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.