PRENATAL CARE: is the art and science of helping a woman and baby through pregnancy.

 

The goal is to culminate with a healthy mother and healthy baby. Science and fact can help us achieve this goal. The problem is that not everyone sees the same facts -- or understands them in the same way. An agreement on facts can help us reach agreement and understanding, even if our philosophies differ widely. Midwives NEED to know the same facts which doctors know. I think every midwife should be able to hold her own with any obstetrician on the subject of normal childbirth! Stand proud. We should learn the medical language -- facts, the definitions,  and   the buzzwords -- even if we would never use term with our clients or even if we disagree with them!

 

-- reaction to facts: seeing what’s there. Sometimes midwives and doctors overreact to certain facts - and under-react to subtle ones.  We have to walk a careful balance Is  a problem really a problem -- is it only a “potential” problem. “Risk” does not equal "fact" - it only means potential. What is the real risk? Is it detectable preventable, beneficial to avoid -- does the treatment outweigh the risk, or the potential risk?

 

POINTS OF PRENATAL CARE

 

1. Is the woman healthy and is she likely to remain healthy? Does she have underlying problems; infections, malnutrition, anemia – or some uncommon but serious conditions like heart disease, diabetes, renal disease thyroid etc? How can we discover this?

·         (there is great value in a recent physical exam. In  a perfect world, all pregnant women would have a complete physical about three months before they conceived)

·         complete family history

·         complete medical history

·         complete current history - symptoms.

 

(SIMPLE DETECTIVE WORK can discover most problems, or most potential problems. Sometimes things just come out of the blue, but they USUALLY are the end point on  a long pathway. If we can discover the problem BEFORE it is serious, we might be able to still achieve a happy ending.

 

CHARTS

Charts can help us a lot especially in our early years. Some people like everything written down, so that every question is asked. I personally dislike paperwork and prefer to write only if something is there -- rather than having rows of boxes marked "no". But you should do what's most comfortable for you. Some people work off of a list - or you can ask the questions by 'category". Or more conversationally , as in “Tell me about yourself....Have you ever been in the hospital, ever had an operation, have you seen the doctor for any reason in the last five years?” etc.

Do what works best for you -- just make certain the questions are asked!  (You are Sherlock Holmes on a detective mission! Ask those probing questions. Search out the facts!

Ask about: personal history, gyn history, birth history, social history.

hint: don't make this an interrogation session. it can be a tool to help you get to know the woman and to see her in the whole context.

CHARTING – is a visual record of the FACTS of the course of the pregnancy. We gather each fact to help us Use your charts to help you “see” the pregnancy! (charts may also be a legal document or tool, but that’s a separate issue).

 

2. FIND OUT what’s wrong, but also find out what’s RIGHT! Reassurance and reduction of anxiety are some of the most important parts of prenatal care - in fact, since problems are rare then most of our focus should be on reassurance, education, and family aids -- remember our wider goal is to help the baby enter a healthy, loving family, and a healthy loving world. Everything is a piece of the picture. -- a healthy baby with an injured, anxious mother and isolated father, is born with a handicap, even though all is physically well. Wellness is a wide concept -- it includes social, emotional economic, generational, and even “national” health.

 

At every prenatal ask yourself:

·         what is “right” about this pregnancy  (and TELL the woman - she needs to hear this)

·         is anything  “wrong” here. (SHE MIGHT - OR might not, need to hear THIS).

·         is something different or unusual. (this might be good or it might be bad -- "unusual" is not necessarily "abnormal" -- and even "abnormal" might not be a bad thing. There is a huge range within the definition of normal.

 

CHARTING – is a visual record of the FACTS of the course of the pregnancy. Use your charts to help you “see” the pregnancy! We gather each fact to help us see the picture -- the clues - the pieces of the puzzle.

 

A STANDARD CHART begins with, at minimum:

·         history - personal and family

·         baselines – initial labwork (blood type, antibody screen, vdrls, hematocrit, hemoglobin)

·         pregnancy test date?

·         LMP. ASK QUESTIONS about the Last Menstrual Period -- was it normal? short, long. Are her periods regular? How SURE is she about that date? Is it just a guess?

·         EDD (estimated date of delivery). Taking extra time to confirm a due date now, will save you a lot of worry later on. (A large portion of babies thought to be postdate are simply babies who were conceived later than first thought). Can the woman remember ovulation symptoms and dates? ADJUST THE DUE DATE according to the woman’s OWN cycle history!

·         Weight – pre-pregnancy, and then on occasion during pregnancy

·         blood pressure

·         pulse (for a baseline). There is no need to repeatedly take the pulse

 

 

PRENATAL VISITS

Time according to what is usual in your community; usually monthly till 32 weeks then biweekly or weekly after 34.

Chart:

·         Date: (including year)

·         Weeks: wks (gestation according to lmp)

·         Fundal Height: FH, the height of the uterine fundus measured in centimeters above the woman’s pubic bone should equal roughly the weeks of gestation –within about 3 cms range. This measurement is useful ONLY AFTER 20 weeks. It is not accurate before that point, and is only a very rough guage afterwards. Consider it as a tool to measure consistent growth – IE 4 weeks equals 4 cms growth. (Traditional landmarks work better – but may be harder to quantify). Write them down anyway!

·         Blood pressure: BP. Many things can affect BP, especially the systolic measurement – anxiety, last meal, caffeine, smoking, position, talking etc. The BP normally ranges throughout the day (is probably lowest about an hour after a large meal). A rising BP “may” be a sign of pre-eclampsia.

·         Edema: ED. Almost all women have edema to some degree. It is normal in pregnancy, but note if it increases or if it is “above the waist”.

·         Urinalysis: UA. Many are beginning to do “dipsticks” less routinely – testing for glucose or protein occasionally or according to symptoms.

·         Fetal Heat Tones: FHT. (Or Fetal Heat Rate, or Baby’s Heart). Range, location, reactive?

·         Fetal Position:

·         Your remarks: how is the woman feeling, how is the baby moving (ask!). Any questions, changes, worries?