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CASE NOTES
Tuesday 31st May 2005, 9.00-9.30pm
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RADIO SCIENCE UNIT

CASE NOTES
Programme 1. - Pregnancy 

RADIO 4

TUESDAY 31/05/05 2100-2130

PRESENTER: MARK PORTER

REPORTER: CLAUDIA HAMMOND

CONTRIBUTORS: PROF. ANDY SHENNAN
ROY FARQUARSON
ANNETTE BRILEY
SUSAN BEWLEY

PRODUCER: BETH EASTWOOD 
 
NOT CHECKED AS BROADCAST

PORTER
Hello. In today's programme we'll be looking at the complications of pregnancy. The vast majority of women sail through the whole process - but for some, things don't go quite so smoothly, and if you are very unlucky it can mean a long spell on the ante-natal ward.

VOX POPS
I'm 34½ weeks pregnant and I'm expecting twins and my waters have gone on one twin and I'm also bleeding. So I've been here for the last two and a half weeks. All the staff here have been amazing, there's quite a lot of camaraderie amongst people who are in here, you know people are concerned for other people. I actually feel quite safe.

I'm 33 weeks and two days and I'm here because I'm expecting a baby with a heart condition. Being in hospital's been an interesting experience, with a seven week stretch ahead of me, it seems to be dragging on a bit and I have a two and a half year old daughter, so it's very hard on her and I get quite upset because I don't get to see her very often. And I've lost a child before. So for me I have good days and bad days - yesterday was a terrible day. Sometimes it feels like this baby's got no chance of coming home with us either.

I have been here since Friday. It's really hard for me to accept to come in because I've got other children at home to look after and I'm worrying about them while I'm here. Plus you are so anxious because of what they might find, in case your baby's really born early, it's not the bestest of feelings to be in hospital to be honest.

I've become extremely docile, institutionalised as I've been here. After a few initial sort of days of denial and anger I've realised that the best way to sort of survive is just to follow the routine. It's a very, very simple existence here, we're all highly hormonal and difficult to deal with and the midwives are very good to us I have to say. It can't be easy dealing with 30 pregnant ill bad tempered women.

PORTER
Some of the anxious inpatients there on the ante-natal ward at St Thomas's Hospital, London - somewhere that I'm sure will be very familiar to my guest today, Andy Shennan, who is Professor of Obstetrics at the hospital.

Andy, pregnant women who are admitted to hospital must have quite serious complications, we don't like bringing women into hospital unless we absolutely need to. What are the sort of things that you see?

SHENNAN
Well absolutely not, we only bring people in who really need to be in these days, so if they're in they tend to have problems that are of concern. I think if you walk into an antenatal ward there are a number of things women might have, I think the more common ones are things like bleeding, if women have low placentas they really aren't safe to be at home, they may have a large bleed. People at risk of giving birth early, they've either got ruptured membranes or perhaps have been bleeding that causes the early birth. And other things like high blood pressure, Pre-eclampsia, that's a concern and we have to have people in hospital in case something serious happens.

PORTER
We'll talk more about Pre-eclampsia a bit later, let's go to preterm labour - this is where women go into labour early. What's the difference between going into labour and having a miscarriage in terms of timing?

SHENNAN
Well the first thing to say, early miscarriages are extremely common.

PORTER
And by early you're defining those as ...?

SHENNAN
Well certainly before 12 weeks. As you get further on the causes of the miscarriage and the implications of them are different and between that early miscarriage and say up to 24 weeks we still call that a miscarriage, but it is rarer and the reasons may be different and the treatment may be different. Beyond 24 weeks that's really what we call preterm.

PORTER
Are there particular women who are at risk of going into preterm labour?

SHENNAN
I think probably the biggest factor about who we worry about is what happened to them before, so if a woman has had one of these later miscarriages or an early birth we would be concerned that they are at higher risk, although the majority of them will be okay.

PORTER
Well some women who miscarry late, or go into preterm labour, do so because of a weakness in their cervix - that's the narrow lower end of the uterus. As the pregnancy progresses the cervix starts to dilate - something that should normally only happen just before baby is born. Supporting the cervix with a suture or stitch - that's basically a thread that runs around the cervix to keep it closed - can literally prevent the developing baby falling out, as Claudia Hammond discovered when she visited the Miscarriage Clinic at Liverpool Women's Hospital.

