Oxford Handbook of Midwifery (24 page)

Emotional and psychological considerations

Health considerations

Educational considerations

Information and discussion to obtain consent for the following:

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Taking a sexual history

• Unprotected sexual intercourse resulting in pregnancy may also put a woman at risk of contracting an STI.
  
• Sensitive discussion about her past and current sexual health will determine the need for STI testing.
  
• It is important to raise the issue of sexual health and STIs early in pregnancy to initiate diagnostic testing, appropriate referral to the sexual health service and sexual health promotion, if applicable.
  
• The rates of STIs in the UK have risen sharply in the past decade. The highest rates are found in women, gay men, teenagers, young adults, and black and ethnic minority groups.
  ¹
  
• While a programme of chlamydia screening in the 16–24-year age group has been instituted in the UK, this common STI is by no means limited to this age group and it is good practice to offer every pregnant woman urine-based screening, as a prevention for her ongoing, long- term sexual health and to prevent vertical transmission to her baby during vaginal birth.
  

  •
  Unrecognized/untreated STIs may be vertically transmitted to the baby following rupture of the membranes and vaginal birth. b See Chapter 3 for more specific discussion on individual infections.
  

  The discussion should include:
  

• Length of current relationship
  
• Number of sexual partners in the past 12 months.
  

  Symptoms
  

• Change in vaginal discharge
  
• Vulval/vaginal soreness or irritation
  
• Intermenstrual bleeding
  
• Postcoital bleeding
  
• Pain during sex (dyspareunia)
  
• Abdominal pain
  
• Contact of STI
  
• Past history of STI
  
• Contraceptive method(s)
  
• Condom use
  
• Is she an intravenous drug user past or present?
  
• Has she had sex with an intravenous drug user?
  
• Has she been paid for sex?
  
• Is her partner bisexual?
  
• Has any partner been of non-UK origin, in this country or abroad?
  

  Investigations
  

  Investigations may include:
  

  Chlamydia
  

• Endocervical swab
  
• Self-taken swab
  
• Urine test (first catch).
  

  TAKING A SEXUAL HISTORY
  

  53
  

  Gonorrhoea
  

Blood testing

Other

• Has the woman been called for screening at all? This will depend on the country she resides in and the age at which the screening programme commences.
  
• If appropriate, has she been screened at all and when was her last test?
  
• Has she ever been asked to attend for repeat testing within the
  

  normal recall time and has she ever had an abnormal result?
  

1
Health Protection Agency (2010).
Health Protection Report: HIV/Sexually Transmitted Infections
. Available at
www.hpa.org.uk/hpr/infections/hiv_sti.htm (accessed 2.4.10)

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Principles of antenatal screening

As science and technology advance, we are able to elicit more information about pregnancy, the mother, and the fetus than ever before. The scru- tiny with which we examine every aspect of pregnancy has never been more detailed. It is very likely that further advances in these techniques will expose women to increasingly difficult choices and dilemmas. The midwife will need to be well prepared and informed to guide her clients through this process.

A range of activities come under the banner of ‘antenatal screening’. Certain activities are a fundamental part of midwifery practice, e.g. measuring the fundal height, listening to the fetal heart, and the routine blood tests, including full blood count, group and Rh factor, and maternal serum for rubella antibodies. We may classify these as low intervention, unlikely to cause any ethical concern. Other types of screening, such as those undertaken to detect fetal abnormality, can lead to much moral difficulty.

The aims of screening

The whole pregnant population is screened because, although collectively

this population has a low risk of abnormality, screening aims to iden- tify those at a higher risk, so that more specific diagnostic tests can be applied.

Benefits of screening and diagnosis

• Reduce fetal abnormality.
  
• Reduce genetic reoccurrence.
  
• Reduce the incidence of mental handicap.
  
• Reduce the burden on family and society.
  
• Increase resources for those disabled individuals who are not detected before birth.
  

  Adverse effects of screening and diagnosis
  

• Anxiety provoked by screening procedures.
  
• Psychological sequelae for parents.
  
• Risks of diagnostic tests to woman and fetus.
  
• Risks to the woman of a late termination of pregnancy.
  
• Risk of aborting a normal fetus.
  
• Long-term effects on society’s attitude to the disabled.
  

  Implications
  

• Inadequate counselling at the time of the test could mean that clients are not prepared for adverse outcomes, such as being recalled with a high-risk result, or giving birth to an affected child after having a low- risk result from the screening test.
  ¹
  
• No matter how good a test is technically, screening uninformed, unsupported clients by unprepared staff is a recipe for, at best, confusion and, at worst, great distress. This is avoidable.
  ²
  

PRINCIPLES OF ANTENATAL SCREENING

55

Consent and counselling