Potential Effects of the Various Alerts Identified during an Antenatal Clinic on the Client and Her Unborn Child - Case Study Example

Case Study Essay Name: Institution: Date: Case Study Essay Introduction Most women who undergo domestic and family violence or abuse often have numerous and complex needs such as mental health issues, alcohol and other drug problems, child protection challenges and extensive histories of trauma and abuse, among others. Even though these concerns are normally interconnected (as contributory, causal, or resultant factors) health service actions to address these varied needs are frequently fragmented, demanding women to seek multiple services to access the support and care they require. On the other hand, the complexity of the client’s needs is also challenging and demanding for health service providers who specialize in one particular area, since their efforts to support and care for the client with complex needs may correlate directly with or be contingent upon another practitioner’s efforts with that same client. The challenge for the health practitioner dealing with a client with complex needs increases if that client is pregnant, whereby any efforts of support and care must also extend to the unborn child. As such it is imperative that the health service practitioner develops an effective identification and understanding of the complexities inherent in the client’s experiences so that they can be addressed with minimal fragmentation and discontinuity. In essence the health practitioner should apply critical thinking in all adopted interventions in order to provide an integrated and collaborative response and ensure that the client’s safety is prioritised (Newbigin & Leggett, 2009). This paper is a case study of a thirty six year old pregnant woman with complex needs. The paper will apply critical thinking to evaluate the potential effects of the various alerts identified during an antenatal clinic on the client and her unborn child. Further, the paper will discuss the appropriate support and care interventions to address the identified alerts as well as the possibility of inter-agency or collaborative care. Moreover, the current paper will also analyse the importance of the application of the Partnership Model in this case. Case Summary Josie is a 36 year old woman who is attending antenatal clinic at 22 weeks gestation to have her history collected. During this session, the midwife is alerted to a number of issues that Josie reveals about herself. Josie has had three term pregnancies with spontaneous labours and births, among which one birth occurred when she was sixteen and was forced to relinquish the baby for adoption and has had no contact. Josie has also had one termination of pregnancy. Josie smokes an average of thirty cigarettes per day and binge drink half a bottle of liquor weekly, which she says she has stopped since she realised she was pregnant. She also has a history of anxiety and depression which was last treated in 2010, but is under the care of a psychologist. Josie was also sexually abused as a child. In addition, Josie lives with her two teenage children, has a BMI of 42 and has a history of anaemia that was treated with oral iron supplements. At the end of the interview, Josie confesses that she is overwhelmed and requested to attend the midwives clinic where her midwife can tell her what to do in her pregnancy. Potential Effects of the Identified Alerts on Josie and Her Foetus/Newborn Baby According to the case summary, the leading issues of concern in Josie’s case include smoking, alcohol bingeing, anxiety and depression, obesity, anaemia and her overall mental status as influenced by her abuse, bringing up teenage children and the unwilling adoption of her first child. Research has shown that smoking during pregnancy has severe implications on the health of both the mother and the unborn child. Particularly, convincing evidence has been gathered and published on the contributory effects of pre-pregnancy and pregnancy exposure to tobacco and nicotine on numerous reproductive and obstetric syndromes. Such conditions include delays in conception, placental pathologies1, ectopic pregnancy2, stillbirth, preterm delivery3, low birth weight 4and Sudden Infant Death Syndrome (SIDS)5. Further, various studies have also revealed that maternal smoking is associated with emotional, cognitive, temperamental and behavioural difficulties all through the life of the child. Particularly, issues most closely linked to MSDP include negativity, attention disorders, difficult temperament, hyperactivity, and behavioural problems6 , as well as issues of substance use problems as well (Button , Maughan, & McGuffin, 2007). Moreover, during early infancy, some studies have linked MSDP to infant irritability, variations in crying behaviour and soothability (Stroud , et al., 2009). According to Stroud, et al. (2009), neonates exposed to heavy maternal smoking (more than 20 cigarettes per day) exhibited more irritability as compared to unexposed neonates or neonates exposed to moderate maternal smoking (Stroud , et al., 2009). Additionally, babies exposed to both heavy and/or moderate maternal smoking were found to be more hypertonic in comparison to unexposed neonates. Indeed, according to studied, continued heavy smoking in the case of Josie increases the risk for morbidity and mortality for both mother and child (Canals Sans, Hernández-Martínez, Val, & Subías, 2012). Another issue of concern in Josie’s case is alcohol bingeing. Even though Josie says that she has stopped drinking since she discovered her pregnancy, this does not guarantee abstinence hence the concern. Alcohol use during pregnancy has been linked with a variety of adverse impacts on the growth, cognitive development, and behavior of the exposed neonate. Indeed, significant research has identified three main levels of prenatal exposure to ethanol associated with the quantity of alcohol consumed. Specifically, exposure to heavy drinking (above 48–60 gr. ethanol/day) may result in foetal alcohol syndrome; exposure to mildly high drinking (24–48 gr. ethanol/day) that may result typically in “alcohol effects” and binge drinking occasions (overall more than 90 gr. ethanol/drink) (Martinez-Frias , Bermejo , Rodriguez-Pinilla , & Frias , 2004) . According to Ornoy and Ergaz (2010), the quantity of alcohol consumed, the duration of phase using alcohol and the embryo and foetus developmental stage at exposure mediate the impacts of alcohol intake on the growing foetus (Ornoy & Ergaz, 2010). Additionally, alcohol ingestion, even in moderate quantities, is also related to an augmented risk of spontaneous abortions, particularly in the first trimester (Eriksen, et al., 2012). Moreover, maternal alcohol consumption may be correlated with cognitive dysfunction behaviours including declined learning abilities, attention disorders, probability to plan and organize as well as inability to deduce cause -and-effect functions (Hepper, Dornan, & Lynch, 2012). Consequently, the health practitioner in Josie’s case must ensure that she does not resume alcohol consumption during the rest of her pregnancy especially due to the fact that she also smokes heavily. The other issue of concern in Josie’s case is her history of anxiety and depression and the fact that she is off medication. Josie has been off her medication for almost two years and it is likely that the pregnancy might lead to a relapse or further complicate her mental status. Moreover, signs of a relapse are already manifesting as indicated by Josie’s confession of feeling overwhelmed. Indeed, considerable research literature has pointed to a link between prenatal maternal psychological distress and negative foetal, neonatal and obstetric outcomes (Alder , Fink , Bitzer, Hösli, & Holzgreve , 2007). According to Schetter and Tanner, (2012) prenatal maternal anxiety and depression may lead to an increased risk of spontaneous pre-term births, low birth weight as well as adverse effects on foetal neurodevelopment (Schetter & Tanner, 2012). Further, Dawe et al. (2012) found that prenatal anxiety and depression at 18 and 32 weeks had significant effects on the cardiovascular development of offspring in a longitudinal study (Dawe, et al., 2012). In addition, prenatal maternal anxiety and depression has been attributed to increased risk of child maladjustment and the occurrence of depression among the offspring especially at ten years of age or teenage (Barker, Jaffee , Uher , & Maughan , 2011). Further, Josie’s history of anaemia is another issue of concern that may lead to negative outcomes for her, and her unborn child. Perinatal maternal anaemia is commonly regarded as a risk factor for poor pregnancy outcomes and can often result in adverse complications that jeopardise the life of both the foetus and mother (Scholl , 2005). Such complications may include preterm birth, restricted foetal growth, low birth weight and perinatal death (Ren , Wang , Ye , Li , Liu , & Li , 2007). Further, anaemia has been linked to augmented risks of maternal death and a number of maternal complications, such as infection, preeclampsia, pregnancy‐induced hypertension, eclampsia, premature rupture of foetal membranes and postpartum depression (Ahmadoom, Kalsoom, Sughra, Hadi, & Imran, 2011). Josie’s’ body weight is also another issue of concern. From the case summary, her BMI is 42, suggesting that she is obese, which may have potentially adverse impact on her pregnancy as well as the foetus. Josie’s obesity may be attributed to her mental issues particularly depression as well as heavy smoking. Indeed according research, a high BMI (> 30) increases the risk of