JANE
With the first baby I lost at 20 weeks, my little boy Connor, we'd got loads and loads of stuff because we'd got past the 12 weeks and so we'd got a house full of little clothes and nappies and things like that and started thinking about the nursery. And it was just horrendous to have to come home without him to the house full of things, it was just awful. So when I got pregnant with my next baby we just didn't get anything, we didn't want to tempt fate.

HAMMOND
For women like Jane who've had miscarriages at around 20 weeks, one possible solution is to have a cervical stitch, also known as a vaginal stitch, which is what Jane decided to do. Her doctor today is Roy Farquarson, consultant in obstetrics and gynaecology at Liverpool Women's Hospital.

FARQUARSON
It is a single stitch that's inserted around the neck of the womb to close the canal. If all goes well the stitch will last throughout pregnancy and then it's removed at 34-36 weeks and this allows the woman to labour normally and to deliver normally after that.

HAMMOND
Obviously if a woman goes into labour prematurely or if a miscarriage starts, as happened with Jane, the stitch has to be taken out urgently.

JANE
Again around 19 weeks I had a bleed and then I started to have contractions. I mean they tried to leave the stitch as long as possible, obviously because the moment that they remove that stitch the baby's born and doesn't stand a chance of survival at 20 weeks. But I was contracting quite regularly and they got stronger and stronger, so they had to remove it very quickly then because the baby was nearly born actually through the stitch, which would have torn my cervix very badly.

HAMMOND
Jane was unlucky because this type of stitch can work. Success rates vary, partly because in the past it might have been used in women who weren't likely to benefit but times have changed.

FARQUARSON
We know of more reasons why women lose pregnancy. There are two new conditions, for instance, called bacterial vaginosis and Antiphospholipid Syndrome that play a big part in producing a late miscarriage between 12 and 24 weeks. And before that knowledge was available to us everyone thought it was due to weakness in the neck of the womb, hence a lot of unnecessary vaginal stitches were perhaps inserted.

[ACTUALITY]
FARQUARSON

Good morning.

ALICE
Morning.

FARQUARSON
How are you today?

ALICE
I'm fine thank you.

FARQUARSON
And how have you been keeping in early pregnancy?

ALICE
I'm feeling very well.

FARQUARSON
Oh good.

ALICE
Which is great.

FARQUARSON
How unusual. We've got to do a few tests today to establish the length of pregnancy haven't we.

ALICE
Yes.

HAMMOND
Alice is six weeks pregnant and is trying to decide what sort of treatment to have this time, having already tried the vaginal stitch. She could go for a more invasive specialised procedure - the trans-abdominal stitch.

ALICE
I've had quite a number of miscarriages and I've had two premature births at 23 weeks. But at the second one it was my cervix that gave way and although I have in the past had a vaginal suture that didn't work either, so Dr Farquarson believes that having one that's abdominal will be much more successful. It's a balance between the vaginal one and the abdominal one and I have to have one of them so I just thought I might as well have the one that is going to be much more successful.

[ACTUALITY]
FARQUARSON
Shall I go through how we do the stitch?

ALICE
Yes. I want to know how it's better than a vaginal stitch.

FARQUARSON
Right. We feel that the abdominal stitches should be seen as a last resort because ultimately the risks associated with it are very high.

HAMMOND
Only a few specialised centres in the country do this. Women come to the Liverpool Women's Hospital from as far afield as Cornwall and the Isle of Man, but many women never even hear about the procedure. Jane is pregnant again and this time she's had a trans-abdominal stitch put in.

JANE
I had it when I was 10½ weeks pregnant and it's major surgery. They go through your abdomen and it's a similar procedure to a caesarean really and everything's moved out of the way - the uterus, the bowel, the bladder - and then the stitch goes in at the very top of the cervix. So yeah, it was a big procedure and quite a shock really but I did recover quite quickly.

FARQUARSON
The reason it's a last resort is that the complications are considerable and there's always a risk that you could damage the womb, the bladder or the bowel when performing the surgery.

HAMMOND
This kind of stitch is permanent. It stays in place for future pregnancies and the babies must be born by caesarean. This is a rare procedure and even at this centre they only do four to six a year, but they do have patients who've gone on to have two or three babies with the stitch in place. For Jane the chance to try something else has given her new hope.

JANE
My local hospital had said we can't help you and there's no chance that - to actually be said well this is definitely what's wrong and this is how we treat it was just overwhelming relief. We were given a 90% chance of success with this treatment.

