Things for midwives to consider when taking a woman's history at the beginning of her pregnancy
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Transcript of Things for midwives to consider when taking a woman's history at the beginning of her pregnancy
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History Taking
http://www.flickr.com/photos/koolwaaij/2654610149/
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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
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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
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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
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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
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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
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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?
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What information needs to be collected and what information given by midwife?
• Demographics
• Present pregnancy
• Previous pregnancy
• Medical history
• Family history
• Social factors
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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
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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
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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
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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)
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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?
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Present pregnancy
• Emotional response
• LNMP - EDD
• Menstrual history
• Contraceptive history
• Pregnancy symptoms
• Bleeding
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Social factors
• Support
• Mental health
• Lifestyle
• Nutritional status
• Finances
• Spiritual
• Family violence
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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
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• 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
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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