Feeling slightly less impressed with my antenatal care...

[buonasera]

Not a massive thing but at 14 weeks I developed this painful itchy chapping around the corners of my mouth. Mentioned/showed it to my MW at my next antenatal appt and was brushed off with "oh ask your GP, if we refer you to a skin clinic it'll take ages". Well, it's only chapped skin and I'm not going to take any medication when I'm pregnant anyway so I didn't bother and then recently (I'm 29 weeks) it cleared up by itself.
By the by, my 28w blood test last week showed anaemia and I got prescribed iron tablets for it, started taking them, oh, about the same time my skin started to heal. Idly looking up anaemia on the NHS website I find that one of the signs of anaemia is angular chelosis... chapping at the corners of the mouth.
So I've been anaemic for 14 weeks, and I mentioned this skin thing to my midwife, and it's a blooming symptom of anaemia, which they specifically test for because a) pregnant and b) having twins so blood volume has increased by loads, but she didn't twig.
Luckily it's one of those nutrients where the wee ones get their share, and then mum is last in line... but no wonder I've been so knackered for the last 3 fecking months. Out of breath walking to the train station in the morning... blood roaring in my ears at night. All avoidable.

The midwife recommended you see your GP. You didn't. So possibly avoidable, yes, had you done what she advised you.

Seems a bit unfair. Yes the midwife advised that course of action but then people take their cues from how important or not something is from the way the people with expertise respond. If you go to some one who you believe to be an expert for help and they show no interest or concern in what you're telling them then that can implicitly tell you that there is nothing to worry about and act as discouragement for actually seeking further help - which is what it sounds like it happened to me.
Some patients are also susceptible to worrying about being a bother and/or not taking things seriously themselves (I know this, being in a caring profession and at times having to make sure the importance of health issues is properly communicated to those liable to not taking them seriously). I do think the onus is on health professionals to make sure the importance of taking symptoms seriously and going for further checks is properly communicated, but I don't think health professionals always do this.

According to the nhs website here it is open sores that are an occasional sign of anaemia, but certainly not one of the major ones.

Exhaustion is something which happens to most during pregnancy and as you're having twins it will affect you even more.

I think you are being entirely unreasonable suggesting you have had poor care. You did not see the GP when suggested - so you are at fault.

Bonasera I think you've fallen prey to the off hand midwife, in my experience there are too many of hem who brush off your comments with an 'oh what do you expect' or 'we see that all the time'. I told mine that I knew I had a fibroid at my booking in appointment she brushed it off with 'oh women get them all the time and it's nothing' and said that I had to stay in midwife led care. At my 11 week scan I was told off as I should have known that I'd need to be under a consultant for a fibroid to be monitored. It now transpires that I'm going to need a c section as the fibroid is blocking my cervix! Yet if my mw had had he way she'd just have brushed the whole thing off. IMO look everything up for yourself on the Internet and ask loads of questions! Good luck having your twins :)

Thank goodness the preachy comments have been balanced out by some constructive and understanding ones.

Well I did have very severe anaemia in my last pregnancy... which would have been picked up earlier if my MW hadn't disappeared. That was shit. My bloods came back showing anaemia and she didn't contact me or even do my next two MW appointments. Luckily I had shared care with my GP who were brilliant and picked up the slack and referred me for more bloods. I was cross at needlessly being breathless, feeling like crap and looking like death for best part of 6 weeks. That was poor care.

I think you are being unfair expecting anaemia to be picked up from chapped skin. What were your blood tests like?

Well, thanks to the people who understood anyway... I'm not trying to say that my midwife was negligent, but dizzy and boggler get it - her manner strongly implied that whatever it was, it wasn't pregnancy-related, so I let it ride, because getting to my GP essentially means taking a half day off work (I commute) and the work has to be made up somewhere, and I could spend the time resting. Since it's a specialised multiples clinic, and anaemia is especially common in multiple pregnancies, I don't think it's unreasonable to expect them to recognise the rarer signs of anaemia as well as the more common ones - especially as they don't actually test for it between about week 12 and week 28. How am I supposed to recognise it? The other big one you look out for in a twin pregnancy is pre-eclampsia and we've got a little blood pressure machine in the house so when I have a rough day I can come in and check my BP's not spiked - I can't do the same with anaemia.

