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Things for midwives to consider when taking a woman's history at the beginning of her pregnancy
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Things for midwives to consider when taking a woman's history at the beginning of her pregnancy


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This presentation sets a framework for taking the history of a pregnant woman. If you have any comments about it, please add them to the "comments" section here

This presentation sets a framework for taking the history of a pregnant woman. If you have any comments about it, please add them to the "comments" section here

Published in: Health & Medicine

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  • 1. History Taking /
  • 2. Aims
    • Provides opportunity to assess woman’s physical, psychological, emotional, and spiritual well being and health.
    • Establishment of length of gestation
    • Review of current and past health status in order to maintain and improve health in pregnancy
  • 3. Aims (cont)
    • Review of midwifery, medical, obstetric, social and psychiatric history in order to identify risk factors - early detection of deviations from the normal
    • Awareness of the sociological influences in pregnancy – identification of support networks
    • To provide information that will form basis for informed choice and consent
  • 4. Aims (cont)
    • To commence the preparation of a care plan based on the woman’s individual needs
    • To provide opportunity for discussion of woman’s individual needs and wishes
    • To provide foundation for a trusting relationship with woman and family
  • 5. Process
    • Consider environment - who is there, comfort
    • What info does midwife/woman already have?
    • Woman’s expectations - what info do you need to bring with you, how much time allowed?
    • ‘ Getting to know you’ - communication skills, first impressions, sharing of yourself
    • Privacy Act implications
  • 6. Privacy Act Key Concepts ( )
    • Midwives should only collect relevant information
    • Women must be told why information is being collected
    • Information must be stored securely
    • Women should be allowed access to her information
    • Information may only be shared with other agencies with woman’s permission, or some health and safety or law enforcement reasons
    • Do I need this information?
    • Am I asking the woman for the information and, if not, why not?
    • Does the woman know why I need the information?
    • Am I collecting the information in a way which protects the woman’s privacy?
    • Is the information stored in a way that protects the woman’s privacy?
  • 8. What information needs to be collected and what information given by midwife?
    • Demographics
    • Present pregnancy
    • Previous pregnancy
    • Medical history
    • Family history
    • Social factors
  • 9. Demographic details
    • Full name, address, telephone no (work), DOB, NOK
    • Marital status - ? Long time to get pregnant, support for single mum
    • Ethnicity - special needs/customs, specific conditions
    • Religion - specific needs
    • Occupation - economic status
  • 10. Medical history
    • Any illness, operation or accident which complicate pregnancy
    • rheumatic fever
    • cardiac - hypertension
    • respiratory - asthma, TB
    • renal disease - frequent UTI
    • endocrine disorders - thyroid disease, disease
    • Thrombo-embolic - PE., DVT
    • mental illness
    • STD
  • 11. Medical history (cont)
    • Infectious diseases of childhood - chicken pox
    • Gynaecological operations/breast surgery
    • Accident involving spine, pelvis
    • Deformity to spine or pelvis - CDH, polio
    • Medications - teratogenic effect on baby
    • Previous blood transfusion - reactions?
    • Smoking, alcohol, drug addiction (risk of HIV, Hep. B)
    • Last cervical smear
    • Allergies
  • 12. Family history
    • Woman’s family and close members of father’s familial
    • Familial disease - diabetes, heart disease, deafness, TB (BCG for baby), asthma, eczema, mental illness
    • Congenital defects - Down syndrome, CDH, cleft lip/palate, spina bifida
    • Twins (dizygotic - non-identical)
  • 13. Previous pregnancy
    • Miscarriage or TOP - stage, interventions
    • Full details of all previous pregnancies, labours, births, post natal, including details of babies, feeding - any complications
    • Can you access old notes to confirm details?
  • 14. Present pregnancy
    • Emotional response
    • LNMP - EDD
    • Menstrual history
    • Contraceptive history
    • Pregnancy symptoms
    • Bleeding
  • 15. Social factors
    • Support
    • Mental health
    • Lifestyle
    • Nutritional status
    • Finances
    • Spiritual
    • Family violence
  • 16. Health information and education
    • Choices for pregnancy education
    • Self-care advice - smoking, alcohol, exercise, employment
    • Choices for pregnancy and birthing care
    • Begin development of birth plan
    • Discuss breastfeeding
  • 17.
    • Community support agencies
    • Discuss midwifery/medical students
    • Discuss institutional polices that may impact on choices
    • Information about midwife - share what your expectations are, how you practice as a midwife, your philosophy, your practice statistics/outcomes
  • 18. References
    • Pairman, S., Pincombe, J., & Thorogood, C. (2006). Midwifery: Preparation for practice . Chatswood : Elsevier.
    • Sinclair, C. (2003). A midwife’s handbook .
    • St Louis, USA: Saunders