Ebook Murtagh''s patient education (6th edition): Part 1

Murtagh’s
PATIENT
EDUCATION


To my wife, Jill, and our children, Paul, Julie,
Caroline, Luke and Clare, for their understanding,
patience and support.


Murtagh’s
patient
education
6e

John Murtagh AM
MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG
Emeritus Professor in General Practice, School of Primary Health Care, Monash University, Melbourne
Professorial Fellow, Department of General Practice, University of Melbourne
Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle, Western Australia
Guest Professor, Peking University, Health Science Centre, Beijing

iii


NOTICE
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The
editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally
in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the
editors, nor the publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained

herein is in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources. For example, and
in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the
information contained in this book is accurate and that changes have not been made in the recommended dose or in the contraindications for administration.
This recommendation is of particular importance in connection with new or infrequently used drugs.
First edition 1992
Second edition 1996
Third edition 2000
Reprinted 2001
Fourth edition 2005
Fifth edition 2008, reprinted 2009
Sixth edition 2012
Text © 2008 John Murtagh
Illustrations and design © 2008 McGraw-Hill Australia Pty Ltd
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National Library of Australia Cataloguing-in-Publication data
Murtagh, John

John Murtagh’s patient education / John Murtagh
6th edition
ISBN 9781743070109 (pbk.)
Includes index.
Previous ed.: 2008.
1. Patient education 2. Family medicine
615.5071
Published in Australia by
McGraw-Hill Australia Pty Ltd
Level 2, 82 Waterloo Road, North Ryde NSW 2113
Associate editor: Fiona Richardson
Senior production editor: Yani Silvana
Editor: Nicole McKenzie
Proofreaders: Rosemary Moore, Carol Natsis
Indexer: Shelley Barons
Cover design: George Creative
Internal design: Dominic Giustarini
Illustrator: Aptara Inc., New Delhi, India/ diacriTech, India
Typeset in JoannaMT 10/11 by diacriTech, India
Printed in China on 80 gsm woodfree by China Translation and Printing Services Ltd


Foreword

During my student days in the late 1940s the idea of educating patients about their illnesses was
never discussed. From memory I am not aware that this omission was even noticed, although it
may have been by those students who were wiser and more broadly educated than myself. When
later I began medical practice as a solo general practitioner, I remember being surprised by the
number of patients who had had major surgical procedures (as judged by their obvious scars) and
who were quite ignorant of these procedures or what organs they no longer possessed. I found

this lack of available information often interfered with the process of diagnosis due to incomplete,
and often highly relevant, past medical history.
Another memory of my early years in practice was the number of times I was called out of bed
because a child had a fever, only to be met on arrival at the home by a mildly ill child playing with
a box of toys. This provided sufficient motivation to start teaching the family about the relative
unimportance of a single sign in assessing illness severity, and the need to look at the whole child
and not just the thermometer reading. Within two years, despite an increasing population of children
in a new suburb, there were two observable results. First, the number of such requests for night and
weekend calls had markedly reduced and, second, there was positive feedback from patients, such
as ‘Thank you for giving your time to explain things to me’. At the time many general practitioners
were learning that this educational role was a legitimate and important part of being a competent
general practitioner, which is not surprising since the word ‘doctor’ originally meant ‘teacher’.
When I moved to academia, I then had a chance, together with my colleagues, to develop these
ideas further and to formalise patient education as an essential part of patient management in the
context of today’s society. Patient education now forms a major part of a formal undergraduate
teaching program embracing a number of consulting skills. In addition to the verbal communication
skills of this program, we have developed a matching series of take-home pamphlets to reinforce
these educational messages.
John Murtagh has taken up the concept of extending the consultation by writing patient handouts focusing on illnesses and their management. These have been published over many years in
Australian Family Physician, and adopted for use by many general practitioners during the consultation.
They have been gathered together and rewritten in this format for use by doctors and other health
professionals as an aid to improving quality of care, reducing its costs and encouraging a greater
input by patients in the management of their own illnesses. The unique objective of this publication
is the author’s wish to encourage doctors to use the material and to photocopy or even modify
those hand-outs considered most useful. A logical extension of this information is to use it in an
electronic format; Patient Education is also available on computer software.
Many doctors, especially younger doctors and medical students, have claimed that Patient Education
has been a helpful form of doctor education and very useful in preparation for examinations, both
undergraduate and for the fellowship of the Royal Australian College of General Practitioners.
In a society where informed consent is increasingly expected by the public, and the legal

profession in particular, it is important for doctors to be aware of the need to provide patients and
families with much more information than in the past. Professor Murtagh is to be congratulated
for producing the important messages in non-technical language within the confines of a single
page. This no doubt is a result of many years of experience in general practice, where he has learned
the skills of effective communication.
EMERITUS PROFESSOR NEIL CARSON, MD, AO,
Past Chairman,
Department of Community Medicine and General Practice,
Monash University, Melbourne

v


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Contents
Forewordv
About the author
xiv
Prefacexv
Acknowledgmentsxvi
Part 1 Stages of human development

1

1Marriage
Making your marriage work............................................................... 2
2 Pregnancy and postnatal care
Pregnancy planning............................................................................. 3

About your pregnancy........................................................................ 4
Breastfeeding and milk supply............................................................ 5
Establishing breastfeeding................................................................... 6
Mastitis with breastfeeding................................................................. 7
Miscarriage.......................................................................................... 8
Nipple problems while breastfeeding................................................. 9
Postnatal depression.......................................................................... 10
3 Children’s health
Allergy in your baby......................................................................... 11
Asthma in children............................................................................ 12
Atopic eczema................................................................................... 13
Attention deficit hyperactivity disorder............................................. 14
Autism............................................................................................... 15
Autism: Asperger’s syndrome............................................................ 16
Bed-wetting (enuresis)...................................................................... 17
Birthmarks........................................................................................ 18
Bow legs and knock knees................................................................. 19
Bronchiolitis...................................................................................... 20
Bullying of children.......................................................................... 21
Chickenpox (varicella)...................................................................... 22
Child accident prevention in the home............................................. 23
Circumcision..................................................................................... 24
Coeliac disease in children................................................................ 25
Croup................................................................................................ 26
Crying baby....................................................................................... 27
Down syndrome............................................................................... 28
Dyslexia and other SLDs.................................................................... 29
Earache in children........................................................................... 30
Encopresis......................................................................................... 31
Febrile convulsions............................................................................ 32

Feeding your baby............................................................................. 33
Fever in children............................................................................... 34
Flat feet............................................................................................. 35
Gastroenteritis in children................................................................. 36
Glue ear............................................................................................. 37
Growing pains................................................................................... 38

