Giving an explanation / Taking Consent

Question 1

What steps must be taken in gaining consent for a laparoscopic sterilization?

Answer 1

1. Review risks and benefits of reversible and permanent methods of contraception as well as information about male sterilization
2. The womans reasons for choosing sterilization.
3. Screening for risk indicators of regret
4. An explanation of the details of the procedure, including anaesthesia
5. The permanence of the operation, and the risks and benifits.

Question 2

Laparoscopic sterilization: What is a laparoscopic sterilization, and what other options are available?

Answer 2

A laparoscopic sterilization is an operation that blocks or seals the fallopian tubes, meaning your eggs can no longer be fertilized by your partners sperm through sexual intercourse. It is suitable if you are sure that you do not want more children, or that you never will want children.

If you are a couple, you should consider both vasectomy and tubal occlusion. Other long term methods of contraception which are reversible include:

• Copper IUD
• Progestogen IUS
• Progestogen Implants

The main advantage of these is that they can be reversed.

Question 3

Laparoscopic Sterilization: what does the procedure involve?

Answer 3

It is performed under general anaesthetic (put to sleep). It can be done at any time in your menstrual cycle, providing you have been using effective contraception right up to the day of the operation. To avoid getting pregnant, contraception needs to be continued until your first period after the operation.

There will be two cuts made, one in or just below the belly button, and one at or just above the bikini line. Once the surgeon has access, the tubes will be sealed off with a “Fishlie clip,” and stiches will be put into your tummy. The operation is ‘day case’ so you’ll be able to go home after it.

Question 4

Laparoscopic Sterilization: How permanent is the procedure? Can it be reversed?

Answer 4

All sterilization operations are meant to be permanent. The chances of an operation to reverse it being successful vary a great deal, and there is no guarantee of success. It is not an operation that is performed by the NHS - you would have to pay for it.

Question 5

Laparoscopic Sterilization: What are the risks and benefits of the operation?

Answer 5

Risks

• Risk of failure: if 1,000 women were sterilzed, over a 10 year period, 2 / 3 would be come pregnant. The chance is higher than with a vasectomy.
• Risk of ectopic: if the operation does fail, it is more likely the pregnancy will be ectopic.
• Risk of regret: particulalry if below 30, and have previously had children
• Risk of operation: bleeding, infection, VTE. Bladder and bowel risk - opening for laparotomy
• Anaesthetic risk: general anaesthetic

Benifits

• No need for contraception to prevent pregnancy. If partner changes, you are not protected against STIs.

Question 6

Laparoscopic Sterilization: Any Other Information that is useful to know?

Answer 6

1. You should give yourself plenty of time before making a final decision, discuss with your partner and don’t rush into anything.
2. There is no evidence that having an occlusion affects your sex drive
3. There is no evidence that it can cause problems that mean you need a hysterectomy.

Question 7

What steps should be taken in gaining consent for a Caesarean section?

Answer 7

1. Do you know why you have had a caesarean recommended? / Why do you want to have a caesarean?
2. What the procedure involves
3. Risks
4. Benefits
5. Future pregnancies

Question 8

Caesarean section: What does the procedure involve?

Answer 8

1. Usually performed under epidural or spinal anaesthesia; this means injecting anaesthetic into the back to cause numbing in the abdomen and legs but keeping the mother awake. A partner is usually able to accompany you into the operating room. You’ll be able to meet with the anaesthetist before-hand to discuss any questions you have
2. Clean the abdomen, and make a cut across your abdomen about 1-2 inches above the pubic hair line. This gives access to the womb, allowing the baby and then the placenta to be delivered.
3. Sew up. Operation usually takes less than 30 minutes once the anaesthetic is working.

Question 9

Caesarean section: what are the risks?

Answer 9

With every surgical operation, we tell you the risks that are most likely, and those that are most serious. These have to be balanced with the risks of alternative treatment, including no treatment.