HAMMOND
Ninety per cent?  Wow.

JANE
Yeah incredible.

HAMMOND
That's good.

JANE
Yeah, I couldn't believe it when Mr Farquarson said yeah 90% chance it was like crickey.

FARQUARSON
The success rate is 90% and it's remained remarkably stable over the years. All the failures that we've had have been in patients who've also had either bacterial vaginosis, Antiphospholipid Syndrome or both.

HAMMOND
Meanwhile Jane has been in hospital on bed-rest while she waits to see whether this, her fourth pregnancy, might finally bring her a baby.

JANE
I'm 24 weeks and a day.

HAMMOND
Was that a real relief passing that 20 week period?

JANE
Yeah, that was the worst bit, I think around 20 weeks I became quite pessimistic, I couldn't imagine this pregnancy would go past that time but I'm beginning to feel excited but there's the little bit that's still really frightened obviously that things could go wrong. And so yeah I think that we can definitely imagine taking this little chap home, so that'll be just great if that happens.

PORTER
Claudia Hammond talking to Jane at Liverpool Women's Hospital. And I'm pleased to report, that when we checked just before coming into the studio, Jane was back at home and doing well.

Andy, those success rates for trans-abdominal suturing are pretty impressive, how do they compare to the cervical stitch?

SHENNAN
One of the problems here Mark is that even if you had many problems in the past your next pregnancy is likely to be successful, so it's actually very difficult to judge what you're doing to someone is the thing that's making the benefit or whether it would happen anyway. One of the problems with abdominal sutures is, as we've heard, you're never going to have a huge series. Nevertheless if you look at the series that had been published they are impressive and this 85-90% figure is commonly quoted.

PORTER
Presumably techniques like these are mostly used on women who've had a late miscarriage in the past, the only way you're going to find out they've got a problem in most cases is that unfortunately they lose a baby. Do we have to wait until they've lost a baby or is there a way that we can monitor normal pregnancies or perhaps identify women who are at particular high risk and treat them before?

SHENNAN
I mean this is a very important clinical question because actually most babies born early, preterm, come from women who haven't had a problem before, so it would be fantastic if we could find a way of identifying who's at risk. There are lots of factors, like smoking and taking drugs and things like that which predispose to early birth but unfortunately there's no precise test we can do. There are one or two tests now available that are looking promising. Just by scanning the cervix and looking at the length of it will predict who's going to give birth early reasonably accurately, much better than your previous history.

PORTER
A scan when, at what sort of stage are you talking about?

SHENNAN
The most data comes from doing scans relatively early on, round about 23 weeks or before that. One of the problems is, is it's not just a tummy scan, it's actually an internal scan. The other test is just taking a simple swab from the vagina and looking for a protein called fetal fibronectin. Now the problem with those tests, although they're very good, it's the so what factor - even if you know that person's at risk we don't have anything magical we can do to stop the problem. So it hasn't really filtered into normal clinical practice yet.

PORTER
I was interested there in the piece - a sort of throwaway line about infection antiphospholipid, two possible causes for late miscarriage certainly that may have been confused with a problem with the cervix in the past, can you explain a little bit more about those?

SHENNAN
Well certainly infection is very commonly associated with early preterm birth, the serious ones that we're worried about.

PORTER
And what sort of infections are we talking about?

SHENNAN
Well it's a difficult concept because infection really means when you have bacteria or bugs where they shouldn't be, so often it may be perfectly normal healthy bacteria that have just got into the wrong place. Now this bacterial vaginosis condition really means an abnormal mix of bacteria that can be found in the vagina. Now lots of normal women will have it and be perfectly okay but there's no doubt if you have it your risk of giving birth early is increased. And although we do give antibiotics to some women to help this it hasn't been a cure all that we hoped it would be.

PORTER
What about the antiphospholipid?

SHENNAN
I mean antiphospholipid is something which is found in some women who have recurrent obstetric problems, including these mid-trimester loses and we do look for it in cases which we're concerned may have a recurrent cause. And the good thing about it is there are potential treatments for it, by giving tablets or injections that will thin the blood, such as aspirin and so on.

PORTER
Well I want to move on to another problem now that tends to occur a bit later on in pregnancy.

VOX POPS
At the moment I'm 31 weeks plus six days. Basically I'm here because previous pregnancies I had pre-eclampsia, from 28 weeks is the peak time when this Pre-eclampsia starts, so they're having a closer eye on me and I've been getting some hypertension which is part of the Pre-eclampsia. So they're worried and anxious, that's why they're keeping me in hospital for monitoring basically.