CONTENTS

vii


Hearing problems in children........................................................... 39
Immunisation of children................................................................. 40
Impetigo........................................................................................... 41
Infant colic........................................................................................ 42
Intoeing in children (pigeon toes).................................................... 43
Measles.............................................................................................. 44
Mumps.............................................................................................. 45
Nappy rash........................................................................................ 46
Normal development in children...................................................... 47
Peanut allergy.................................................................................... 48
Rearing a happy child....................................................................... 49
Reflux in infants................................................................................ 50
Roseola.............................................................................................. 51
Rubella (German measles)................................................................ 52
Scoliosis............................................................................................ 53
Seborrhoea in infants........................................................................ 54
Slapped cheek disease........................................................................ 55
Sleep problems in children................................................................ 56

Snuffling infant................................................................................. 57
Squint and loss of vision................................................................... 58
Stuttering.......................................................................................... 59
Tantrums........................................................................................... 60
Tear duct blockage............................................................................. 61
Teething............................................................................................ 62
Testicle, undescended........................................................................ 63
Thumb sucking................................................................................. 64
Toilet training your child.................................................................. 65
Umbilical hernia............................................................................... 66
Urine infection in children............................................................... 67
Viral skin rashes in children.............................................................. 68
Vulvovaginal irritation in children.................................................... 69
4 Adolescent health
Acne.................................................................................................. 70
Depression in teenagers..................................................................... 71
Eating disorders................................................................................. 72
Osgood–Schlatter disorder................................................................ 73
Understanding the adolescent........................................................... 74
Understanding your menstrual cycle................................................ 75
5 Women’s health
Breast cancer..................................................................................... 76
Breast lumps...................................................................................... 77
Breast awareness and breast self-examination.................................... 78
Cystitis in women............................................................................. 79
Dysmenorrhoea (painful periods).................................................... 80
Endometriosis................................................................................... 81
Fibroids............................................................................................. 82
Hair loss in women........................................................................... 83
Hirsutism.......................................................................................... 84

Incontinence of urine........................................................................ 85
Menopause........................................................................................ 86
Menorrhagia (heavy periods)............................................................ 87
Painful breasts................................................................................... 88
Pap test.............................................................................................. 89
Pelvic inflammatory disease.............................................................. 90
Pill: the combination pill................................................................... 91
Polycystic ovary syndrome................................................................ 92
Premenstrual syndrome.................................................................... 93
Tubal ligation.................................................................................... 94
Vaginal thrush................................................................................... 95

viii

CONTENTS


6 Men’s health
Erectile dysfunction (impotence)...................................................... 96
Foreskin hygiene............................................................................... 97
Male pattern baldness........................................................................ 98
Prostate: prostate cancer.................................................................... 99
Prostate: prostatitis.......................................................................... 100
Prostate: the test for prostate cancer................................................ 101
Prostate: your enlarged prostate...................................................... 102
Prostate: your prostate operation..................................................... 103
Scrotal lumps................................................................................... 104
Testicular cancer.............................................................................. 105
Testicular self-examination (TSE).................................................... 106
Vasectomy....................................................................................... 107

7 The elderly
Arthritis in the elderly..................................................................... 108
Dementia......................................................................................... 109
Eye problems in older people.......................................................... 110
Falls in older people........................................................................ 111
Hearing impairment in older people.............................................. 112
Leg ulcers........................................................................................ 113
Osteoporosis................................................................................... 114
Parkinson’s disease.......................................................................... 115
Retirement planning....................................................................... 116
Stroke.............................................................................................. 117
Tinnitus........................................................................................... 118
Part 2 General health

119

8Prevention
Cardiovascular (including coronary) risk factors............................. 120
Cholesterol: how to lower cholesterol............................................. 121
Diet guidelines for good health....................................................... 122
Obesity: how to lose weight wisely................................................. 123
Smoking: quitting........................................................................... 124
9Infections
Bacterial meningitis and meningococcus........................................ 125
Bed bug bites.................................................................................. 126
Bronchitis: acute bronchitis............................................................ 127
Bronchitis: chronic bronchitis......................................................... 128
Chlamydial urethritis....................................................................... 129
Common cold................................................................................. 130
Ear infection (otitis media)............................................................. 131

Glandular fever................................................................................ 132
Gonorrhoea..................................................................................... 133
Hand, foot and mouth disease........................................................ 134
Hepatitis A....................................................................................... 135
Hepatitis B....................................................................................... 136
Hepatitis C...................................................................................... 137
Herpes: genital herpes..................................................................... 138
Herpes simplex (cold sores)........................................................... 139
Herpes zoster (shingles)................................................................. 140
HIV infection and AIDS................................................................... 141
Influenza......................................................................................... 142
Labyrinthitis.................................................................................... 143
Laryngitis........................................................................................ 144
Lice: head lice................................................................................. 145
Lice: pubic lice................................................................................ 146
Malaria............................................................................................ 147

CONTENTS

ix


Molluscum contagiosum................................................................. 148
Pharyngitis...................................................................................... 149
Pneumonia...................................................................................... 150
Ringworm (tinea)........................................................................... 151
Scabies............................................................................................. 152
Sinusitis........................................................................................... 153
Tetanus............................................................................................ 154
Tinea pedis...................................................................................... 155

Tonsillitis......................................................................................... 156
Tuberculosis.................................................................................... 157
Viral infection................................................................................. 158
Warts............................................................................................... 159
Warts: genital warts......................................................................... 160
Whooping cough (pertussis).......................................................... 161
Worms............................................................................................ 162
10 Eye disorders
Blepharitis....................................................................................... 163
Bloodshot eye.................................................................................. 164
Cataracts.......................................................................................... 165
Chalazion (meibomian cyst)........................................................... 166
Colour blindness............................................................................. 167
Conjunctivitis.................................................................................. 168
Dry eyes.......................................................................................... 169
Floaters and flashes.......................................................................... 170
Foreign body in the eye................................................................... 171
Glaucoma........................................................................................ 172
Macular degeneration...................................................................... 173
Stye................................................................................................. 174
Watering eyes.................................................................................. 175
11 Musculoskeletal disorders
Backache......................................................................................... 176
Baker’s cyst...................................................................................... 177
Bunions........................................................................................... 178
Bursitis and tendonitis of the outer hip........................................... 179
Calf muscle injury........................................................................... 180
Carpal tunnel syndrome.................................................................. 181
De Quervain tendonitis of the thumb............................................. 182
Exercises for your knee................................................................... 183

