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Reproductive health

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The World Health Organization (WHO) defines reproductive health as being a state of complete physical, mental and social well-being (WHO 2015). The concept of reproductive health therefore covers the full spectrum from sexual relationships and contraception through to being able to choose when to become pregnant and how to optimise the chances of a healthy pregnancy and delivery.

This resource, consisting of five assessment questions at advanced level, tests your knowledge of these issues. The advanced level of these questions reflects the fact that they are aimed at people working in an extended role who are also likely to be independent nurse prescribers. Complete the resource, including the recommended reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio. You can save featured articles to ‘My Folders’ and use the ‘Save Reflections’ facility to record activities.

On completion of this resource, you should have an understanding of:

The importance of offering contraception advice for people of reproductive age

The role of the GPN in pre-conceptual counselling

How to assist people with sub-fertility problems

The GPN’s responsibilities when caring for pregnant women

How to support women who have suffered from female genital mutilation to optimise their reproductive health

http://www.who.int/topics/reproductive_health/en/

Focus of women’s health: Preconceptual care

Gillian is 14 years old and has come in to see you about her heavy, unpredictable periods. She expresses an interest in starting on the pill. During the consultation she discloses that her 16 year old boyfriend of 3 months is keen for them to have a sexual relationship and that she feels ready for this. She has discussed this with her friends but has attended alone. What would you do?

The correct answer is to offer counselling and advice then discuss the various forms of contraception, assess her suitability and preferences and arrange access to her chosen method/s, assuming that she has been assessed as being Fraser competent. That being the case, it is not appropriate to insist that she brings an adult with her for a further consultation, although all health care professionals should encourage under 16s to discuss the situation with an adult. Recommending condoms as her only form of contraception would leave her at increased risk of a pregnancy as condoms are often inadequate as a stand-alone method for young people; using a hormonal method with condoms offers the best protection against both pregnancy and sexually transmitted infection, along with potential relief of menstrual problems. While it is true that sexual intercourse under the age of 16 is against the law, health care professionals are not expected to inform police about relationships outside of the age of consent unless there is a suspicion of abuse or coercion.

NICE. Contraceptive services with a focus on young people up to the age of 25, 2014 

https://www.nice.org.uk/guidance/ph51/resources/guidance-contraceptive-services-with-a-focus-on-young-people-up-to-the-age-of25-pdf

http://www.who.int/mediacentre/factsheets/fs351/en/

How much do the healthcare team in the practice understand about Fraser competence? How would reception staff respond to a request for an appointment from a person under the age of 16? Do you have a written policy and is it followed? Discuss this at the next practice meeting.

Question 1

Winnie is 28 years old and has come for an asthma check. She states that she has stopped her preventer and reliever asthma inhalers as she is trying to get pregnant. What advice would you give?

This patient should continue with both inhalers and start taking a folic acid supplement. The British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guidelines (2014) state that pregnant women should continue with their normal asthma treatment before and during pregnancy as poorly controlled asthma may harm both mother and child and the risk: benefit ratio of asthma therapies favours continued use. Regarding folic acid, this should be taken prior to getting pregnant. NHS Choices (2015) explains why and also recommends daily vitamin D for women who are pregnant.

https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2014/

NHS Choices (2015) Vitamins and nutrition in pregnancy 

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/vitamins-minerals-supplements-pregnant.aspx#close

Find 5 women who have recently had a pregnancy confirmed in the practice and see how many were already taking folic acid supplements when they attended to confirm the pregnancy. Consider whether the practice needs to take a more proactive approach to this issue and if so, how you could go about it.

Question 2

Lizzie, age 32, has been trying to get pregnant for 8 months now. She has never been pregnant before. She feels very low as her two sisters got pregnant straight away. She is keen to have investigations but her partner Tim, age 35, has said it is too early and they should ‘let nature take its course’. What would you do?

