Angela Bernardi

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Background

Angela is 32 years old and is in clinic to discuss her pregnancy: "I'm 28 weeks pregnant, and I've been seeing a midwife. I really want to have a home birth, and I wanted to talk to a doctor about that." She indicates that she has been cared up to now by a midwife. The dates of her pregnancy were verified by an ultrasound.

This is Angela's fourth pregnancy. The first was in high school and she had an abortion. The second was with her first common-law partner at the time (not her present husband) and her son was born on time, weighing 6 pounds. He is currently 7 years old and doing well in school, living at home with her. Her third pregnancy was 4 years ago. She had a girl with her husband, who was born early (at 34 weeks). She went into spontaneous preterm labour because "there was too much fluid". The baby weighed 2 lbs and 4 oz and had a large spinal cord defect, which was corrected at birth. Her daughter is not able to walk and still needs diapers. Her upper motor control is good; she has no genetic problems but is slightly delayed in her learning. Because she was breech, Angela had a Caesarean-section for that birth. She was not aware that folic acid should be taken to prevent neural tube defects: "Is this something that my family doctor should have done for me?" She knows nothing about a "maternal serum screening test" but is certain that she did not have this during that pregnancy.

Angela has a past history of alcohol abuse but does not drink anymore. Her husband had been quite abusive to you when she was quitting drinking (he is an alcoholic). She and her husband are currently in counseling for this and their relationship. Despite the fact that she has reformed her life significantly, she is angry that she has been feeling a lot of guilt over her daughter's birth as she had been drinking fairly regularly during that time. There was no other drug use, but she feels that her alcoholism is to blame for all of her little girl's troubles.

Angela is a non-smoker and she denies taking illicit drugs. She does smoke marijuana a couple of times a month with old friends. She was on the birth control pill when she became pregnant this time. She admits that this pregnancy was "an accident", but she is not unhappy about it. She was not taking any extra medications at the time she conceived, but she did have a few hangovers that made her feel quite ill (i.e., she vomited the birth control pills up after taking them).

She feels that her preparation for this pregnancy has been sub-optimal from the medical profession. However, she has no problems with her midwife. She had one ultrasound at eight weeks, but none since. She believes that her bloodwork was normal — including an HIV screen that she consented to. She did not have any genetic testing and wants to know what exactly that is, and why she should have it done.

Angela feels that she has made major changes to her life and she have sought the care of a midwife for this pregnancy because of the terrible memories she has of the hospital and the physicians and nurses who cared for her during her two deliveries. In fact, she would like to deliver at home.

Objectives (2003)

Medical:

  1. Pregnancy and Risks
    • Maternal age and medical history
    • What does MSS screening detect / not detect?
    • What does ultrasound detect / not detect?
  2. Premature infant birth (growth, age risks)
  3. Vaginal birth after Caesarean section
  4. Neural Tube Defects (genetic / environmental risks, implication for later pregnancies)

Social:

  1. Home Births and Midwifery
    • Canadian demographics, benefits, risks, cost coverage
    • Physician duty, responsibility and advocacy role
    • What will be your approach?
  2. Alcohol, Tobacco, Marijuana
    • Specific risks of each to pregnancy
    • Couselling patients and public health measures
  3. Abuse
    • Effects physical, verbal, emotional abuse on pregnancy
    • Shelter availability and referral for abused women and women with addictions

Legal:

  1. Discuss "appropriate standard of care" in regard to pregnancy
  2. What is physician responsibility and professional approach when "appropriate standard of care" (by another physician) has apparently not been met
  3. Are high obstetrician's insurance premiums justified?

Objectives (2004)

  • Roles and responsibilties of the midwife, and the regulations involve
  • Language /cultural barriers in physician-patient relationships
  • "Rules" and logistics of home birth
  • Folic accid supplementation (and guilt of Angela after)
  • FAS; marijuana in pregnancy; use of "substances"
  • Birth
  • Stress and pregnancy outcomes
  • Late term abortions
  • Roles of family and specialists (conflict in care?)
  • Responsibility to notify CAS afer birth and life situation (need to vs. want to) huh?
  • Indications for a section
  • Vaginal birth after section? home birth?
  • Care needs for Angela's child at home

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