Exercises for your lower back.......................................................... 184
Exercises for your neck................................................................... 185
Exercises for your shoulder............................................................. 186
Exercises for your thoracic spine..................................................... 187
Fibromyalgia................................................................................... 188
Gout................................................................................................ 189
Hamstring muscle injury................................................................ 190
Hip: osteoarthritis........................................................................... 191
Knee: anterior knee pain................................................................. 192
Knee: osteoarthritis......................................................................... 193
Neck: painful neck.......................................................................... 194
Olecranon bursitis........................................................................... 195
Osteoarthritis.................................................................................. 196
Paget’s disease of bone.................................................................... 197
Plantar fasciitis................................................................................ 198
Plaster cast instructions................................................................... 199
Polymyalgia rheumatica.................................................................. 200
Rheumatoid arthritis....................................................................... 201
Sciatica............................................................................................ 202
Shoulder: frozen shoulder............................................................... 203
Shoulder: tendonitis........................................................................ 204
Spondylosis..................................................................................... 205

x

CONTENTS


Sports injuries: first aid................................................................... 206
Sprained ankle................................................................................. 207

Temporomandibular joint dysfunction............................................ 208
Tennis elbow................................................................................... 209
Trigger finger.................................................................................. 210
Warm-up exercises for the legs....................................................... 211
Whiplash......................................................................................... 212
Wry neck (torticollis)..................................................................... 213
12 Common general problems
Adrenaline autoinjector use............................................................. 214
Alcohol: harmful use of alcohol...................................................... 215
Amphetamines................................................................................ 216
Anal fissure...................................................................................... 217
Anger management......................................................................... 218
Angina............................................................................................. 219
Anticoagulation therapy.................................................................. 220
Anxiety............................................................................................ 221
Aphthous ulcers.............................................................................. 222
Appendicitis.................................................................................... 223
Asthma............................................................................................ 224
Asthma: correct use of your aerosol inhaler.................................... 225
Asthma: dangerous asthma.............................................................. 226
Atrial fibrillation............................................................................. 227
Basal cell carcinoma........................................................................ 228
Bell’s palsy....................................................................................... 229
Bereavement.................................................................................... 230
Bipolar disorder.............................................................................. 231
Bites and stings............................................................................... 232
Bladder cancer................................................................................. 233
Body odour..................................................................................... 234
Bowel cancer................................................................................... 235
Bullying in the workplace............................................................... 236

Burns and scalds.............................................................................. 237
Calluses, corns and warts on feet..................................................... 238
Cancer............................................................................................. 239
Cannabis (marijuana)...................................................................... 240
Chronic fatigue syndrome............................................................... 241
Chronic obstructive pulmonary disease.......................................... 242
Circulation to legs: poor circulation................................................ 243
Cocaine........................................................................................... 244
Coeliac disease in adults.................................................................. 245
Constipation.................................................................................... 246
Contact dermatitis........................................................................... 247
Coping with a crisis........................................................................ 248
Cramp............................................................................................. 249
Dandruff......................................................................................... 250
Deep vein thrombosis and travel..................................................... 251
Depression...................................................................................... 252
Depression: medication for depression........................................... 253
Diabetes........................................................................................... 254
Diabetes type 1................................................................................ 255
Diabetes: type 2............................................................................... 256
Diabetes: blood glucose monitoring at home.................................. 257
Diabetes: foot care for diabetics....................................................... 258
Diabetes: healthy diet for diabetics.................................................. 259
Diabetes: insulin injections............................................................. 260
Diarrhoea: acute diarrhoea in adults............................................... 261
Diverticular disease......................................................................... 262
Dry skin.......................................................................................... 263
Ear: otitis externa............................................................................ 264
Ear: wax in your ear........................................................................ 265
CONTENTS

xi


Ecstasy............................................................................................. 266
Epidermoid (sebaceous) cysts......................................................... 267
Epilepsy........................................................................................... 268
Fainting (syncope).......................................................................... 269
Fatty liver........................................................................................ 270
Fatty tumour (lipoma).................................................................... 271
Fever................................................................................................ 272
Gallstones........................................................................................ 273
Gambling: problem gambling......................................................... 274
Ganglion......................................................................................... 275
Gastritis........................................................................................... 276
Goitre (thyroid swelling)................................................................ 277
Haemochromatosis......................................................................... 278
Haemorrhoids................................................................................. 279
Halitosis.......................................................................................... 280
Hangover......................................................................................... 281
Hay fever......................................................................................... 282
Head injury..................................................................................... 283
Heart failure.................................................................................... 284
Heartburn....................................................................................... 285
Heroin............................................................................................. 286
Hiatus hernia................................................................................... 287
House dust mite management......................................................... 288
Hypertension.................................................................................. 289
Hyperthyroidism............................................................................. 290
Hypothyroidism.............................................................................. 291

Infertile couples.............................................................................. 292
Inflammatory bowel disease............................................................ 293
Ingrowing toenails.......................................................................... 294
Inguinal hernia................................................................................ 295
Iron deficiency anaemia.................................................................. 296
Irritable bowel................................................................................. 297
Kidney disease................................................................................. 298
Kidney stones.................................................................................. 299
Leukaemia....................................................................................... 300
Lung cancer..................................................................................... 301
Lymph gland enlargement............................................................... 302
Lymphoma...................................................................................... 303
Melanoma....................................................................................... 304
Ménière’s syndrome........................................................................ 305
Migraine.......................................................................................... 306
Nail disorders.................................................................................. 307
Nose: stuffy, running nose.............................................................. 308
Nosebleed....................................................................................... 309
Obstructive sleep apnoea................................................................. 310
Pancreatitis...................................................................................... 311
Peptic ulcer...................................................................................... 312
Perianal haematoma........................................................................ 313
Personality disorders....................................................................... 314
Phobias............................................................................................ 315
Pityriasis rosea................................................................................. 316
Post-traumatic stress disorder.......................................................... 317
Pressure sores (bed sores)............................................................... 318
Pruritus ani..................................................................................... 319
Psoriasis.......................................................................................... 320
Raynaud’s phenomenon.................................................................. 321

Reflux disease.................................................................................. 322
Restless legs syndrome.................................................................... 323
Rosacea and perioral dermatitis...................................................... 324
Schizophrenia.................................................................................. 325
Seborrhoeic keratoses...................................................................... 326
Skin cancer...................................................................................... 327

xii

CONTENTS


Sleep problems: insomnia............................................................... 328
Snoring........................................................................................... 329
Social phobia................................................................................... 330
Squamous cell skin cancer............................................................... 331
Stress: coping with stress................................................................. 332
Sunburn.......................................................................................... 333
Systemic lupus erythematosus......................................................... 334
Teeth grinding (bruxism)............................................................... 335
Tension headache............................................................................ 336
Tongue soreness.............................................................................. 337
Travel: air travel............................................................................... 338
Travel: guide for travellers............................................................... 339
Travel sickness................................................................................. 340
Tremor: essential tremor................................................................. 341
Urticaria (hives).............................................................................. 342
Varicose veins.................................................................................. 343
Vertigo: benign positional vertigo................................................... 344
Vertigo: exercises for benign positional vertigo.............................. 345

