I’m a specialist screening/fetal medicine midwife

[FMMidwife]

Obviously I can’t comment specifically on peoples individual pregnancies or plans of care, and there is a really informative and brilliant AMA below by a midwife. But if anyone had any questions about this specialist area I’d be happy to answer.

Background.... trained in economically deprived area, but have been working in a very middle class (and therefore older mothers, and therefore more issues with abnormalities) area for 11 years. Primarily worked in triage, birth centre and home birth before specialising two years ago.

What made you pick this specialism?

There were two streams to it.... one was a lifestlye change, to something that wasn’t nights and weekends and Christmas and finishing an hour late with pee the colour of orange juice. The other was a fascination with the science, of screening especially (my first degree was in Genetics). I already knew I was good at supporting women through various difficult choices and situations and I was mature and I had completed my own family, which is important in this role.

I don’t want to think I would never deliver a baby again though.... I am happy where I am for the moment, but I will be looking to incorporate birthing centre shifts into working pattern within the next couple of years.

What do you think about women being told to take aspirin in pregnancy to prevent foetal growth restriction .

A. Any known side effects ?
B. Strength of evidence that aspirin helps ?

Also why do some women get scans every three weeks through pregnancy to monitor baby growth ... Should they be worried

Hi Floote..... there is really good evidence that aspirin in pregnancy reduces the risk of pre eclampsia and associated growth restriction. If you google Cochrane review Aspirin in pregnancy it will take you to the meta analysis. Known side effects at that low dose are very rare.

Interestingly I went to a fetal cardiology conference (my mind still boggles that medicine can be so specialist that there are doctors who deal solely with the hearts of the unborn..... incredible) and they were concerned about the rise in taking aspirin and their concern was heart defects associated with it.... they had a good debate with the obstetricians present and I think that’s still generally a hot topic. I know guidelines will be expanding soon to recommend that more women take aspirin in pregnancy.

Regarding growth scans, various findings might trigger regular growth scans. Previous growth restricted baby, abnormal uterine artery dopplers or small fetal measurements at 20 weeks, various other things. Women shouldn’t be worried, what’s the point? They should be told to come in if they have any concerns about movements, stop smoking if they do and the scans will keep an eye on the growth of the baby. The surveillance level is high and therefore we will see problems as they arise. It’s much more worrying for those babies who are growth restricted and we haven’t spotted and aren’t getting scans.

Interesting. I refused aspirin in my last pregnancy. I did not get pre eclampsia but my baby did have IUGR. I am happy with my decision as there don't appear to have been lasting effects from the IUGR and obviously no drug related side effects.

Hi,
I’m currently 18 weeks pregnant and have a fetal medicine appointment today because of increased fluid at the back of baby’s neck(3.8) at 12 weeks. I had cvs done and everything came back clear. I’m assuming today will be a cardiac scan? What can I expect at appointment and do I need a full bladder.
Thanks xxx

No questions but you lot are bloody legends.

The care I had with a late loss was extraordinary and the midwife held me on the bed when I was sobbing.

She cried too. I sent her a card. I’ll never forget her name.

Hi Pinkflower.... obviously I can’t say for definite but today is more likely to be an early anomaly and the cardiac scan will follow either immediately or within the next couple of weeks. The fetal cardiologists don’t tend to scan until the anomaly has been done. They are also only based at tertiary centres so unless you are going today to a large eminent teaching hospital, regional centre of excellence type thing then you may have to travel a bit for the fetal echo. Good luck x

Troopers, thank you. I am so sorry for your loss. That midwife will have been so touched and happy she was able to support you.

Very slightly off topic, my daughter is seeking to become a midwife and has been researching Universities, lots of difference options, any thoughts to narrow the choice for us?

What are your thoughts on screening for talipes in pregnancy?

I had ds twelve years ago, born with severe bilateral talipes that had not been picked up on the 20 week scan.

Six years later when pg with dd, I asked them to look for talipes and the sonographer said that it is no longer routinely looked for as people were having terminations if it was spotted. I believe this is because it can be a marker for other conditions.

I think it’s become less competitive since they removed the bursary, but your daughter should still try and gain as much experience as possible!

She needs to have a look at things like where are the placement hospitals from where she will living, and how will she get there for shift start times and get home again. She is unlikely to be able to choose her placement hospital so if there are several associated she needs to have a plan for all of them, and for her night shifts.

She’ll be working 37.5 hours a week and will only have 7 weeks off a year so working and earning extra money is hard. Many student midwives live at home because of this and also it’s not a typical uni course with loads of drinking and doing societies and stuff.