Common

• Infection of the womb: 5 in 100 for a planned caesarean, antibiotics given before operation to reduce risk.
• Infection of wound: 5-7 in 100, usually 4-7 days after the operation
• Excessive bleeding during the operation requiring transfusion: 1 in 100
• Discomfort for a few months after surgery 9 in 100
• Re-admission to hospital 5 in 100
• Risk to fetus: birth trauma is rare. Temporary respirartory problems are more common, because the baby is not squeezed through the vaginal canal, which reduces the reabsorption of fluid in the infant’s lungs.

Uncommon but serious

• VTE: 2 in 1000, 4x higher than in live births. Will give stockings, and if necessary medication to reeduce risk
• Injury to bladder / bowel / ureters: 2 - 3 in 1,000. Rare, but if it happened we would have to open up and repair any damage that has been done.
• Emergency hysterectomy: 7-8 / 1,000: rare
• Death: 1 - 12,000 rare. Very rare.

Question 10

Caesarean section: What are the benefits of the operation?

Answer 10

Advantages of a planned caesarian section include:

• Know exactly when the baby will be born, making issues related to work, childcare and help at home easier.
• Avoids possibility of a post-term pregnancy
• Reduces unknowns such as how long the labour and delivery will last
• Reduces injury to the pelvic muscles and tissues, and the anal sphincters.

Question 11

Caesarean section: What are the implications for future pregnancies?

Answer 11

1. Increases likelihood of requiring a C/S in future pregnancies, even if a vaginal delivery is attempted
2. Increases risk that the placenta will attach to the uterus abnormally in subsequent pregnancies, which can lead to serious complications
3. Cutting the uterus weakens it, increasing the risk of rupture in future pregnancy. This risk is small (2-7 in 1,000) and depends upon the type of cut made.

Question 12

What steps should be taken in breaking a diagnosis of Pre-Eclampsia?

Answer 12

1. Gain patients knowledge of condition / pre-conceptions / how much they would like to know about it
2. What is pre-eclampsia, why do I need to know about itand what are the symptoms
3. What are the risks of pre-eclampsia to baby and mum
4. How is pre-eclampsia monitored, and what happens next?
5. What happens if I develop severe pre-eclampsia
6. What happens after the birth, what are the risks to future pregnancies?

Question 13

Pre-eclampsia: What is pre-eclampsia? Why do I need to know if I have it, and what are the symptoms?

Answer 13

A condition that usually occurs after 20 weeks of pregnancy. It is a combination of raised blood pressure (hypertension) and protein in the urine (proteinuria). The exact cause of it is unknown.

Often there are no symptoms; it may be picked up at a routine antenatal appointment when blood pressure and urine is tested.

It is common and effects 2-8% of women during pregnancy. IT is usually mild, and normally doesnt have a big impact on pregnancy. However, in a small number of people it can develop into a serious illness, which can be life threatning illness. Around 1 in 200 women develop severe pre-eclampsia during pregnancy, and symptoms tend to occur late on in pregnancy. Symptoms include:

• Severe headache that doesn’t go away with pain killers
• Problems with vision, such as blurring, or flashing before the eyes
• Severe pain just below the ribs
• Heartburn that doesn’t go away with antacids
• Rapidly eincreasing swelling of face hands or feet
• Feeling very unwell.

These are very serious, and you should seek help immediately.

Question 14

What are the risks of Pre-Eclampsia for baby and mum?

Answer 14

Mum:

• In the most severe cases, pre-eclampsia progresses to convulsions or seizures just before or just after the baby’s birth. This is rare, occurring in 1 in 4,000 pregnancies.
• Stroke due to high blood pressure
• Progression to HELLP: liver and kidney damage with bleeding problems

Baby

• Pre-eclampsia affects affects the development of the placenta (afterbirth), which may prevent baby growing as it should. There may also be less fluid around baby in the womb.
• If the placenta is severely affected, the baby may become very unwell, and in some cases may die in the womb. Monitoring aims to identify those who are most at risk.
• Increased risk of placental abruption, heavy blood loss.

Question 15

How is pre-eclampsia monitored? What happens next?