Because I'm expecting twins, in addition to seeing a midwife I also saw my obstetrician a bit more frequently and she noticed that my standard sort of urine samples had a trace of protein, even though I had very low blood pressure she asked for additional tests and it was disclosed that I had pre-eclampsia, which can give rise to problems for the mother. I gather she can have a type of epileptic fit or her blood pressure can rise also, things that could happen to me but also the child's at risk because the placenta doesn't function very well. I've been here since the 1st May, I'm exactly 36 weeks pregnant today and I expect to be here until about mid June, I'm hoping to be induced around the 8th.

PORTER
Andy, pre-eclampsia - a common and potentially very serious problem?

SHENNAN
Yes it is potentially serious, unfortunately it still kills women, although that's very rare and the key thing is to diagnosis it and deliver people before they become seriously ill.

PORTER
What are the warning signs that maybe women themselves can spot and we the professionals can look for?

SHENNAN
Well unfortunately a lot of women will feel completely well, even though they have serious disease, so that is why it is very key to measure blood pressure and dip stick the urine every time the woman is seen in pregnancy. That's what we rely on to pick it up in most people.

PORTER
And what are the implications for mother and baby, what's it actually doing to them that should concern us, why do we go looking for it so aggressively?

SHENNAN
It's a funny condition, it affects the whole body, including the baby and many of the organ systems in the mother - so the kidneys, the liver, the brain and so on. So it is a multi-system disease and at its worse, as I've said, can still kill people.

PORTER
So if we don't pick it up the implications for baby are - I mean it affects baby's growth and development? I mean let's assume that it's not really severe, we don't lose baby but baby's impacted in some other way.

SHENNAN
There are two issues there, one is it affects the placenta so the baby doesn't grow, that's not universal but probably more important impact on the baby is the way to cure it is to deliver the baby. And maybe one in five very early deliveries is because of pre-eclampsia.

PORTER
That you're actually inducing or operating on the women in ...

SHENNAN
Exactly, that's the only way to get rid of it.

PORTER
And if you don't deliver the baby what risk are you putting mum at?

SHENNAN
If the disease gets serious it's progressive, it won't go away until that baby is delivered. And ultimately she can have fits or strokes, anything - that is very serious.

PORTER
What about the cause? It's a contentious issue, isn't it, because no one really knows.

SHENNAN
Yes, the disease of theory as it's called, we don't know but we're getting clues now and we now think that the poor blood flow to the placenta causes lack of oxygen, we think that that probably results in free radical release which then damages all the linings of the blood vessel which explains why it's this multi-system disease.

PORTER
And this is so-called oxidative stress and in fact your hospital were looking at using antioxidant vitamins weren't they, back in '99 you published quite a promising paper?

SHENNAN
Yes a small study in about 300 women, much to our surprise we had this huge benefit in women who received these antioxidants - vitamin C and E - that their chance of pre-eclampsia was at least halved, so that's a very promising area where we're going to look further.

PORTER
Well Annette Briley is the clinical trial manger for the Vitamins in Pre-eclampsia Trial - otherwise know as VIP - a new study designed to come up with a definitive answer. Do vitamins help protect against pre-eclampsia or not? VIP is using the same doses of vitamins C and E used in that 1999 trial - that's a gram of C and 400 international units of E - levels that are way beyond any balanced diet!

BRILEY
These are bucket loads of vitamins. To get a gram of Vitamin C you'd need to eat 22 oranges everyday and to get 400 international units of Vitamin E it's a 117 avocados everyday.

PORTER
And how are the vitamins actually working, what's the theory behind their protective effect, if indeed there is one?

BRILEY
We believe that pre-eclampsia is caused by a condition known as oxidative stress and when that happens there's an overproduction of substances known as free radicals, all of us have free radicals and the women would have their own body's defence mechanism in terms of antioxidants and it's the imbalance between one and the other. The way I would describe it to the women is the free radicals are like a crowd of youths, if you've got a few youths they're fine but if you've got a mob then that can be a bit of trouble and the antioxidants are a bit like the police keeping them in check.

PORTER
So you're basically boosting the woman's natural police force?

BRILEY
Absolutely.

PORTER
And the free radicals are produced why? Because of lack of blood flow to the placenta?