pregnancy complications such as pre-eclampsia7, gestational diabetes8, hyperlipidaemia9 ,overweight babies, lower apgar score, still births, gross congenital malformations10, and infections (kidney, bladder or wound) (Briese , Voigt, Hermanussen, & Wittwer-Backofen, 2010). A high BMI also presents challenges in monitoring of foetal development through ultrasound and foetal heart monitor. Moreover, maternal obesity may also present challenges in epidurals11, lead to emergency caesarean delivery, shoulder dystocia, thromboembolism and heavy bleeding after delivery (Lakhanpal, Aggarwal, & Kaur, 2012). Lastly, another issue of concern is Josie’s overall mental health status which she appropriately sums up as ‘overwhelmed’. Concerns regarding Josie’s mental health may be attributed to a number of factors including childhood sexual abuse, giving up her child for adoption and raising teenage children. Specifically, these factors may have been the underlying causes for her anxiety and depression and in the current states, may lead to even more adverse mental outcomes. Indeed, already Josie is feeling overwhelmed meaning that she is having trouble coping with these issues. Moreover, she is looking forward to or depending on her midwife to guide her on what to do, during the pregnancy. Research shows that perinatal maternal mental dysfunction can directly impact a mother’s sensitivity and responsiveness in interactions with her baby. Moreover, perinatal mental dysfunction also has long term effects on the mental health of the child. In Josie’s case this may lead to neglect of self-care and the care of her other children as well as increased smoking or alcohol use and possibly abuse. Care and Considerations Required For Josie to Address These Alerts Notably, each of the alerts identified in Josie’s case have potentially adverse effects on both her health and of the foetus/child. Accordingly, all care interventions adopted by the health practitioner should seek to address each issue, with an aim of improving the overall patient outcomes. The precedent in this case would be to seek collaborative care whereby with the help of other professionals, the practitioner may achieve better outcomes for Josie. Furthermore, primary care objectives should take into consideration of Josie’s contextual factors as well as ensuring that the treatment options suggested are appropriate and supportive. The initial care and management considerations should be to address Josie’s smoking and alcohol bingeing issue. Specifically, Josie needs help to stop smoking and close monitoring so that she does not relapse into drinking. Accordingly, the best approach towards this is by raising Josie’s awareness about the smoking and alcohol drinking concern in a non-judgemental way and emphasizing on the probability of change. The health practitioner should seek to increase Josie’s perception of the risks or implications of not changing, including her safety and that of her unborn child (Newbigin & Leggett, 2009). The rationale is to help Josie make a correlation between her substance use and any mental health and general health symptoms. Further, the practitioner should also help Josie to identify strategies that will help prevent a relapse into drinking and assist her to make the necessary changes in key life areas as required (Newbigin & Leggett, 2009). In addition to counselling, the health practitioner should provide Josie with information regarding additional services including drug and alcohol misuse support services and encourages her to use them according to her needs. Josie’s health practitioner may also, with her consent, refer her to a social worker who may assist her with her issues (RANZCOG, 2011) . Another area of intervention is Josie’s overall mental health in relation of her anxiety and depression history as well as other psychosocial factors such as smoking and alcohol misuse, childhood sexual abuse among others. Indeed research shows that perinatal mental health issues such as anxiety, drug and/or alcohol misuse, depression, and social challenges such as a history of sexual abuse, are critical public health issues and are concomitant with adverse outcomes for women and their children (Johnson, et al., 2012). Further, intervention studies show that perinatal mental health problems can be declined if women and their families participate in appropriate service (Kemp, et al., 2011). In Josie’s case she is already under the care of a psychiatrist though further collaboration is required to enhance her health outcomes. Specifically, discussion with her psychiatrist should evaluate the appropriate physiological or pharmacological interventions and necessary support such as assigning a social worker or non-directive counselling in the context of her home (beyondblue, 2011). Josie also requires extensive psychoeducation and