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Amniocentesis counselling: A role for the midwife-practitioner
Journal of Obstetrics and Gynaecology
Abstract
Recent publication of an evidence-based clinical guideline by the Royal College of Obstetricians and Gynaecologists (RCOG 2005) for invasive testing in pregnancy stimulated a review of our prenatal diagnosis counselling service. This coincided with a reduction in the hours worked by obstetric trainees and a need to streamline antenatal care. We arranged for a senior midwife (KE) with extensive experience in general midwifery and fetal medicine to undergo additional training in counselling for amniocentesis. She then took over the running of the counselling service supported by an in-house care pathway. She had open access to a consultant (RF) for advice. A review of the case notes of 60 consecutive women who attended for counselling showed that the midwife followed the guidelines extremely closely both in terms of process and quality of the documentation. A total of 58 of the women were counselled solely by the midwife-practitioner. Only two required additional counselling by the consultant. Of a subset of 27 women surveyed by telephone questionnaire, only two (7.4%) were surprised to have been counselled by a midwife; 25 (93%) said the counselling was excellent or good; 17 (63%) said they would prefer to see a midwife in any future pregnancy and only one woman said she would prefer to see a doctor.
... Midwife-led services have been found to be effective, efficient, and patient-focused and may ease patient pressure on obstetric and pediatric cardiology specialists. 22 In accordance with previous research, 12,23 this study observed high satisfaction with the specialist consultation. However, the information was also described as being overwhelming, complex, and insufficient. ...
Objective:
To explore the need for information and what information was actually received following a prenatal diagnosis of a congenital heart defect, in a country where termination of pregnancy beyond 22 weeks of gestation is not clinically performed.
Methods:
Twenty-six Swedish-speaking pregnant women (n = 14) and partners (n = 12) were consecutively recruited for semi-structured telephone interviews following the prenatal diagnosis of congenital heart defect. Data was analyzed using content analysis.
Results:
Although high satisfaction with the specialist information was described, the information was considered overwhelming and complex. Objective, honest and detailed information about multiple subjects were needed, delivered repeatedly and supplemented by written information/illustrations. Eighteen respondents had used the Internet to search for information and found issues involving searching difficulties, low quality, and that it was too complex, insufficient or unspecific. Those who terminated the pregnancy criticized that there was a lack of information about termination of pregnancy, both from health professionals and online sources, resulting in unanswered questions and unpreparedness.
Conclusion:
Individuals faced with a prenatal diagnosis of a congenital heart defect need individualized and repeated information. These needs are not all adequately met, as individuals are satisfied with the specialist consultation but left with unanswered questions regarding pregnancy termination.
Objective:
to explore experiences described by posters in Swedish virtual communities before, during and after termination of pregnancy due to a fetal anomaly.
Design:
cross-sectional qualitative study of messages in virtual communities. The messages were purposefully selected in 2014 and analyzed with inductive qualitative manifest content analysis.
Setting:
two large and active Swedish virtual communities.
Sample:
1623 messages from 122 posters (112 females, 1 male, and 9 did not disclose their sex), written between 2008 and 2014. The majority of the posters were females (91%) with recent experience of termination of pregnancy following different prenatal diagnoses (63% less than one year since the termination).
Measurements and findings:
before the termination, posters experienced an emotional shock and a difficult decision. During the termination, they needed compassionate care from present caregivers, experienced intense emotional and physical pain, lacked an understanding about the abortion, and expressed varied feelings about the option to view the fetus. After the termination, posters used different strategies to come to terms with and accept the decision, experienced a perinatal loss, expressed fears of recurrence, and longed for a new child.
Key conclusions:
spanning across the time before, during and after the abortion, women who terminate a pregnancy due to a fetal anomaly express considerable physical and emotional pain, with psychosocial and reproductive consequences.
Implications for practice:
information and preparation, including the decision whether or not to view the fetus, are important aspects to consider when caring for individuals who have decided to terminate a pregnancy for a fetal anomaly. The findings indicate a need for structures that offer support to women who suffer from fears of recurrence in future pregnancies.