BRILEY
Yeah we know free radicals are produced as an end product of oxygen metabolism, so we all have it because we all breathe oxygen in the air but we know that they are overproduced, in the situation of little blood flow.

PORTER
So basically the trial showed an interesting result but not one that you could go out to people and say look vitamins do prevent pre-eclampsia, we should be using them more often?

BRILEY
Well no, the real danger was that clinicians and certainly women who'd had this problem are so desperate to look for something that will prevent pre-eclampsia or at least ameliorate the devastating effects of the disease that they would go out and either the women self-medicate or the clinicians prescribe the vitamins and it was very important that we actually saw whether it was generalisable to the whole population. So the Wellcome Trust funded us to recruit 2,400 women in 23 UK hospitals but we also have ethical committee approval to see women who aren't booked in one of our participating hospitals and we can recruit them as self-referrals with their doctor's knowledge.

PORTER
And they'll be given the vitamins from when?

BRILEY
They'll be randomised to take the vitamins or the placebo from between 14 and 21 weeks and six days gestation and we ask them to take one of each tablet everyday from the time we recruit them until they have their baby.

PORTER
When do you expect to have a result?

BRILEY
Well we're actually recruiting the last few women now, so bearing in mind we've obviously got to wait for them to have their babies, we would hope to have the results in December or early January.

PORTER
Annette Briley who is managing the Vitamins in Pre-eclampsia Trial - and she still is looking for volunteers across the country, so if you are interested do call our action line on 0800 044 044 or visit the Case Notes website via bbc.co.uk/radio4.

Andy, what about safety, those are very high doses of vitamins that you're using in the trial, do we know that they're safe?

SHENNAN
Extremely high doses Mark and I think you've got to realise we're not giving a supplement because of a deficiency, we're actually replacing something that's missing, so it's a reasonable thing to do. We don't know whether these drugs are safe or not, and I call them drugs because I think in this dose we must treat it as a drug, we have to prove that it's okay and one of the things we will do in this current study is find out whether it's safe for the baby and we wouldn't recommend you go out and take these sort of doses, not without close supervision from your consultant.

PORTER
What about other vitamins during pregnancy because there has been some concern about Vitamin A as well, is that something you worry about?

SHENNAN
There are some vitamins like Vitamin A that have been associated with causing problems and we wouldn't recommend you go around eating a lot of liver for example when your pregnant because that can have too much Vitamin A and be dangerous. The supplements you can buy in the chemist and so on know that and they don't have these extra vitamins in and as long as it's a pregnancy recommend supplement that's probably reasonable. But if you have a normal healthy diet you don't need to take extra things, again take advice from your midwife and obstetrician.

PORTER
Well there is another complication of pregnancy that's not so widely discussed - physical abuse of pregnant women by their partners. Dr Susan Bewley is a consultant obstetrician at St Thomas's with a special interest in domestic violence.

BEWLEY
In our research we found that up to 5% of women were in violent relationships, other studies around the world have shown it may be higher than that and certainly that compares with things like pre-eclampsia, blood pressure problem of 2% and diabetes less than 1%.

PORTER
And is pregnancy a particular trigger for domestic violence or are we just seeing a continuation of what's gone on before?

BEWLEY
Some people think it's business as usual but other women have described that pregnancy is when violence first started. Some pregnancies are the result of rape, sexual assault, some relationships are very unstable and it may be that the developing baby presents a threat to a very jealous or dominant man. And certainly the rates of domestic violence have been found to be very highest just after the birth of a baby when a woman's attention is diverted.

PORTER
And the impact for both the woman and baby, what sort of problems is that leading on to that are peculiar to pregnancy?

BEWLEY
From the woman's point of view it can cause terrible problems in terms of self-esteem and confidence, she can have problems with injuries, the assaults can lead to premature labour, ruptured membranes, miscarriage and still birth, plus all the extra complications for the baby.

PORTER
And they're all more common in women who are subject to domestic violence?

BEWLEY
Yes.

PORTER
Because there's a significant risk, I mean if a woman is being beaten by her partner there is a high chance that she could lose her baby.

BEWLEY
That's not actually being measured but yes there is a chance that she can lose her baby, particularly if she receives beatings in the abdomen. There's a small risk that she can be seriously injured or even killed and obviously there are things that are known that if people are pregnant, if people use weapons, threats to kill, strangulation or sexual assault the risk of homicide and death to the foetus will be much higher.

