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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

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

    • History Taking http://www.flickr.com/photos/koolwaaij/2654610149 /
    • 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
    • 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
    • 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
    • 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
    • Privacy Act Key Concepts ( http://www.privacy.gov.au/materials/types/law/view/6892 )
      • 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
    • KEY QUESTIONS
      • 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?
    • What information needs to be collected and what information given by midwife?
      • Demographics
      • Present pregnancy
      • Previous pregnancy
      • Medical history
      • Family history
      • Social factors
    • 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
    • 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
    • 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
    • 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)
    • 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?
    • Present pregnancy
      • Emotional response
      • LNMP - EDD
      • Menstrual history
      • Contraceptive history
      • Pregnancy symptoms
      • Bleeding
    • Social factors
      • Support
      • Mental health
      • Lifestyle
      • Nutritional status
      • Finances
      • Spiritual
      • Family violence
    • 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
      • 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
    • 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