I did say it wasn't a massive thing but it's made me realise that, as usual, I'm going to have to yell and make a fuss if I'm to get the care I need when I go in for the birth. It's not really my style, and I'd love to be able to just go in and give them a list of my symptoms and have them act on everything important. As a patient you go in, and the MW says, how are you feeling, and you think, does this woman need/want to know that I have a sore back, sore shoulders, sore feet, sore hands from lifting myself out of my seat, shin splints, constipation from the iron tablets I'm now on, heartburn, occasional nausea, breathlessness, tiredness and what I think (hope) are Braxton-Hicks contractions when I walk to the train station in the morning? Essentially she's going to deal with the first three I give her, there's not time for much else, and she's likely to suggest remedies rather than thinking whether they might suggest something more serious (I phoned them the other week with nausea, headache and a racing pulse and they suggested taking paracetamol, as if I couldn't self-medicate a fecking headache, rather than consider whether it might be a sign of pre-eclampsia). So I try to prioritise and mention the stuff that seems weird/I know can be a symptom of something more serious. Seems like I might as well not bother.

I'm a midwife, I didn't know that chapped skin round the mouth is a sign of anemia. I'd have said the same probably. It would have been nice if she had known but I suspect most don't.

Midwives deal in normality. If something isnt normal they refer to a doctor, direct you to a doctor.

If you are worried tgat certain things you are experiencing are more serious then say so. But all the things you mention are experienced by most women and are not because of something serious.

You should have gone to see your gp, maybe just as you did, her advice was given in response to the level of concern you showed.

Ex-midwife here - I didn't know that chapped skin around the mouth was a sign of anaemia either. In my experience though, iron tablets would not clear up physical signs of anaemia in under a week, so perhaps your chapped lips were nothing to do with being aneamic?

If you are unhappy with your midwife, you could request changing to a different one, but chances are you would get the same type of service. As Viva said, midwives deal with normality, anything that's abnormal SHOULD be directed to a doctor, so I would suggest that your midwife did exactly the right thing.

I would also say that you have to take some responsibility yourself. If you chose not to take her advice, for whatever reason, you have only yourself to blame if your anaemia was detected later than it might have been.

Do any of you really think that if my midwife didn't connect the symptom (it's called angular chelitis) with anaemia, that my GP (who probably sees far fewer pregnant women, and far fewer pregnant women with anaemia) was going to pick it up? If I turned up at this surgery at the end of November with chapped lips do you really think he'd have been moving heaven and earth to look for an explanation? Most likely he would have told me to use a moisturiser or might have given me a fungicidal cream which I'd have been reluctant to take, and maybe I'd have been back and forward to him a couple of times and that would have taken a couple of months anyway.

Loves, I understand that she responded to the level of concern I showed. I wasn't overly concerned because I had no idea it was anything to be concerned about. That's what I rely on the midwife for - as she's a specialist in the day-to-day ailments of pregnancy.

Agatha, I'm well aware that the responsibility is entirely mine as it's me who faced the consequences (thankfully not the kids, probably, as I've read that anaemia tends to affect the mother rather than the children). However, I have to go back to that hospital in a few weeks and have these children, and I'll need to go to my GP for all sorts with the kids, so I really don't want to get myself a reputation as a timewaster who worries about nothing. This is my first pregnancy after recurrent miscarriage and it would be the easiest thing in the world for a HCP to read my notes and dismiss my worries as the over-reaction of someone who's seen nothing but disaster. I've got a balancing act to do between turning up at the clinic every day with each new symptom, or on the other side being too quiet and letting things go that I should be chasing up. I rely on my midwife's judgement as to what to chase, and when she says in an offhand manner "oh we can't really do anything about that, you'd be better going to your GP" I interpret that as being a polite "sod off" - she can't really tell me to man up and get over it, but it's a world away from saying "oh you really need to get that checked out by your GP".

Anyway, when next I see my midwife I'll politely mention to her what I saw on the NHS website and maybe it'll ring alarm bells for her the next time she sees it.

I think that your GP might see more people with anaemia, not just pregnant women. Others might have had this symptom.

I don't see why you're annoyed that the midwife didn't pick up on it when you seem to think that a GP with 5 years of medical school wouldn't have picked up on it either.

I understand you are upset but you are over reacting. That is understandable - I've had anaemia it's really awful and makes everything feel like a battle.

It really isn't the midwife's job to deal with anything other than a normal pregnancy. Anything else is referred to a doctor, either the GP or an obstetrician. Presumably you were having regular blood tests throughout your pregnancy? One of the things they look at are your haemoglobin levels which indicate anaemia. Unless those looked anything other then normal I think you are bring unreasonable to expect a midwife to diagnose from a secondary symptom.