PORTER
And what sort of factors would alert you as an obstetrician to the fact that one of your patients may be being abused?

BEWLEY
I think there are certain presentations where it's a bit more common, if people turn up in premature labour with abdominal pain, bleeding, if women are confused or coming in late after something happened a full two days ago for a check up would be peculiar and I think if women are discharging themselves against advice, missing appointments, things like that, I'd be alert to is something going on at home, it might be a violent relationship, it might be something else but it might be something that's difficult to tell me unless I ask carefully.

PORTER
On your figures we're looking at something like 1 in 20 women may be subject to violence, I mean that's putting it way ahead of problems like gestational diabetes, the sort of problem that we screen for in pregnancy, do you think we should be screening for domestic violence as well?

BEWLEY
I certainly think we need to have a much greater awareness of it and recognise that this may be a reality in women's lives and the reason they're turning up to our clinics or in labour in the middle of the night. In terms of screening I think we should be asking sensitively, there isn't a treatment in the same way that there is for diabetes or pre-eclampsia and I think we must be careful not to be doing more harm than good. But I certainly think we should be asking, finding out, informing women of what they can do about it and where they can go for sources of help.

PORTER
Okay practically, let's assume that we've identified a woman who may be at risk, she admits to that, what can we do to help and protect her and her baby?

BEWLEY
I think the very first thing to do is to listen to her and to recognise that violence is a crime and we can't go in and rescue her from that situation, we can witness it - it's very important that we document what she tells us and document the injuries, that may be relevant to court cases later. We can give her advice about where she can go, she may have a particular issue with housing or immigration or benefits, it may be that she wants to talk to Women's Aid - they're the voluntary provider of the refuge spaces and they do outreach work and counselling over the telephone line. But I think it's very important to recognise that the woman herself knows whether she's safe or not and she must make the decisions about her options when she's ready and when she chooses to. Sometimes we have to offer women to come into hospital because their lives are endangered then and there, so they can think about their options. But there's a variety of things we can offer.

PORTER
Susan, what plans are there to deal with this problem at a national level?

BEWLEY
The Department of Health has issued guidelines to professionals about the training in domestic violence and asking about domestic violence. And the confidential inquiry into maternal deaths has also recommended we must protect the confidential time in midwifery and medical consultations, so that we're able to talk to women alone and raise the subject of domestic violence because it's been associated with maternal death.

PORTER
You mentioned confidentiality there, one of the problems we certainly have in general practice is that we're encouraging the partner to be involved in all of the consultations and it's actually very difficult to get the woman on her own alone to ask her those sorts of questions.

BEWLEY
It is a problem, not merely for this but for finding out lots of private information and we're having to have guidance both from the Department of Health and the confidential inquiry to remind us that all women in all consultations should have some confidential time - that's a very basic building block of our relationship. And although it's been very good for many men to be more involved with pregnancy, birth and looking after children, on the other hand we've made this particular group of women more vulnerable because we can't talk to them alone.

PORTER
Obstetrician Susan Bewley.

Andy, that point about confidentiality is very important isn't it, how do you approach it practically in your clinics?

SHENNAN
It is a difficult area, I think the key thing - as Susan has said - is that you need to be aware of the clues and think of the situation, just think of it. You can manipulate the situation to a degree and obviously there are times when you examine a woman and a partner will leave and you can just ask a quick question appropriately at the right time. You have an absolute requirement to look after the woman who's with you and that includes checking she's safe.

PORTER
But it's all pretty academic isn't it because what we do at the end of the day these days is we drop a note down into the patient records which the patient holds themselves, so if the partner wants to have a look at what you've written how do we get round that?

SHENNAN
You can't document things like that. I think the thing to do is have the conversation with the woman on a confidential level and find out what it is she's prepared for you to write down.

PORTER
So you alert the other healthcare professionals involved by phone or whatever, it's not going into the notes.

And I want to end on a positive note Andy, because we doctors have a rather warped perspective of what's normal for pregnancy because we only actually get involved with the problems but the vast majority of women don't really need our help do they.

SHENNAN
Absolutely, most people enjoy pregnancy and so they should because they're likely to have a normal outcome in modern obstetrics and they can look forward to a happy and successful pregnancy.

PORTER
That's all we have time for, Professor Andy Shennan thank you very much. Next week's programme is all about arrhythmias - common disturbances in heart rhythm that vary from the inconvenient, to the potentially lethal.

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