Index

346

CONTENTS

xiii


About the author

John Murtagh AM
MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG
Emeritus Professor in General Practice, School of Primary Health Care, Monash University, Melbourne
Professorial Fellow, Department of General Practice, University of Melbourne
Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle,
Western Australia
Guest Professor, Peking University Health Science Centre, Beijing

John Murtagh was a science master teaching chemistry, biology and physics in Victorian secondary
schools when he was admitted to the first intake of the newly established Medical School at Monash
University, graduating in 1966. Following a comprehensive postgraduate training program, which
included surgical registrarship, he practised in partnership with his medical wife, Dr Jill Rosenblatt,
for 10 years in the rural community of Neerim South, Victoria.
Dr Murtagh was appointed Senior Lecturer (part-time) in the Department of Community
Medicine at Monash University and eventually returned to Melbourne as a full-time Senior Lecturer.
He was appointed to a professorial chair in Community Medicine at Box Hill Hospital in 1988 and
subsequently as chairman of the extended department and Emeritus Professor of General Practice
in 1993 until retirement from this position in 2000. He now holds teaching positions as Professor
in General Practice at Monash University, Adjunct Clinical Professor, University of Notre Dame

and Professorial Fellow, University of Melbourne. He combines these positions with part-time
general practice, including a special interest in musculoskeletal medicine. He achieved the Doctor
of Medicine degree in 1988 for his thesis ‘The management of back pain in general practice’.
Dr Murtagh was appointed Associate Medical Editor of Australian Family Physician in 1980 and
Medical Editor in 1986, a position held until 1995. In 1995 he was awarded the Member of the
Order of Australia for services to medicine, particularly in the areas of medical education, research
and publishing.
Practice Tips, one of Dr Murtagh’s numerous publications, was named as the British Medical
Association’s Best Primary Care Book Award in 2005. In the same year, he was named as one of
the most influential people in general practice by the publication Australian Doctor. John Murtagh
was awarded the inaugural David de Kretser medal from Monash University for his exceptional
contribution to the Faculty of Medicine, Nursing and Health Sciences over a significant period
of time. Members of the Royal Australian College of General Practitioners may know that he was
bestowed the honour of the namesake of the College library.
Today John Murtagh continues to enjoy active participation with the diverse spectrum of general
practitioners—whether they are students or experienced practitioners, rural- or urban-based, local
or international medical graduates, clinicians or researchers. His vast experience with all of these
groups has provided him with tremendous insights into their needs, which is reflected in the
culminated experience and wisdom of John Murtagh’s General Practice.

xiv


Preface

In modern medicine patient education has become a very important and expected method of
patient care. People are more interested than ever before in the cause and management of their
problems, and for this reason access to information in an easy-to-follow presentation is very
beneficial. Furthermore, patients need and deserve the best possible access to information about
their health. The material presented in this book is not intended to be used as an alternative to the

verbal explanations given by the doctor during the consultation but as complementary information
to be taken home. Experience has shown that better understanding of a problem or potential health
problem leads to better cooperation and compliance with treatment.
The author has produced patient education information to fit onto one sheet, which can be
handed to the patient or person seeking health information. Medical practitioners often refer to
this information as ‘doctor education’ as well as ‘patient education’. Such practitioners are invited
to use this information for a variety of purposes, such as a basis for their own patient education or
for computer information programs. These sheets should have considerable value in undergraduate
courses for doctors, nurses and other health professionals.
The catalyst for the initial production of this material came from two sources. The Royal Australian
College of General Practitioners, through its official publication Australian Family Physician (AFP),
encouraged the author to write patient education material as a service to general practitioners and
their patients. The strategy was to present information on the most common problems presenting to
general practitioners, each on a single A4 sheet and in the lay person’s language. Patient education
sheets have been a feature of monthly publications of AFP since 1979, and doctors have ordered
them in vast quantities. This concept has also been promoted by Australian Doctor, which commissioned
the author to write a series  of patient education information in that popular publication. We
have not simply featured illnesses, but have also included preventive advice and health promotion
wherever possible.
The other impetus for this project came from the members of the Monash University Department
of Community Medicine and General Practice, who realised the importance of this material for the
education of medical students. Apart from providing valuable learning material for the students,
it gave them the basis for illness and preventive advice to patients during the consulting skills
learning program.
Following a rather indifferent response to the initial production of material in AFP, it is interesting
to now discover that since the launch of the first edition of Patient Education the use of this material
is rising very rapidly. It is now a much requested inclusion in computer programs for doctors and
is blossoming on the Internet. These trends reinforce the perceived value of this form of health
education.
The author believes that the subject matter in this book covers common everyday problems

encountered by doctors and hopes that the dissemination of this information will benefit both
health-care providers and people who are interested in their health.

xv


Acknowledgments

The author would like to thank the Publication Division of the Royal Australian College of General
Practitioners for encouraging the concept of patient education and for their permission to reproduce
much of the material that has appeared in Australian Family Physician. Also, my colleagues in the
Department of Community Medicine, Monash University, have provided valuable assistance. Professor
Neil Carson’s far-reaching vision of general practice training includes the value of this educational
medium. Thanks also to Dr Kerri Parnell and the Editor of Australian Doctor who have agreed to permit
publication of selected patient education material that appeared in Australian Doctor in this book.
Other educational organisations that have provided ideas and material are the Paediatric Health
Education Unit, Westmead Hospital, NSW, and the Parks Community Health Centre, Angle Park, SA.
Colleagues who have given considerable advice are Malcolm Fredman, James Kiepert, Don Lewis,
Robin Marks, Alison Walsh, Abe Rubinfeld and Lucie Stanford. The main reference was the Macmillan
Guide to Family Health (1982) edited by Dr Tony Smith. Other reference material includes Better Health
patient information (Victorian Government) and patient information conditions from Patient Co,
United Kingdom.
Individual contributions, including full or part authorship, have come from the following
practitioners, to whom I am indebted:
Lisa Amir (Establishing breastfeeding), Michael Axtens and Lou Sanderson (Common cold), Tim
Bajraszewski (Osteoporosis), Bruce Barker (Angina, Diverticular disease, Hepatitis A, Osteoarthritis),
Jenny Barry (Dysmenorrhoea), Robin Beattie (Stress: coping with stress), Grant Connoley (Melanoma),
Joan Curtis (Autism), Denise Findlay (Breast self-examination, Pill: the combination pill), David
Fonda (Incontinence of urine), John Goldsmid (Lice: head lice, Lice: pubic lice, Scabies), Jenny
Gunn and Pat Phillips (Diabetes: blood glucose monitoring at home, Diabetes: healthy diet for

