Candice is 18 years old. She lives with her mum, Anna, aged 42. Candice is at College where she is about to complete her course after studying 2 days a week and working the other 3 days in a veterinary practice as part of an apprenticeship scheme, sponsored by the veterinary Practice, where she hopes to work full time after qualifying as a veterinary nurse later this year.
Candice is engaged to Gary aged 19, who she met last Summer at College where he was studying and he now works with his dad in the family run painting and decorating business.
Candice is now 12 weeks pregnant and attends antenatal clinic today with Gary.
On entering the room Gary asks “how long is this going to take as we have been waiting ages and I’ve a lot on today and I’ve parked on a meter.”
As her named midwife you apologise for the delay but explain that “there are a lot of questions at this 1st visit and some blood tests so probably be an hour.”
Without prompts Gary asks “can I answer these questions then to speed her up? My mum and dad are happy about us getting hitched and having a baby, it were planned and my mum and dad have found us a rented flat of our own near and we move there in a few weeks’ time, they’ve paid the deposit and 1st 2 months’ rent as well are going to decorate the flat before we move in so I’ve sorted it all out.”
Gary’s mobile phone rings and he leaves the room to answer the phone. Candice is clearly agitated. She says “sorry for Gary being a bit off with you.. he does have a lot on at the moment…… also my mum and him had a big row this morning before we set out. She wanted to come today instead of him. She bought me a nice top to wear today and some baby bits but he said we didn’t want them as she always buys cheap stuff. I’m going have to ring her later when he goes back to work – she was really upset.”
You state that Candice can choose who she wants to attend visits and when she is in labour and you show her a copy of a birth plan. She says “well ideally I want my mum and Gary to be there at the hospital when I have the baby and at the scans.”
Gary enters the room and overhears this and says “am not happy about that idea…its either just us two as we are the kids parents ……. don’t see why Candice’s mum should have the privilege of being at the birth when my mum is paying for everything for us so by rights if anyone’s mum should be there it should be mine.. ….also as we will be living that side of town by then near my parents my mum could drive you there ……your mum would have to get 2 buses and she don’t even have credit on her phone most days……. and my mum might end up looking after the kid if you have to retake your exams if you fail them so you can get a job and earn money of your own.”
Candice becomes very upset. Gary says”he has to leave anyway as his dad needs some equipment delivered.” He says he will return in an hour for Candice “so he hopes you’ re done by then” and leaves the clinic.
Using a PISCES model think of one thing that may affect each of the following in relation to Candice’s wellbeing:
PHYSICAL
INTELLECTUAL
SOCIAL
CULTURAL
EMOTIONAL
SPIRITUAL
- Using the latest NICE Guidelines identify what are the key things the midwife needs to ask when Candice “books” with you as her community midwife?
Review NICE guidelines Clinical guideline [CG62]
Antenatal care Quality standard [QS22]
- Who else in the MDT could the community midwife refer her to for support?
- What other multi-disciplinary agencies could the community midwife encourage Candice and her family to contact to support them?
- What specific health education/health promotion topics should you highlight to Candice today in light of her occupation?
- What additional Health Education/Health promotion issues do you need to highlight today?
- What specific guidance is there to pregnant women in regards to lambing season?
- What blood tests will be offered to Candice today?
Candice states “that is the only thing worrying her is that she hates giving blood and has a needle phobia” when you started discussing blood tests.
- What resources are available to you to help allay her anxieties today?
After a subsequent scan in her pregnancy Candice is obviously anxious when she rings you after her appointment at the hospital stating that she overheard someone at the hospital tell another midwife “that her baby is really small and she heard something about the baby being called growth retarded.”
- What would your plan of care be once she has contacted you today?
Candice has an uneventful pregnancy although is reviewed regularly at the local hospital re growth of the baby.
Candice births a baby boy, Alfie, at 38 weeks. Alfies birth was quick and the CTG trace showed fetal distress and there was meconium stained liquor at ARM hence an assisted birth by instrumental delivery with an episiotomy.
Alfie weighs 2.9 Kgs and both Candice and Alfie are transferred to the community early on day 3.
She decided to move back in with her mum, Anna, after returning home from the hospital to help her with the baby – she plans to stay at least a week. Gary is really busy at work as “she delivered early and he was planning to have completed this big job out of town before the baby came” so he is happy with this arrangement. He is really upset that he missed the birth though and Candice returns to this a number of times in conversation in the week after the birth.
She has read that it is important to breast feed so is really keen to “make it work, even though her friends have either never tried or given up after a week.”
- What help can you offer re positioning in light of Candice experiencing perineal discomfort?
On day 5 when you visit you note that there are clearly tensions between mother and daughter. On further discussion it appears that they disagree about childcare.
You think it is important that you speak to Candice alone without mum present. Candice is “angry as she keeps interfering. She wants me to bottle feed so she can take over and she keeps putting Alfie down on his tummy and I’ve told her thats wrong nowadays and then I turn him over and then he wakes up – its doing my head in .”
- What resources are available to you to explain safe sleeping practices to Anna?
- What evidence do you have to support your advice?
As the 1st antenatal visit as the named midwife you will be expected to offer and carry out a number of tests and procedures today.
The last LNMP for Tiffany was 1st July 2019.
However she says that really she is unsure and sometimes her cycle has been as long as 35 days between her periods.
Calculate her EED?
Calculation of BMI:
BMI=weight in kilograms
(Height in metres)2
Her height is 157cms
Her weight today is 63Kg
This is classed as overweight.
- What are some of concerns re being overweight and pregnant?
- What are some of the possible reasons for being overweight?
Review NICE guidelines Clinical guideline [CG62]
Antenatal care Quality standard [QS22]
- What are some of the possible reasons for being overweight?
On further discussion Tiffany is very conscious of her weight and shares that she has suffered from bullying in the past.