To the Editor Dr Kuppermann and colleagues¹ reported a decrease in invasive prenatal testing, as well as patients making more informed choices, when randomized to receive a computerized, interactive decision-support guide. The control group received no specific counseling or information on screening and diagnostic tests.
The guideline from the Royal College of Obstetrics and Gynaecologists on amniocentesis and chorionic villous sampling recommends that all women undergoing these procedures provide written informed consent prior to testing. This consent should include risk of miscarriage associated with invasive testing.²
Over the last decade, nurse-led services have been introduced as an alternative pathway of patient care, in part to undertake work performed by trainee medical staff before the reduction in working hours. In response to the loss of trainee hours resulting from implementation of the European Working Time Directive, we set up a new service with a highly experienced gynaecology nurse who underwent additional training in preoperative assessment and consenting. The service was founded on the nurse-practitioner's expertise, together with the use of an integrated care pathway and 12 preformatted consent sheets. We undertook a case note review of 100 consecutive patients. The review of the service showed a high level of compliance for performance of laboratory and radiological investigations, both in terms of completion and the avoidance of unnecessary tests. In addition, the nurse-practitioner was able to obtain written consent from almost 87% of women undergoing surgery using a range of just nine preformatted sheets. No serious medical issues were overlooked and no operations were cancelled on the day of surgery. The quality of documentation was exemplary and there were no complaints or clinical incidents related to the nurse-practitioner in 4 years of service. The quality of patient care can be maintained, if not improved, by integrating nurse-led preoperative assessment into the departmental clinical pathway for women choosing elective surgery.
A high proportion of pregnant women attending for urgent assessment do not need emergency care and they have lower clinical priority compared with women who have serious complications in labour. We are aware that this results in a high number of complaints about waiting times. We set up a midwife-led service founded on the introduction of integrated care pathways for the six commonest conditions, based on national recommendations. A review of the case notes of 100 consecutive women who attended the maternity assessment centre was undertaken, of which 99 were suitable for analysis. On average, eight new patients were seen each day. The study found that 60% of the sample were cared for by a midwife alone and just one in three underwent direct medical assessment. The proportion cared for by midwives alone varied widely according to the presenting condition; more than 90% of those with reduced fetal movement but just one in three of those attending with antepartum haemorrhage. On average, women waited for a total of 80 min (range 35-290 min). More than 80% were in the unit for less than 120 min. On average, the wait times appeared to be longer for those women presenting with hypertension, probably because of the greater need for laboratory testing. Of a subset of 20 women surveyed by telephone questionnaire, only one (5%) was surprised to have been seen by a midwife; 17 (85%) said the counselling was excellent or good; 18 (90%) said they would be content to see a midwife for any future visit but two women said they would prefer to see a doctor at a future visit.
There are therapeutic dilemmas regarding fertility-preserving treatment among young women with well-differentiated endometrial carcinoma.
Twenty-one patients with stage IA well-differentiated endometrial adenocarcinoma were enrolled in a prospective study. The treatment initiated with 160 mg/d of megestrol acetate. The patients underwent dilatation and curettage and hysteroscopy after 3 months, and in cases of normal pathology, the therapy continued for another 3-month period. In patients who did not respond to treatment, the dosage of the drug was doubled (320 mg/d), and the therapy continued for another 3 months. At the second time, patients who did not respond to treatment were recommended for hysterectomy, and in patients who responded to treatment, an additional 3 months of treatment with megestrol acetate (320 mg/d) was administered.
Our results showed a response rate of 85.71% (18 patients), and 3 patients underwent hysterectomy. The mean (SD) treatment duration was 8.85 (2.00) months (range, 6-12 months). The response to therapy was observed in 5 patients (27.78%) with a dosage of 160 mg/d, and the remaining patients with 320 mg/d. Pregnancy occurred in 5 patients (27.78%). Recurrence happened in 3 (16.67%) of 18 patients who responded to treatment who did not give a permit to undergo hysterectomy and received medication again. Two (66.67%) of these patients experienced remission again, whereas the other one was candidate for hysterectomy.