Also you don’t say how old your daughter is but I will say that being a midwife requires huge levels of maturity and insight. I have known some fantastic midwives who started their training at 18, but most are not emotionally equipped and many midwives come to it a bit later in life. Women bring all their emotional baggage to the delivery room. It’s worth thinking about whether she’s ready for that or whether she comes back to it in five years.

The ultrasound standards for what the sonographers look for are set by the government in their FASP. They consider how easy it is to see something, what can they do if they see it, what the success rate is of seeing it, what the management can be etc etc and set auditable protocols on what should be reported on in scan and what should not. Talipes isn’t part of FASP at the moment, because it’s too hard to see properly, what we should do with the information isn’t clear and what the extent of the talipes might be (positional, severe etc) is not easy to discern on scan. It’s not to do with termination.

However, if any anomalies are picked up, a woman would be referred to fetal medicine and they will look for talipes as part of an overall picture. And if they see them along with lots of other things then that might guide the care planning.

Personally I think this is the right approach.

That’s great advice thank you, she is the youngest in her year and I’m hoping to persuade her to take a year out first and work in public facing roles, retail, coffee shop etc to up gain dealing face to face with a variety of people.

The hours wouldn’t faze her, her school hours are (from leaving in the morning until returning in the evening) are 7 -5.30 she has had at times a tough upbringing, single parent so is more mature, sometimes more so than her peers.

She has a very strong stomach, unlike me for dealing with all sorts. I’m an ex Police Officer and dealt with all sorts from injuries to lost limbs but can’t deal with sick or dirty protests, she would have no trouble, she is very practical and no nonsense

Very good point re accommodation, this will assist with choice. We have Notts nearby so potentially could stay at home. Although I’m looking to move to the South Coast so I’ll look into this as an option also.

Thank you. X

How do you feel about NIPT?

What are your thoughts on home dopplers?

I think NIPT is amazing, scientifically/technically. We offer it as part of our standard screening for women when the combined test puts them into a high risk category. It’s massively reduced our rate of invasive tests which is fantastic for women. I have a small concern about what it can be used to screen for in the future. We have close ties with a group for people with Down’s syndrome and they have massive ethical problems with it and with termination for DS in general. I think it’s sort of a “shame” that so many babies with DS are terminated, but essentially I believe in the choice of women so I’m at peace with it.

Home Doppler should be banned. There’s no conceivable reason they should be on sale.

There was an article on the BBC about how DS was virtually unheard of in Iceland due to NIPT.

What do you find the hardest thing about your job?

The hardest thing is being called by a sonographer to talk to a woman when they’ve found something on the anomaly scan. Often I’ve not heard of it before or I’m not sure what it means, and of course women want answers, stats, likelihoods etc. I don’t want women to come out feeling like there aren’t in safe hands IYKWIM, and often they are very distressed and have other children with them. Despite being a midwife for many years I still hear of something new at least once a week.

Also organising TOPs when I’m not sure if it’s the right decision for that woman. Organising TOPs generally can be a real organisational ballache and obviously women want it done ASAP once they’ve decided so it’s managing their expectations.

Also just generally not being able to give women everything they want straight away. Or instinct is to care and protect these families but you can’t. They have to go out in the big wide world and cope, they have to wait for test results, wait for appointments, and that’s really hard for them and me.

Hi op.
I know testing has moved on, but in your experience, how many miscarriages occur after cvs & Amnio? is it the often quoted 1 in 100, or is it much less ( or more? ) & how do you know which miscarriages were definitely caused by these procedures to arrive at the 1 in 100 figure?

Thank you.

Do you know how many women refuse the standard 12-week screenings? I haven’t had them in any pregnancy, and had really mixed reactions from midwives at booking appointments. One was insistent on getting me to sign the consent form anyway “and you can just change your mind on the day if you want to!”

Do you think all the testing we have now is a good thing or do you think it causes more worry? I'm on the fence because I declined the triple test/nuchal fold measurement but I also benefited greatly when my son's cleft lip was diagnosed at my 20 week scan and I had time to get my head around it before he was born.

Do you/fetal medicine doctors get told the outcomes of monitored pregnancies?
One of my children had a heart hole identified, then a suspected bowel defect upon scanning at fetal medicine unit. She did have a very small heart hole, but her bowel was perfectly normal and therefore misdiagnosed on the ultrasound. I've often wondered if this was fed back to the doctor who diagnosed it, so that they were aware of if this information was just lost in the system.