done based on the documents which reflect the
background (Smolowitz et al., 2015; Lavin et al., 2015). As Vanessa has had sporadic
antenatal care elsewhere, it is necessary that the needed treatment going ahead would require
the additional care which has to be well managed. It is important that the treatment pre
requisites are well adhered (Smolowitz et al., 2015; Lavin et al., 2015).
Communication And Documentation
The importance of communication with the patient along with the family cannot be ruled out.
It is very important the patient and the family does get to know the complications if any and
the treatment. With the blood pressure reports and ascertaining the habit of the patient, it was
crucial to step in and make the patient and the family understand the ill effects and the risks
pertaining to the serious cigarette smoking by Vanessa. As she is 30 weeks pregnant, the mild
abdominal pain she is getting needs to be well comprehended. The reason for the pain and by

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carefully examining the morphology ultrasound, it has to be well made understood to
Vanessa that the fetal heart rate stands to be normal between 120 -160 beats in a minute and
the same needs to be communicated. Also that in her case, the fetal heart rate being 130 bpm
is normal. The documentation that would need to be well kept in order is the assessment of
ultrasound and the record of blood pressure, fetal heart rate along with the medical condition
to be well documented before the doctor arrives.
Referral Requirements And Support
The referrals to other service providers would not be needed in the case. With the
investigation done and the medical records in place, the important issue that has to be
considered is the effective coordination with the team to monitor the patient. The local
support workers would need to have a consultation with the senior staff.
Conclusion
Having a healthy baby is the dream for all women. In case of Vanessa, the report clearly does
indicate that the placenta was reported as situated in the upper anterior quadrant and she is 30
weeks pregnant. There is due care and diligence which is expected to be well delivered to
avoid and risks and uncertainties taking place. The collaborative management approach in
well coordinating the activities and the decision that needs to be taken as part of the care
service provisioned is crucial in the case. Vanessa also has got done the sporadic antenatal
care elsewhere, it is necessary that the needed treatment going ahead. The significance of
communicating with patient is crucial .The various activities would encompass taking
decisions along with acting in a manner that the pre-requisites are accordingly handled until
the doctor could have been available. Early Pregnancy can have complications associated and
are common in medical science, which include pregnancy loss, threatened miscarriage,
ectopic pregnancy, molar pregnancy and hyperemesis. The family of patient too needs to be
educated on the concerns and development. With the blood pressure reports and ascertaining
the habit of the patient, it was crucial to step in and make the patient and the family
understand the ill effects and the risks. The complications in early pregnancy have to be well
attended and the position of mid wife involves greater roles and responsibility too.

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References
AIHW (2017). Our Services. Retrieved from:
https://www.aihw.gov.au/
Briley, A. L., Barr, S., Badger, S., Bell, R., Croker, H., Godfrey, K. M., ... & Patel, N. (2014).
A complex intervention to improve pregnancy outcome in obese women; the
UPBEAT randomised controlled trial. BMC pregnancy and childbirth, 14(1), 74.
Cirillo, P. M., & Cohn, B. A. (2015). Pregnancy Complications and Cardiovascular Disease
Death: Fifty-Year Follow-Up of the Child Health and Development Studies
Pregnancy Cohort. Circulation, CIRCULATIONAHA-113.
Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., & Callaghan, W. M. (2015).
Pregnancy-related mortality in the United States, 2006–2010. Obstetrics &
Gynecology, 125(1), 5-12.
Denno, D. M., Hoopes, A. J., & Chandra-Mouli, V. (2015). Effective strategies to provide
adolescent sexual and reproductive health services and to increase demand and
community support. Journal of Adolescent Health, 56(1), S22-S41.
Edwards, J. G., Feldman, G., Goldberg, J., Gregg, A. R., Norton, M. E., Rose, N. C., ... &
Watson, M. S. (2015). Expanded carrier screening in reproductive medicine—points
to consider: a joint statement of the American College of Medical Genetics and
Genomics, American College of Obstetricians and Gynecologists, National Society of

MEDICAL ASSIGNMENT (ID, NAME, UNIT)
9
Genetic Counselors, Perinatal Quality Foundation, and Society for Maternal-Fetal
Medicine. Obstetrics & Gynecology, 125(3), 653-662.
Fan, X., Rai, A., Kambham, N., Sung, J. F., Singh, N., Petitt, M., ... & Gambhir, S. S. (2014).
Endometrial VEGF induces placental sFLT1 and leads to pregnancy
complications. The Journal of clinical investigation, 124(11), 4941.
Garland, E. M., Celedonio, J. E., & Raj, S. R. (2015). Postural tachycardia syndrome: beyond
orthostatic intolerance. Current neurology and neuroscience reports, 15(9), 1-11.
Gillon, T. E., Pels, A., von Dadelszen, P., MacDonell, K., & Magee, L. A. (2014).
Hypertensive disorders of pregnancy: a systematic review of international clinical
practice guidelines. PLoS One, 9(12), e113715.
Heitmann, K., Solheimsnes, A., Havnen, G. C., Nordeng, H., & Holst, L. (2016). Treatment
of nausea and vomiting during pregnancy—a cross-sectional study among 712
Norwegian women. European journal of clinical pharmacology, 72(5), 593-604.
Jurkovic, D., Overton, C., & Bender-Atik, R. (2013). Diagnosis and management of first
trimester miscarriage. BMJ, 346, f3676.
Lavin, M., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and
professional nursing care documentation in acute care settings. OJIN: The Online
Journal of Issues in Nursing, 20(2).
Magee, L. A., Pels, A., Helewa, M., Rey, E., von Dadelszen, P., Audibert, F., ... & Firoz, T.
(2014). Diagnosis, evaluation, and management of the hypertensive disorders of

MEDICAL ASSIGNMENT (ID, NAME, UNIT)
10
pregnancy: executive summary. Journal of Obstetrics and Gynaecology
Canada, 36(5), 416-438.
May, L. E., Suminski, R. R., Berry, A., Langaker, M. D., & Gustafson, K. M. (2014).
Maternal physical activity mode and fetal heart outcome. Early human
development, 90(7), 365-369.
Mitchell‐Jones, N., Gallos, I., Farren, J., Tobias, A., Bottomley, C., & Bourne, T. (2017).
Psychological morbidity associated with hyperemesis gravidarum: a systematic
review and meta‐analysis. BJOG: An International Journal of Obstetrics &
Gynaecology, 124(1), 20-30.
Mol, B. W., Roberts, C. T., Thangaratinam, S., Magee, L. A., De Groot, C. J., & Hofmeyr, G.
J. (2016). Pre-eclampsia. The Lancet, 387(10022), 999-1011.
NSW (2017). Maternity - Management of Early Pregnancy Complications. Retrieved from:
http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_022.pdf
Serin, S. O., Karaoren, G., Okuturlar, Y., Unal, E., Ahci, S., Karakoc, E., & Ucak, S. (2017).
Thiamin and folic acid deficiency accompanied by resistant electrolyte imbalance in
the re-feeding syndrome in an elderly patient. Asia Pacific Journal of Clinical
Nutrition, 26(2), 379.
Shaffer, F., McCraty, R., & Zerr, C. L. (2014). A healthy heart is not a metronome: an
integrative review of the heart's anatomy and heart rate variability. Frontiers in
psychology, 5.

MEDICAL ASSIGNMENT (ID, NAME, UNIT)
11
Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., & Wood, L.
(2015). Role of the registered nurse in primary health care: Meeting health care needs
in the 21st century. Nursing Outlook, 63(2), 130-136.