diabetics), Anthony Hall (Warts), Judith Hammond (Premenstrual syndrome), Rod Kruger (Ear:
otitis externa, Ear: wax in your ear, Foreign body in eye), Deirdre Lewis (Hirsutism), Jim McDonald
(Haemorrhoids), Peter Macisaac (Travel: guide for travellers), Ian McKenzie (Child accident
prevention in the home), Benny Monheit (Cannabis), Jane Offer (Understanding your menstrual
cycle), William Phillips (Foreskin hygiene), Leanne Rowe (Prostate: test for prostate cancer), Jill
Rosenblatt (Dysmenorrhoea, Menopause, Vaginal thrush), Ann Salmons (Asthma), Chris Silagy
(Smoking—quitting), John Tiller (Sleep problems), Jane Tracey (Asperger’s syndrome), Cynthia
Welling (Incontinence of urine), Lyndall Whitecross (Pill: the combination pill), Richard Williams
(Exercises for your knee, Exercises for your shoulder).
Finally, thanks go to Nicki Cooper, Kris Berntsen, Jenny Green and Caroline Menara for typing
the manuscript.

xvi


Part 1

Stages of human
development


Making your marriage work
When a couple marries, a bond of love is invariably present;
this bond will at times be put to the test, because marriage
is no ‘bed of roses’. For most couples this bond will grow,
mature and become a wonderful source of joy despite the
rough times. However, others may not cope well with the
problems of living together. To split up is a terrible loss in
every respect, especially for any children of the marriage.
Many troubled couples have achieved great happiness by

following some basic rules of sharing.
The three keys to marital success are caring, respect and
responsibility.

Some common causes of marital trouble
•
•
•
•
•
•
•
•
•
•
•
•
•

Selfishness
Financial problems/meanness
Gambling
Sickness (e.g. depression)
‘Playing games’ with each other
Poor communication
Unrealistic expectations
Not listening to each other
Drug or alcohol excess
Jealousy, especially in men
Fault finding

Driving ambition
Immaturity

Some important facts
• Research has shown that we tend to choose partners who
are similar to our parents and that we may take our childish
and selfish attitudes into our marriage.
• The trouble spots listed above reflect this childishness; we
often expect our partners to change and meet our needs.
• If we take proper care and responsibility, we can keep
these problems to a minimum.
• Physical passion is not enough to hold a marriage
together—‘when it burns out, only ashes will be left’.
• While a good sexual relationship is great, most experts
agree that what goes on out of bed counts for more.
• When we do something wrong, it is most important that
we feel forgiven by our partner.

Positive guidelines for success
1. Know yourself. The better you know yourself, the better you
will know your mate.
2. Share interests and goals. Do not become too independent
of each other. Develop mutual friends, interests and

2

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

hobbies. Tell your partner ‘I love you’ regularly at the
right moments.

3. Continue courtship after marriage. Spouses should continue
to court and desire each other. Going out regularly for
romantic evenings and giving unexpected gifts (such as
flowers) are ways to help this love relationship. Engage
in some high-energy fun activities such as massaging
and dancing.
4. Make love, not war. Learn about sex and reproduction. A good
sexual relationship can take years to develop, so work at
making it better. Explore the techniques of lovemaking
without feeling shy or inhibited. This can be helped by
books such as The Joy of Sex and DVDs on lovemaking. Good
grooming and a clean body are important.
5. Cherish your mate. Be proud of each other, not
competitive or ambitious at the other’s expense. Talk
kindly about your spouse to others—do not put him or
her down.
6. Prepare yourself for parenthood. Plan your family wisely and
learn about child bearing and rearing. Learn about family
planning methods and avoid the anxieties of an unplanned
pregnancy. The best environment for a child is a happy
marriage.
7. Seek proper help when necessary. If difficulties arise and are
causing problems, seek help.Your general practitioner will
be able to help. Stress-related problems and depression
in particular can be lethal in a marriage—they must be
‘nipped in the bud’.
8. Do unto your mate as you would have your mate do unto you. This
gets back to the unconscious childhood needs. Be aware
of each other’s feelings and be sensitive to each other’s
needs. Any marriage based on this rule has an excellent

chance of success.
The Be Attitudes (virtues to help achieve success)
BE honest
BE loyal
BE loving
BE desiring
BE patient
BE fun to live with
BE forgiving
BE one
BE generous
BE caring

Making lists—a practical task
Make lists for each other to compare and discuss.
• List qualities (desirable and undesirable) of your parents.
• List qualities of each other.
• List examples of behaviour each would like the other to
change.
• List things you would like the other to do for you. Put
aside special quiet times each week to share these things.


Pregnancy planning
Planning to become pregnant?

Listeria and toxoplasmosis

If you’re planning to have a baby it is advisable to be well
informed and prepared to provide the best care for yourself

and your baby. Most pregnancies invariably go smoothly.
Commonsense and scientific evidence tell us a healthy body
is the best environment to achieve implantation of the fetus
and carry it to term.

These infections, which are potentialy fatal to the fetus,
are caused by organisms present in contaminated food,
either uncooked or undercooked. Infected cats can transmit
toxoplasmosis. If contracted during pregnancy, it has a high
fetal death rate (30 to 50%).
To prevent listeria infection avoid unprocessed foods such
as unpasteurised milk, soft cheeses, cold processed meats,
pâté, raw seafood and smoked seafood. Also carefully wash
raw vegetables, thoroughly cook all food of animal origin,
reheat leftover foods and ready-to-eat food until steaming
hot and always thoroughly clean utensils after preparing
uncooked food.
To avoid toxoplasmosis pregnant women should get
another person to clean cat litter boxes daily, wear disposable
rubber gloves for handling soil likely to be contaminated
with cats’ faeces and carefully wash hands after gardening
or handling raw meat.

Getting pregnant
Most normal, fertile couples achieve a pregnancy within the
first 12 months of trying. It can take up to 6 months after
stopping the contraceptive pill for ovulation to resume.
Women over 35 or who smoke can take twice as long to
conceive. Intercourse 3 to 4 times a week at ovulation time
maximises the chances of conception.