The correct approach would be to offer counselling and lifestyle advice, and arrange to see this patient again in a few months. NICE guidelines state that over 80% of couples trying for a pregnancy will conceive within 1 year if the woman is aged under 40 years, they are not using contraception and they have sexual intercourse every 2-3 days (NICE 2013). About half of those couples who have not achieved a pregnancy during the first year of trying will be successful in the second year, meaning that 90% of couples will become pregnant within 2 years of trying. NICE recommends that an initial assessment of lifestyle and sexual history should be offered to all individuals concerned about delays in conception. Referral is generally considered after 12 months of trying for a baby without success, although referral may be made earlier for women over 36 or who have other medical problems that make earlier referral desirable – for example, they are undergoing cancer treatment.

http://pathways.nice.org.uk/pathways/fertility

The NICE guidelines include a list of lifestyle areas that should be discussed as part of an initial assessment for people who are concerned about conceiving. Have a look at the guidelines and see what they are and how they contribute to problems conceiving.

Question 3

Charlotte is 10 weeks pregnant and is awaiting her first appointment with the midwife. She attends your ‘first contact’ clinic as she has symptoms of a urinary tract infection (UTI). There is no midwife on the premises and the GP has asked you to see her. You are a qualified prescriber. Urinalysis confirms the presence of leucocytes and is positive for nitrite. What is the best course of action now?

Perhaps surprisingly, the correct answer is to refer this woman back to the GP or midwife. The RCN guidance on the role of advanced nurse practitioners (ANPs) states that only a registered medical practitioner or a practising midwife can provide care for a pregnant woman (RCN 2012). In terms of treating the infection, SIGN (2014) guidelines state that around one in five pregnancies may be complicated by a UTI and that this can increase the risk of miscarriage or premature labour. In this situation, SIGN states that a symptomatic UTI in a pregnant woman should be treated with an antibiotic after taking a urine sample for culture. The choice of antibiotic should be dictated by local guidelines. A further urine culture should be carried out after 7 days to ensure the infection has resolved. However, in line with guidance about treating pregnant women, only the GP should treat this patient in this situation.

https://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003207.pdf

SIGN (2014) Management of suspected LUTI in pregnant women 

http://www.sign.ac.uk/pdf/sign88_algorithm_pregnant_women.pdf

Look up your local guidelines on antibiotic prescribing for UTIs in pregnant women, non-pregnant women, men and children. How do they differ?

Question 4

Patience, aged 24, has been living in the UK for 10 years. Prior to her arrival she was subjected to female genital mutilation (FGM) in her native country. She is now in a relationship but is not yet sexually active. She has got to know you over the years and prefers to see a female as the GPs in the practice are male. She requests advice on her FGM and how it might affect her ability to have full sexual intercourse and bear children. How would you respond?

According to intercollegiate recommendations women who are identified as having had FGM should receive information on the health impacts of the procedure and its legal status in the UK (Royal College of Midwives et al 2013). They should also be offered referral for ongoing medical and psychological assessment and support as appropriate. This must be done very sensitively. According to the WHO, FGM is classified into four main types: 

, which involves partial or total removal of the clitoris; [bold]excision[bold] of the clitoris and the labia minora with or without excision of the labia majora; 

, which involves narrowing the vaginal opening by cutting and repositioning the labia, with or without removal of the clitoris and finally, any 

 mutilating, non-medical procedures such as piercing, incising or cauterizing the genital organs. GPNs should be able to ask sensitively about FGM, using terminology such as circumcision, cutting or closing which may all be more commonly used by lay people. Women with FGM are considered to be victims of crime so referral to the police may be considered, as should any potential risks that children from the same family may face, although it should not be assumed that all women who have experienced FGM will automatically expect the same for their daughters. Issues of consent to share information still apply to women with FGM unless children are thought to be at risk.

Royal College of Midwives, Royal College of Nursing, Royal College of Obstetricians and Gynaecologists, Equality Now, UNITE (2013) Tackling FGM in the UK. Intercollegiate recommendations for identifying, recording and reporting 

https://www.rcog.org.uk/globalassets/documents/news/tackingfgmuk.pdf

http://www.who.int/mediacentre/factsheets/fs241/en/

FGM is often first identified during ante natal care. Does your practice midwife have any experience of dealing with this that she might share with the team? Set up a practice meeting to discuss this issue.

Reproductive health

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