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

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

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