Nutrition
It is important to have a well-balanced and nutritionally
sound diet. Women should aim for an ideal weight before
conception. A high-fibre, low-fat diet that is rich in vitamins
is the basis of good health. Eat freshly cooked or freshly
prepared food. Drink lots of water (preferably filtered). Iodine
intake is important, so use iodised salt and eat fish regularly.

Folic acid before pregnancy
Folic acid reduces the risk of having a baby with a neural tube
defect such as spina bifida. Those at high risk include those
previously affected and those with a family history, diabetes or
on anti-epileptic medication, but folic acid supplements are
advisable for all pregnant women. Those at risk should take
5 mg daily at least 1 month before pregnancy and ideally for
12 weeks. All other women should have 0.5 mg tablets daily
4 weeks before conception, continuing for 3 months after.

Smoking, alcohol and other drugs
You should not smoke during pregnancy and ideally quit
3 months before conception. Avoid exposure to passive smoke
and get a smoking partner to cooperate.
The National Health and Medical Research Council advises
against drinking alcohol before and during pregnancy. Alcohol
and other social drugs, especially amphetamines, can cause
deformities in the child. Stop other recreational drugs and
discuss over-the-counter drugs with your doctor. Caffeine
intake should also be reduced.

Genetic counselling

Sensible, regular, non-contact exercise is important. Avoid
high-level exercise and getting overheated.

Genetic or developmental disorders need to be considered if
there is a history of a genetic condition in the family, or the
mum-to-be is in an older age group (generally considered
to be over 35).
Genetic disorders include thalassaemia, cystic fibrosis,
haemophilia, Down syndrome and Tay–Sachs disorder.
Your doctor will advise about testing for you and your
partner.

Serious infections

Blood group

Most conceptions have ideal outcomes but the fetus can
be affected by certain infections, especially in the early
stages of pregnancy, so it is wise to try to reduce the risk of
contracting these infections while trying to become pregnant
and throughout the pregnancy.
These infections include rubella, varicella, hepatitis B,
syphilis, toxoplasmosis, listeria, cytomegalovirus and HIV.
It is advisable to have blood tests for rubella, varicella, syphilis,
hepatitis B and HIV.

It is a good idea for both partners to know their blood group
so they know their Rhesus factor. A negative blood group

in the female combined with a positive group in the male
partner requires careful attention.

Exercise

Vaccination
Rubella (German measles) acquired during pregnancy is a
big concern. Most women these days have been vaccinated
and are probably immune but this immunity can wear off.
It is advisable to be tested before becoming pregnant
and given the vaccine if not immune. It is also advisable
not to become pregnant within 3 months of being vaccinated.
Varicella (chickenpox) is best avoided and the same rules
apply as for rubella. Immunisation against hepatitis B is advisable.

Checkpoint summary
•
•
•
•
•
•
•
•
•
•
•
•
•

Stop smoking.
Stop alcohol and other social drugs.
Reduce or stop caffeine intake.
Review current medications.
Follow a healthy diet rich in iron and calcium.
Take folic acid for 4 weeks before conception.
Have a good exercise routine.
Ensure rubella, varicella and hepatitis B immunity.
Have a breast check and Pap test.
Eat freshly cooked and prepared food.
Consider genetic and family history.
Consider health insurance cover.
Get moderate sunlight exposure to boost your vitamin D.
MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

3


About your pregnancy
Congratulations on becoming an expectant parent—this is
a very exciting time in your life, even though you may be
inclined to feel flat and sick at first. Your baby is very special
and deserves every opportunity to get a flying start in life
by growing healthily in your womb. Pregnancy is a very
normal event in the life cycle and usually goes very smoothly,
especially if you have regular medical care.

Why have regular checks?
Antenatal care is considered to be the best opportunity in life
for preventive medicine. It is important to check the many

things that can cause problems—these are uncommon, but
preventable. A special possible problem is pregnancy-induced
hypertension, which can lead to a serious condition called preeclampsia or toxaemia of pregnancy, a condition of weight
gain, high blood pressure and kidney stress, which shows
up as protein in the urine.
Areas that need to be checked include:
• blood count
• blood grouping and Rhesus antibodies (Rh factor)
• immunity against infections that may affect the baby
(e.g. rubella, varicella (chickenpox), hepatitis B and C, HIV)
• number of babies (one or more)
• size and state of your pelvis
• blood pressure
• urine (for evidence of diabetes or pre-eclampsia)
• cervix (Pap test)
• progress of the baby (e.g. size of uterus, heartbeat)
• mother’s progress, including emotional state
• blood sugar (for possible diabetes)
• vitamin D
• risk for Down syndrome through first-trimester combined
screening test.

When should you be checked?
The recommended routine is as early as possible and then
every 4 to 6 weeks until 28 weeks of pregnancy, then every
2 weeks until 36 weeks, and then weekly until the baby arrives
(usually 40 weeks). An ultrasound is usually performed at
about 18 weeks.

What common things can cause problems

in the baby?
•
•
•
•

Infections such as rubella, varicella and genital herpes
Diabetes (can develop in pregnancy)
High blood pressure
Smoking—retards fetus growth and should be stopped (if
impossible, limit to 3 to 6 cigarettes per day)
• Alcohol—causes abnormalities, including mental
retardation. The National Health and Medical Research
Council has advised ‘not drinking alcohol is the safest
option for the developing fetus’
• Other social drugs
• Aspirin and various other drugs (check with your doctor)

What is usually prescribed?
Folic acid is now recommended for 4 weeks and preferably
12 weeks before getting pregnant, then for the first 3 months.

4

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

No iron tablets are needed if you have a healthy diet and
do not have severe morning sickness.

What important areas should you

attend to?
Nutrition
A healthy diet is very important and should contain at least
the following daily allowances:
1. Eat most:
• fruit and vegetables (at least 4 serves)
• cereals and bread (4 to 6 serves).
2. Eat moderately:
• dairy products—3 cups (600 mL) of milk or equivalent
in yoghurt or cheese
• lean meat, poultry or fish—1 or 2 serves (at least
2 serves of red meat per week).
3. Eat least:
• sugar and refined carbohydrates (e.g. sweets, cakes,
biscuits, soft drinks)
• polyunsaturated margarine, butter, oil and cream.
Bran with cereal helps prevent constipation in pregnancy.
Drink ample fluids (e.g. 2 litres of water a day).
Talk to your doctor about Listeria infection, which is
contracted from fresh and unprocessed foods such as soft
cheeses, pâté and unpasteurised milk.
Antenatal classes
Trained therapists will advise on antenatal exercises,
back care, postural advice, relaxation skills, pain relief in
labour, general exercises and beneficial activities such as
swimming.
Breastfeeding and nursing mothers
Breastfeeding is highly recommended. Contact a local
nursing mothers’ group for support and guidance if you
need help.