Answer 15

Monitoring:

• Keep an eye on your BP and protein with twice weekly visists.
• Scan baby 2 - 4 weeks, and more if there are any signs of compromise
• If there are signs that it is getting worse, admission to hospital will be needed.

Medication (control symptoms, cannot cure)

• Anti-hypertensives (note: use nifedipine or labetalol, both are safe in pregnancy)
• MgSO4 drip if in danger of eclampsia
• Steroids for fetal lung maturation if necessary

Conduct of delivery

• Delivery is the only way to cure PET. Timing will depend on how the condition is progressing, which can be quite unpredictable.
• Mild: induction at 37 weeks, vaginal delivery.
• Moderate: induce at 34 - 36 weeks.
• Severe: C-section, regardless of gestation.

Question 16

What happens if I develop severe pre-eclampsia?

Answer 16

If it becomes severe, we will deliver the baby, irrespective of the gestation - this will be handeled by a specialist team. Whatever happens, we’ll try to balance the risks so that the best outcome is achieved, and as far as possible our plan takes steps to minimise the risk of severe complications.

Question 17

Pre eclampsia: What happens after the birth, what are the risks to future pregnancies?

Answer 17

• Pre-eclampsia usually goes away after birth. However, complications can still occur in the first few days, so you will continue to be monitored, and you may need to continue taking medication to lower vlood pressure.
• If baby is born early, or is smaller than expected, they may need to be monitored. There’s no reason why you shouldn’t breast feed.
• Overall 1 in 6 who have had pre-eclampsia will get it again in future pregnancy.

Question 18

What steps are taken in explaining HRT?

Answer 18

1. Review where patient is with symptoms / treatment, how much they understand, how much they’d like to know.
2. What HRT is? Why do they need it?
3. What are benifits?
4. What are the side effects?
5. What are the risks?
6. What are the alternatives?
7. Discuss the options together, and decide which would be most suitable for you.

Question 19

What HRT is? Why do they need it?

Answer 19

HRT is replacement of hormones that ‘drop off’ during the menopause, most imporrtantly oestrogen that your ovaries no longer make after hte menopause. It aims to reduce the symptoms of the menopause, both in the short term and minimize some of the longer term risks.

Question 20

HRT: What are the benefits?

Answer 20

The principle benefits are easing symptoms of the menopause, and reducing the risk of osteoporosis:

Menopausal Symptoms:

• Reduces hot flushes and night sweats within a few weeks
• Reverses changes around the vagina and vulva usually within 1-3 months, but can take up to a year in some cases. This means HRT can:
  
  • Improve vaginal dryness
  • Improve discomfort during intercourse
  • Reduce recurrent urine infections
  • Improve any frequency of passing urine.
• Some evidence suggesting improvement in mood and sleep
• May improve joint aches and pains

Reduced risk of osteoporosis

5-6 fewer fractures per 1,000 in 55-60 age group for those on HRT.

Question 21

HRT: What are the risks?

Answer 21

There has been media attention surrounding the risks of HRT, particularly with relation to breast cancer, but are comparatively small risks. The effects of HRT have been studiend in over a million women worldwide, and show that for most women it is safe, and works:

• Breast cancer: worse with combined rather than oestrogen only HRT. Actual risk equates to one extra case per year, per 1,000 women taking HRT.
• Clots in legs / lungs: combined patch has approximately 5 extra per 1,000 over a five year period. Contraindicated in people who have a history of VTE.
• Stroke: small increased risk, but not in women under 60
• Cancer: no risk of endometrial Ca when taking combined HRT. Possibly very small increase in risk for ovarian Ca, which reduces following cessation of HRT.

Contraindication to HRT

• History of endometrial, ovarian or breast cancer
• History of blood clots
• History of heart attack, angina, stroke
• Uncontrolled high blood pressure
• If you are being investigated for abnormal vaginal bleeding

Question 22

HRT: What are the alternatives?

