Lecture JW Multiples Diagnosis and Antenatal Care 11 March 2025

Notes to look back at lecture slides for:

• Te whatu Ora referral guidelines 2023

• further learning recommended by reading additional sources

Understanding Multiple Pregnancy Support

• Awareness of Needs

  • Pregnant individuals may require support during the first trimester.

  • Symptoms like nausea, vomiting, and tiredness can vary greatly from previous pregnancies.

  • It's crucial to identify those needing assistance who may not realize it themselves.

Folic Acid Supplementation

• Folic Acid Importance

  • Folic acid is essential during pregnancy, particularly during the first trimester.

  • The Ministry of Health guidelines recommend higher doses for multiple pregnancies.

  • Standard supplementation: 800 micrograms but may need to increase to 5 milligrams for twins.

• Consultation with Healthcare Team

  • If there's resistance to increasing dosage, it's essential to discuss with healthcare team members.

• Guideline Sources

  • Information is based on evidence and various guidelines including Ministry of Health and other health authorities.

Special Considerations in Diabetes

• Folic Acid and Diabetes

  • New guidelines under review suggest those on insulin should take 5 milligrams of folic acid.

  • Other diabetes cases do not yet have confirmed recommendations.

Care Protocols and Monitoring

• Frequency of Appointments

  • Increased frequency in monitoring is required for multiple pregnancies.

  • Discuss care schedules with both midwifery and obstetric teams.

• Transition of Care

  • Midwives should collaborate with specialists to determine care frequency and ensure it meets health needs.

Complications Associated with Multiple Pregnancies

• Health Risks

  • Conditions such as placenta previa and placental abruption are risks that need close monitoring.

  • Increased risk of pre-eclampsia due to higher strain on the body with multiple fetuses.

• Management of Complications

  • Prophylactic antibiotics are recommended for labor if membranes rupture before 37 weeks, due to risk of group B strep.

Ultrasound and Monitoring Guidelines

• Ultrasound Scans

  • Initial scans provide crucial information about multiple pregnancies and should happen between 11 to 14 weeks.

  • Regular growth scans are necessary to monitor twins and potential complications.

• Diagnosis and Referral

  • Early diagnosis of conditions such as twin-to-twin transfusion syndrome should prompt a referral to specialized care.

Patient Autonomy and Documentation

• Informed Choice

  • Patients have the right to make informed decisions regarding their care, including declining certain options.

  • Documentation should follow protocols if patients choose paths contrary to typical guidelines.

• Risks and Benefits

  • Practitioners must discuss the risks and benefits of maintaining midwifery care versus referral to specialist care.

Reference Materials and Guidelines

• Referral Guidelines

  • The referral guidelines serve as essential resources for managing complications during multiple pregnancies.

• Induction of Labor

  • Uncomplicated mono-chorionic twin pregnancies typically induce at 36-37 weeks, while di-chorionic pregnancies may induce at 37-38 weeks.

Midwifery Practice and Collaboration

• Consultation with Colleagues

  • Engage with fellow practitioners regarding experiences and management of multiple pregnancies.

• Documentation and Accountability

  • Ensure proper documentation when a patient opts out of typical care recommendations.

Antenatal Key Points for Multiple Pregnancy

Complications with Twin Pregnancy

• Increased risk of complications such as placenta previa and placental abruption.

• Higher likelihood of pre-eclampsia due to the body handling multiple fetuses.

Ultrasound Requirements

• Initial scans are crucial and should occur between 11 to 14 weeks to gather important information.

• Regular growth scans are necessary to monitor the development of twins and to identify potential complications early.

Woman's Birth Plan

• Discuss the woman's birth plan, considering her preferences and any changes due to her multiple pregnancy.

• If she expresses a desire for no or minimal intervention during labor, discuss the implications.

• Inform her about the benefits and risks of a natural birth versus induced labor, especially in context with multiple pregnancies.

Recommendations

• If the woman prefers no or minimal intervention, discuss pain management techniques that align with her choices.

• Offer education about the potential need for induction, especially based on growth scans or any signs of complications.

• Explore birthing positions and support systems that align with non-interventionist choices.

Changes in Plans?

• Consider how her plans might change based on ongoing assessments, complications, or advice from her healthcare team.

• Encourage regular discussions with midwifery and obstetric teams to ensure her birth plan is safe and appropriate for her situation.