Employment and travel
Check with your doctor. Avoid standing in trains. Avoid
international air travel after 28 weeks.
Normal activities
You should continue your normal activities. Housework
and other activities should be performed to just short of
feeling tired. However, get sufficient rest and sleep.

When should you contact your doctor or
the hospital?
Contact your doctor or seek medical help:
• if contractions, unusual pain or bleeding occur before
the baby is due
• if the baby is less active than usual
• if membranes rupture and a large amount of fluid
comes out
• when you are getting regular contractions 5 to 10 minutes
apart.
Help is only a telephone call away.


Breastfeeding and milk supply
Difficulties with breastfeeding are common, especially
in the first week after birth. As a rule, the milk, which is
present all the time, ‘comes in’ at any time from 24 hours
after birth. It is common for the breasts to become
engorged early on, but in some cases there is insufficient
supply.

Engorged breasts

What is engorgement?
In some women, a few days after delivery the milk
supply comes on so quickly that the breasts become
swollen, hard and sore. This is called engorgement. There is an
increased supply of blood and other fluids in the breast as
well as milk.

What will you notice?
The breasts and nipples may be so swollen that the baby is
unable to latch on and suckle. The soreness makes it difficult
for you to relax and enjoy your baby.

How are engorged breasts managed?
• Feed your baby on demand from day 1 until he or she
has had enough.
• Finish the first breast completely; maybe use one side per
feed rather than some from each breast. Offer the second
breast if the baby appears hungry.
• Soften the breasts before feeds or expressing with a
warm washer or shower, which will help get the milk
flowing.
• Avoid giving the baby other fluids.
• Express a little milk before putting the baby to your
breast (a must if the baby has trouble latching on) and
express a little after feeding from the other side if it is
too uncomfortable.
• Massage any breast lumps gently towards the nipple
while feeding.
• Apply cold packs after feeding. Many women use washed,
cool, crisp cabbage leaves (left in the refrigerator) between

feeds. An opening is left for the nipple and the leaves are
usually changed every 2 hours when appropriate. Some
women prefer to use hot packs.
• Wake your baby for a feed if your breasts are uncomfortable
or if the baby is sleeping longer than 4 hours.
• Use a good, comfortable bra.
• Remove your bra completely before feeding.
• Take ibuprofen or paracetamol regularly for severe
discomfort.
Remember that regular feeding is the best treatment for
your engorged breasts. Follow your demand and your baby’s
demand. As your breasts are used in this way, they gradually
become softer and more comfortable.

Insufficient supply
Studies have shown that many women wean because of
low milk supply. The problem is due mainly to lactation
mismanagement such as poorly timed feeds, infrequent
feeds and poor attachment. This is sometimes a problem
in mothers who tend to be under a lot of stress and find it
hard to relax. A ‘let down’ reflex is necessary to get the milk
supply going, and sometimes this reflex is slow. If there is
insufficient supply, the baby tends to demand frequent feeds,
may continually suck his or her hand, have hard stools and
fewer wet nappies, and will be slow in gaining weight.
Remember that there is always some milk present in your
breasts. Mothers tend to underestimate their milk supply.

What should you do?
• Try to practise relaxation techniques to help condition

your ‘let down’ reflex.
• Put the baby to your breast as often as he or she demands,
using the ‘chest to chest, chin on breast’ method.
• Feed your baby more often than usual.
• Give at least one night feed.
• Express after feeds, because the emptier the breasts are,
the more milk will be produced.
• Make sure you get adequate rest, eat well and drink ample
fluids, but if you feel overly tired go to your doctor for
a check-up.

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

5


Establishing breastfeeding
There are three important things that you should know
about breastfeeding:
1. Positioning the baby on the breast
2. The ‘let down’
3. Supply and demand
Occasionally some women experience engorged breasts or
insufficient milk supply until breastfeeding is fully established.

Positioning

ribs

Your posture

• Make yourself comfortable.
• Sit upright, but let your shoulders relax.
• Support yourself with cushions or a footstool, if necessary.

areola

Your baby
• Unwrap the baby’s arms.
• Turn the baby’s body towards yours.
• Have the baby’s mouth at the same level as your nipple.
• Support the baby’s body well.
• Hold the baby close to you with their chest close to yours.
Latching on
• Support your baby across the back of the shoulder.
• Tickle the baby’s lips with your nipple until the mouth
opens wide.
• Quickly move the baby onto the breast when the mouth is
wide open. (Do not try to bring your breast to the baby.)
• Make sure the baby has a large mouthful of breast and not
just the nipple. Aim your nipple at the top lip, so that the
lower lip will be well below your nipple.
• The baby’s tongue should be over the lower gum. (This
is hard to see yourself.)
• If you feel the baby is not well positioned, slip your little
finger into the corner of the mouth to break the suction,
take the baby off and try again.You are both learning this,
so take a few slow breaths and take your time.
• If you need to support your breast, use your four fingers
under the breast, well away from the areola.

Let down
When your baby is feeding, the nerves in the nipple start
a reflex action that allows the milk-producing alveoli to be
squeezed, which pushes milk along the ducts towards the
nipple. This is called the ‘let down’ reflex. Some women notice a
tingling or a pins-and-needles sensation or a fullness when
this occurs. Others notice leaking from the other breast or
nothing at all. You may notice that the baby changes from

6

clusters of
alveoli

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

milk sinus
nipple with
several
duct openings
Montgomery’s
glands
Anatomy of the breast

sucking quickly at the breast to a slower suck-swallow-suckswallow pattern.
The milk higher up in the breast (the hindmilk) is rich in
fat and kilojoules. It is important that you have a ‘let down’,
so that the baby does not get only foremilk.
If you are anxious, in pain or embarrassed, your ‘let down’
may be slow. If possible, try to address these factors before

feeding. Once breastfeeding is well established, you will be
able to breastfeed anywhere, but in the early days you need
a supportive environment.

Supply and demand
Your breasts produce milk on the principle of supply and
demand. This means that the more the breasts are emptied,
the more milk is made. When breasts are allowed to remain
full, they get the message to slow down milk production.
Your baby automatically controls his or her food intake
by taking as much as needed. When the baby needs to
increase your supply, he or she will feed more frequently
for a couple of days.
If your supply is low, you can increase it by expressing
milk after feeds. You can offer this milk to your baby after
the next feed or in the evening. Usually your breasts will feel
fuller after a few days of resting and expressing.


Mastitis with breastfeeding
What is mastitis?
Mastitis is an area of inflammation of breast tissue, in particular
the milk ducts and glands of the nursing mother. It is caused
by a cracked nipple or blockage of the ducts due to a problem
with drainage of the milk. Germs from the outside get into
and grow in the stagnant milk.