Answer 22

Women choose alternatives because they want a treatment for one particular symptom, they have concerns about the safety and side effects of HRT and believe other treatments are safer, or would prefer a non-medical treatment. There are over 200 non-medical treatment, with different levels of evidence to show that they work and are safe:

Treatments that work and are safe:

• Lifestyle choices:
  
  • Regular exercise (running or swimming)
  • Low intensity exercise (yoga) may reduce hot flushes and improve general well being
  • Reducing caffeine / alcohol intake may reduce hot flushes and night sweats
• Vaginal lubricants and moisturisers
• St John’s Wort appears to be effective in treating depression during the menopause, but can interfere with other medications. It is not proven to help with hot lfushes

Treatments requiring more information

• Include androgens, which may improve sex drive but have unproven long term sequale

Question 23

HRT: What are the options available? What will be the most suitable for you?

Answer 23

Options vary by method of administration, and how the HRT works:

Method of delivery (based on patient preference for compliance)

• Tablets
• Patch
• Cream

HRT Cycle

Progesterone

• Cyclical - 1 bleed every month, or 1 every 3 months
• Continuous - amenorrhoea

Generally, cyclical progesterone, or IUS + oestrogen are given perimenopausally, and continuous combined is given post-menopausally.

Question 24

What are the possible side effects of HRT?

Answer 24

• In the first few weeks some women develop sickeness, breast discomfort or leg cramps. These tend to go away in a few months if you continue to use HRT.
• Some women have more headaches or migranes when they take HRT
• Dry eyes are also thought to be more common in HRT users
• HRT is not contraceptive

Question 25

What steps are taken in discussing a twin pregnancy?

Answer 25

1. Summarise where investigations have got to so far, break news, initial patient response, outline plan to proceed:
2. Information about twin pregnancy, how care is different from a singleton pregnancy
3. Inform about risks of a twin birth
4. Infor about delivery considerations
5. Inform about help available

Question 26

Information about twin pregnancy, how care is different from a singleton pregnancy.

Answer 26

Information about twins

• About 1 in 80 births from natural coneption are twins, and 1 in 4 from IVF.
• There are two different types: identical, or non-identical. Non-identical twins are as genetically different as two babies born at different times. The type of twin can usually be worked out from ultrasound.
• About 1.5 per hundred babies born are twins. It is common to have twins, and birth centres have experience dealing with it

How is care different? What should I be doing differently?

• You will feel more tired and need to rest more, and you may need to stop working earlier than planned. You are more likely to need iron tablets; remember to ear a good balanced diet, with plenty of fruit and vegetables, but try not to eat for two!
• You will be seen more frequently, and will have shared care between community midwives and a hospital doctor. If twins are identical, there you will have more frequent USS from 16 weeks, if non-identical you will have more regular scans from 28 weeks.

Question 27

What are the risks of a twin birth?

Answer 27

Lots of women have uncomplicated pregnancies, and healthy babies - 11,000 sets of twins were born in England in 2010. However, there are risks involved. These include:

Maternal risk

• Symptoms of pregnancy: vomiting, heartburn, backache, ankle slweeing, varicose veins
• PET (high blood pressure)
• Gestational Diabetes
• Anaemia

Risk to pregnancy

• One twin can ‘vanish’ (in identical twins)
• Risk of late miscarriage
• Risk of prematurity: 40% deliver before 36 weeks
• Fetal malpresentation
• Fetal distress more common
• Bleeding after the birth more common

Question 28

What does having twins mean for delivery of the baby?

Answer 28

Delivery will be discussed further nearer to the time, and when we know more about how the babies are developing. Generally, twin deliveries are more likely to require an intervention:

• If the first baby is head down and there are no problems, a vaginal delivery may be tried if that is your choice. Sometimes the second baby may change its position, and a C/S is the safest option.
• Usually delivered earlier:
  
  • 34-37 for identical twins
  • 37-38 for non-identical twins
• Epidural is often recommended as the pain releif.
• There will be a lot of people present for the birth, as baby doctors as well as obstetricians will have to look after the first baby, and get ready for the second.

Question 29

What help is available during / after a twin pregnancy

Answer 29

More information is available at TAMBA - the twin and multiple birth association (if they have access to the internet) which contains practical information about both pregnancy, parenting and financial aspects of having a twin birth.