When we think of pregnancy we imagine rounded bellies nurturing the baby within, expectant mothers adorned in flowing dresses with cascading hair and glowing skin.
For those people who want to have children pregnancy is idealised and we anticipate nine months of radiance and happiness shared with family and friends whilst daydreaming of what the baby will look like, what their little personalities will be and how amazing it will be to have a ‘mini-me’ running around.
“Traumatic, lost, isolated, broken, distraught” are not the words we associate with pregnancy but it is the reality for approximately 15,000 women per year across the UK where these words go some way to describe the devastating medical complication of pregnancy; Hyperemesis Gravidarum (HG). At a time in life where they are expecting to feel happy, optimistic and have the ‘pregnancy glow’ people with HG are instead suffering with; crippling nausea, sickness up to 50 times per day, dramatic weight loss, being house or even bed bound and struggling to eat or drink.
The people that contact the Pregnancy Sickness Support helpline are often in a great deal of distress, overwhelmed and have, in the majority of cases, considered terminating their much wanted pregnancy as they can’t comprehend how they can continue whilst suffering such severe symptoms. Many report being told that there isn’t anything that can be done as this is “a normal part of pregnancy”. Others say their GP’s have told them the medications aren’t safe to take in pregnancy and some even report being laughed or shouted at by their healthcare practitioner and told to try ginger.
You might look at the example above and reassure yourself that you would never behave in this way towards a patient and this type of stigmatising behaviour is thankfully becoming less common but, honestly, have you ever subtlety rolled your eyes when treating a person with HG? Have you ever inwardly sighed when a person tells you they can’t swallow the tablets you’ve provided? Have you ever said to a patient that the sickness should stop by 16 weeks? Have you said that sounds awful and moved on to the next question during a clinic appointment? Or perhaps not you, but a colleague who you left unchallenged in their attitude? These might seem like small things to you but these could be the catalyst for loss of trust in the relationship you have with this patient and reinforces the overwhelming isolation that is experienced by sufferers of this condition.
But we aren’t here to ‘bash’ midwives; we truly appreciate the excellent and skilled care that midwives provide to pregnant women. Rather, we hope to give you an insight, to enable you to understand what women want so that you can develop your practice to benefit your patients. So here are our top tips for supporting and caring for people with HG.
Top tips for midwives
- Reduce sensory stimuli and triggers as far as possible – In particular odours from food, perfumes, coffee and so on but also lighting and noise levels, motion and general interruptions to rest. Women admitted to hospital with hyperemesis gravidarum should ideally be in a side room so as to reduce sensory stimulation.*
- Listen to her: loneliness and isolation may well be a major part of her distress. Believe what she tells you and validate her experience.
- Watch for signs of psychological illness as a result of the condition and refer for assessment as appropriate. Depression is not a cause of hyperemesis but can certainly be caused by it!
- If possible, refer to a physiotherapist to minimise the effects of atrophy from prolonged bed rest
- Measure legs and prescribe TED Stockings to reduce the risk of Deep Vein Thrombosis.
- Ask for permission before discussing food and before mentioning food names in case it triggers symptoms.
- Ascertain the level of sickness by asking what foods and drinks have been tried, what has helped/what has not and taking a thorough history. Encourage her to fill in a daily diary to look for a pattern.
- Be careful if recommending “morning sickness cures” to an HG sufferer; she will have been told innumerable times to try crackers and ginger. It may undermine confidence in healthcare professionals as well as adding to her feeling of isolation. Many sufferers of hyperemesis report that the suggestion of ginger instils feeling of anger and hopelessness.
- Do not challenge what she is or is not eating/drinking; anything is better than nothing (within current recommended guidelines).
- Watch for signs of dehydration, (Ketones are not a sign of dehydration).
- Alleviate any guilt and reassure the mother if she has been unable to take prenatal vitamins. Medication is necessary for severe hyperemesis gravidarum and women should be reassured of the need for safe, effective treatment.
- Remind her to take the pregnancy a day at a time and that the HG will end, even if that is not until delivery.
- Remember that pregnancy sickness is not always a ‘good sign’. There are many cases of women whose HG has continued despite later discovering that the foetus died weeks earlier. Unpublished evidence has shown that women with HG likely to suffer foetal demise (see www.hyperemesis.org/HER-Research). Furthermore remember that many women with HG suffer so badly that they consider termination as their only remaining option.
- Advocate for her to receive appropriate medication.
- Those with prolonged illness and inadequate medical care – e.g., those with greater than 10 per cent loss of pre-pregnancy body weight or those who fail to gain weight for two consecutive trimesters – are at increased risk of serious complications such as pre-eclampsia and pre-term labour. A referral should be made to an obstetrician or assessment unit to check for signs of Intra Uterine Growth Retardation.
- Remember that recovering from HG takes time and that there may be a long-term impact on both mother and baby.
HG is a frustrating condition to manage for healthcare professionals and sometimes people come to hospital and seem so miserable and unwilling to help themselves. It’s because they are utterly exhausted, scared, depressed and feeling guilty, constantly nauseous and desperate for a break in symptoms. Lots of midwives and feel like they can’t help but actually, just being empathetic and supportive of a woman with HG can make the most incredible difference to her miserable experience.
*There are exceptions to sideroom placement such as in the case of epileptic people