What are the symptoms?
You may feel a lump and then a sore breast at first. Then
follows a red, swollen, tender area (see diagram) with fever,

tiredness, weakness and muscle aches and pains (like having
influenza).

What are the risks?
If treated early and properly, mastitis starts to improve within
48 hours. Doctors regard it as a serious and rather urgent
problem, because a breast abscess can quickly develop without
treatment and the abscess may require surgical drainage,
usually by needle aspiration. Apart from the bacterial infection,
infection with Candida (thrush) may occur, especially after
the use of antibiotics. Candida infection usually causes
severe breast pain—a feeling like a hot knife or hot shooting
pains, especially during and after feeding. A breast abscess is
diagnosed by ultrasound examination.

• Cool the breast after feeding: use a cold face washer from
the freezer.
• Apply cool, washed cabbage leaves over the affected side
between feeds (optional).
• Massage any breast lump gently towards the nipple while
feeding.
• Empty the breast well: hand express if necessary.
• Get sufficient rest: rest when you feel the need to do so
and get help in the home.
• Keep to a nutritious diet and drink plenty of fluids.

How can it be prevented?
Breast engorgement and cracked nipples must be attended
to. It is important to make sure your milk drains well. Faulty
drainage can be caused by an oversupply of milk, missed feeds,

the breast not being fully emptied (e.g. from rushed feeding,
poor attachment or wrong feeding positions), exhaustion,
poor nutrition and too much pressure on the breast (e.g. bra
too tight and sleeping face-downwards).
Keep the breasts draining by expressing or by waking the
baby for a feed if he or she sleeps for long periods. For an
oversupply, try feeding from one breast only at each feed.
Avoiding caffeine and smoking may also help.
Golden rule: ‘Heat and drain the breasts.’
Note: It is quite safe to continue breastfeeding with the
affected breast unless your doctor advises otherwise.

What is the treatment?
• Antibiotics: your doctor will prescribe a course of
antibiotics, usually for 10 days. If you are allergic to
penicillin, tell your doctor.
• Painkillers: take aspirin or paracetamol when necessary
for pain and fever.
• Keep the affected breast well drained.
• Keep breastfeeding: do this frequently and start with the
sore side. It is safe to do so.
• Make sure the baby is latched on properly and change
feeding positions to drain the milk.
• Heat the sore area of the breast before feeding: have a
warm shower or use a warm face washer or warm ­hotwater bottle.

red painful
area in breast

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

7


Miscarriage
After a miscarriage you will undoubtedly be confused
and wondering why this sad event happened to you. The
main thing is to remember that it was nothing that you
did wrong, and so you should not feel any sense of blame
or guilt.

What is a miscarriage?
A miscarriage, which is called a spontaneous abortion in medical
terms, is the spontaneous ending of pregnancy before the
baby (fetus) can survive outside the womb. This is usually
considered to be up to the 20th week. A loss after this time
is called a stillbirth. Sometimes it is complete (when both fetus
and afterbirth are expelled); sometimes it is incomplete (when
only part of the pregnancy is expelled).

What are the surprising facts?
• About 1 in 4 pregnancies are ‘lost’ (i.e. miscarried).
• Many are lost soon after conception; in such a case the
woman may not be aware of anything except a small
alteration in her period.
• In most cases, the fetus is lost in the first 12 weeks and is
obvious to the mother.

What are the symptoms?
The first symptom is loss of blood from the vagina, which

can vary from slight to a heavy flow. At this stage it is called
a threatened miscarriage.
When the solid products are passed, you feel pain due
to cramping of the uterus. It is usual for only some parts to
be passed to the outside, while others (e.g. the afterbirth)
stay behind. This is referred to as an incomplete miscarriage
or abortion. However, if the miscarriage is later in the
pregnancy (such as at 20 weeks), it is more usual to have a
complete abortion.

What is the cause of miscarriage?
Most miscarriages occur without an obvious cause.
However, in many there is something wrong with the
developing fetus, and a miscarriage is nature’s way of handling
the problem.
This abnormality may be caused by a genetic disorder,
or by a viral infection that has affected the fetus in the
first 12 weeks. Often the mother is unaware that she has
picked up a serious infection (such as rubella, influenza or
cytomegalovirus), but it is harmful to the delicate growing
tissues of the fetus.
In other cases, abnormalities of the uterus may not allow
the fertilised egg to attach to its lining, or it may reject the
developing fetus later on.
The mother may also have a clotting disorder of the blood.

8

MURTAGH’S PATIENT EDUCATION, SIXTH EDITION © MCGRAW-HILL

Blighted ovum
This occurs when a pregnancy sac is formed in the uterus
but there is no developing baby and the sac is expelled. It is
a common cause of miscarriage.

What are the risks?
There is usually no risk to the mother’s health. However, if
the miscarriage is incomplete and not treated, infection or
anaemia from blood loss could occur. If you get fever, heavy
bleeding, severe pain or an offensive discharge, contact your
doctor. After a miscarriage, you may feel emotionally upset
or depressed, with feelings of loss and grief. If so, you will
require help.

Will it happen again?
Having a miscarriage doesn’t make it any more likely you
will have another miscarriage. The odds favour your next
pregnancy being successful. There is no special treatment to
prevent any further miscarriages, and it is best left to nature
to take its course. However, it is advisable to keep healthy and
not indulge in alcohol, smoking or the use of other drugs.

What is the treatment?
It is usual to have a surgical ‘cleaning’ of your uterus, especially
if the miscarriage was early in the pregnancy and bleeding
continues. This is called a dilation and curettage (D&C). However,
many women, in consultation with their doctor, choose to
‘let nature take its course’ and let it resolve by itself. The
bleeding may then stop in a few days. If it persists, a D&C
is then an option.

Other aspects of treatment include:
• basic pain medication such as paracetamol
• blood tests and possible ultrasound examination
• checking for Rhesus blood grouping (a Rhesus-negative
person may be given immunoglobulin)
• reduced activity and rest for at least 48 hours.
Pay attention to any adverse emotional reactions—make
sure you talk about any unusual feelings. Talk over your
feelings with your partner and family.
You will need at least a week off work.

How soon should you wait before trying
again?
You can safely start trying to get pregnant again very soon. It
is best to wait until you have had at least one normal period.
Your next period may be heavy and abnormal. Use sanitary
towels and not tampons for the next 4 weeks.
Make sure that your body is ready before having sex again.
It usually takes a while to become interested in sex again, and
therefore partners have to be very patient and understanding.