I hope you feel better very soon. Chocolate and dairy are iron rich foods you can enjoy taking and liquid iron supplement can sometimes make you less constipated than the dreaded iron tablets.

viva, I'm not annoyed at her, just annoyed that it wasn't picked up. As I said above I will politely mention it to her when next I see her, and then maybe it will ring alarm bells the next time someone gets it. The reason I think she'd have a better chance of picking it up than the GP is that you wouldn't normally see a skin condition and think anaemia - but the other way round, if you're thinking anaemia, the skin condition would be a warning sign.

Folate, I'm just fine. I had blood tests for anaemia at 14 weeks and 28 weeks, which is normal for my clinic.

Bebe, I do think that if, as people have said above, the midwife is going to respond to my level of concern, then I'm going to have to change my style of communication to sound a bit more concerned than I do now - perhaps that makes me less than delightful but I guess that the delivery suite midwives would rather I did that than we all risk something happening to the babies because I didn't make a fuss. I'm well aware that people have "real problems in pregnancy" - if you have a look at some of my previous posts you'll see that I've had my fair share and more of problems in pregnancy.

Its hard not to be ultra suspicious of things when you've had miscarriages before, so while it might be an over reaction, I can see why you'd be concerned of anything which is different. I think the first thing you can do in these situations is go to your doctor - do not self-diagnose online, you will drive yourself nuts. I speak as someone who had a rash and itching and drove myself nuts thinking that I had some sort of liver issue, only to go to the doctor and understand that I am just not drinking enough water and have very dry skin - hence the itching. This is my second child and is a much harder pregnancy!!

Take the midwife's advice and go to see your doctor. Midwives are so hilariously busy, to be honest, while they do listen for the obvious warning signs of serious issues, something like chapped lips they are not going to spend time on, that is your doctors job. They will however give you all the time you need when you actually have your baby - you will not need to fight for their attention, I promise. Good luck with the twins, how exciting!!

Thanks monkeypuzzel - but it's cleared up! It wasn't worrying me at all which is why I never chased it, but it was such a weird thing to have, then yesterday I'm idly looking at the NHS pages on anaemia and there it is, my odd looking skin condition...

It's encouraging to hear what you say about the actual delivery - my hospital has a very good name for antenatal and delivery so with luck we'll be OK if we can hold out for a few more weeks. I think I will err on the side of speaking up though :)

Ok, Buonasera - disregard my 'real problems' comment. That was crass and I apologise.

However, I can't bear the thought that someone goes into hospital in combatative mode thinking they have to shout and bully to get attention. And re-reading your post, it could be interpreted as the midwife trying to be nice to you rather than fobbing you off. She obviously wasn't making a connection between your lips and low iron but appreciated that you were concerned enough to mention it to her at all and was saying that if you want a referral to a skin specialist go through your GP rather than her as you would get attention quicker that way.

I still can't see she did anything wrong. Sorry. YAstillBU.

oh, my darling.

It's okay to react this strongly to problems when you're pregnant (i was the queen of strong reactions), but everyone's right - you were told to go to your GP, who knows about anaemia.
your MW is not a doctor. she can speculate, but she's not actually supposed to, in case she's wildly wrong and you sue her for it.

I would like to point out, when I had angular chelosis it had nothing to do with chapped, itchy lips. It's actually cuts and sores that develop in the corner of your mouth. I'm not sure you even had angular chelosis so it's unfair of you to be harsh on the midwife. However, I know what it's like to go to the midwife with a problem and be told nothing helpful and have them just brush you off because they are busy.

I've been aneamic for years and have had intermittent "painful itchy chapping around the corners of my mouth", which WAS angular chelosis. I think you described it quite adequately, buonasera.

I seriously think some people on this thread need to get a grip. You all know that pregnancy bring all sorts of amplified concerns and reactions, especially with a first pregnancy. Buonasera started her post by saying "not a massive thing", so I think we know she is only verbalising a small, but legitimate, concern.

What's the problem with giving advice or expressing an opinion without being so smug and snappy? Plenty of people post about minor gripes all the time without being told that they are "at fault". Jeez!

I think you're overestimating the role and training of the midwife. Doctor's diagnose, midwives don't. It's not fair to expect your midwife to be a doctor.

I agree that not all health professionals emphasise the benefits of seeing other professionals enough - in my case I went to the GP with hip and back pain and wasn't referred to a physio, midwife did give me their number, very helpful - they sometimes fail to communicate well between themselves and, because they all know their roles and competencies, they can assume you do too.

The only reasonable response is to take charge of your own destiny a bit, ask what their remit is, check whether there are any other appointments you should be making e.g. signing up for ante-natal classes, which it's sometimes assumed you just know about and follow up on all advice.