The results of this study show that, when an initial response is not achieved or when disease recurs, use of 320 mg/d seems to be associated with a better therapeutic response. Furthermore, serious complications were not observed with this dosage.
Recent improvements in the investigation of bleeding and pain in early pregnancy has led to simplified clinical guidelines. These in turn have created the opportunity for nurse-led early pregnancy assessment. We arranged for a gynaecology nurse-practitioner with experience to undergo additional training in early pregnancy care. She then took over the daily running of the Early pregnancy assessment centre (EPAC). A review of 200 consecutive cases showed that the nurse followed the guidelines extremely closely in terms of categorisation of patients, referral to the medical team for further investigation and selection of women who required anti-Rh(D) immunoglobulin. In addition, in the first 6 months of the clinic no cases of ectopic pregnancy were overlooked by the nurse-practitioner. Sixty-one per cent of the women attending the clinic did not need to see a doctor.
The issue of information and autonomy (informed consent) in prenatal diagnosis (PND) was studied by questionnaires given to women undergoing amniocentesis (group A, n = 122) or chorionic villus biopsy (group V, n = 90). About 1/4 of the women were also interviewed. Sixty-eight percent of the women had learnt most about PND already before visiting the antenatal clinic. More women in group A (75%) than in group V (51%) were satisfied with the information given at the clinic, probably because amniocentesis is a well-known routine, while chorionic villus biopsy is not. Further, in both groups, more of the women who underwent PND because of age were satisfied with the information than those having PND because of strong fear of giving birth to a handicapped baby. This might be explained by the complicated character of this fear, which the medical staff could not always understand and meet. Also the women who were investigated because of a known genetic problem seemed to need more specialized genetic counselling. Fifty-eight percent of the women were well informed about the risk of giving birth to a child with a congenital disorder and 83% about which disorders could be detected by the procedure they were undergoing. Seventy-three percent had not felt any uneasiness when they were offered PND by their midwife or gynecologist; 18% had initiated the discussion themselves. Seventy-four percent of the women recommended that the medical staff actively offered PND. Most women (87%) answered that the midwife's or gynecologist's attitude towards PND had been positive. The majority (85%) considered that there is a risk of persuasion in counselling.(ABSTRACT TRUNCATED AT 250 WORDS)
Amniocentesis and chorionic villus sampling have been shown through prospective, multicenter trials to be safe and effective methods of prenatal diagnosis; accordingly, a knowledge of these tests is important for those physicians who care for women during their childbearing years. We review the indications, techniques, safety, accuracy, and efficacy of amniocentesis and chorionic villus sampling and compare the advantages and disadvantages of each diagnostic test. This review should enable physicians to provide appropriate counseling and information to women at increased risk for fetal abnormalities detectable by either of these procedures.
A recent publication of an evidence-based clinical guideline for male and female sterilisation by the Royal College of Obstetrics and Gynaecology (RCOG) created a stimulus for a review of our female sterilisation service. We arranged for a gynaecology nurse-practitioner (A.O.) with extensive experience in general gynaecology and contraception to undergo additional training in counselling female sterilisation. She then took over the daily running of the sterilisation clinic using a care pathway and pre-printed letters. She had open access to a consultant (R.F.) for advice. A review of 100 consecutive referrals showed that the nurse followed the guidelines extremely closely both in terms of referral to the medical team for advice and/or further counselling and quality of documentation. A total of 59% of the women attending the clinic were cared for by the nurse-practitioner alone. Only four had to see a consultant. All women questioned expressed very positive comments about the style and content of counselling and just one stated she preferred to see a doctor.
Azzolino v. Dingfelder
- North Carolina Court of Appeals
- North Carolina Court of Appeals
Information on prenatal diagnosis at the antenatal clinic. The women's experiences
- B Sjögren
- N Uddenberg
Amniocentesis and chorionic villus sampling, Evidence-based Clinical Guideline
- Rcog