should also be guided on lifestyle issues and sleep, as well as, how these interventions may fit into her daily life. Already josie has exhibited a willingness to seek advice form a professional hence this will help improve her overall outcomes. Pharmacological interventions should be considered according to the EPDS assessment results and patient consent (beyondblue, 2011). Care and management interventions are also necessary to address Josie’s obesity. Accordingly Josie requires glucose tolerance testing to evaluate the risk of gestational diabetes as well as anaesthetic assessment prior to delivery. In addition, Josie should also be under surveillance for the risk of preeclampsia. In addition to these procedures the heath practitioner should evaluate the degree to which Josie understands the risks associated with obesity during pregnancy (Morin & Reilly , 2007). Next the practitioner should provide extensive counselling on the appropriate interventions such as exercise, dietary changes, cessation of smoking and promoting sound mental health. The practitioner may refer Josie to a nutritionist and an exercise physiologist for support on how to alter her weight while pregnant and after delivery (RANZCOG, Management of Obesity in Pregnancy, 2013). Significance of the Partnership Model and Collaborative Care for Josie Collaborative practice is described as the process of communication and decision-making among different health care professionals that allows the application of distinct and shared knowledge and expertise of care providers to synergistically influence the client or patient care delivered. Collaborative promotes patient- and family-centred goals and ideals, offers mechanisms for constant communication among caregivers, enhances staff involvement in clinical decision-making and implementation within and across disciplines, and nurtures respect for interprofessional among care providers. Accordingly, juice’s case requires extensive collaborative care involving professionals such as obstetrician, midwife, exercise physiologist nutritionist, psychiatrist, and social services professionals. This is necessary to address all issues of concern and guarantee a positive health outcome for Josie. Notably, research shows that implementation of collaborative approaches amongst clinical and a range of services offering alcohol and other drug and or justice support directly improves the ability for complex psychosocial and clinical concerns to be effectively addressed (Lee, Keating, de Castel, & Kulkarni , 2010). The Partnership Model involves a professional agreement between the pregnant woman and a midwife during the pregnancy, birth and postnatal period. This care model provides patient centred care and the woman is considered as an equal partner in decision making during this period. This model of care is significant to Josie due to the nature of her psychosocial issues. Particularly, Josie requires close monitoring and help to enable her stop smoking, manage her weight, prevent relapse into drinking and improve her mental health. Accordingly, partnering with a midwife will offer the necessary support she requires to make these lifestyle changes and improve her overall health outcomes. Notably, studies into the partnership model have reported increased satisfaction of childbirth among women and a reduction of interventions (Hatem, Devane, Soltani, & Gates, 2008). Conclusion This paper has examined in detail the issues involved in the care and management of women with complex needs. Specifically, this paper has reviewed the case of Josie a 36 year old pregnant woman who has complex psychosocial needs. Form her initial ante natal history taking a number of alerts are identified including smoking, binge drinking, four previous pregnancies, history of anxiety and depression , BMI of 42, history of anaemia and feelings of helplessness. These concerns present significant risk for Josie and her unborn child and hence require rapid and appropriate care. Among the approaches for care identified is collaborative care with healthcare professionals such as obstetrician, psychiatrist, nutritionist, exercise physiologist and social service professionals. Another significant care approach for Josie is the midwife partnership model which will offer the appropriate support required for Josie to make the necessary lifestyle changes as well as provide continuous care for Josie even after delivery. References Ahmadoom, M., Kalsoom, U., Sughra, U., Hadi, U., & Imran, M. (2011). Effect of Maternal Anaemia on Birth Weight. J Ayub Med Coll Abbottabad 23(1), 77-79. Alder , J., Fink , N., Bitzer, J., Hösli, I., & Holzgreve , W. (2007). Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med, 20(3), 189-209. Barker, E., Jaffee , S., Uher , R., & Maughan , B. (2011). 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