A family practice approach to the pediatric prenatal visit
Patricia Gallagher Becker
Although recommended by many authorities, prenatal pediatric visits are not regularly scheduled. Thirty to 45 minutes should be allowed for review of the family background, obstetric history and psychosocial factors. The discussion should also include hospital concerns, as well as the practical and emotional aspects of returning home with a newborn. In addition, issues such as sleeping arrangements, safety, diapers and feeding should be addressed.
A prenatal pediatric visit has been encouraged for many years and was recently endorsed by the Committee on Psychologic Aspects of Child and Health Care of the American Academy of Pediatrics (AAP). Most family physicians will already be familiar with the family, and this visit will often be a routine part of good prenatal care. However, the physician-family relationship may be a new one if the referral has been generated by an obstetrician.
When the family physician is meeting the family for the first time, a prenatal pediatric visit provides the opportunity to achieve several goals. The physician can (1) become familiar with the pertinent aspects of the current prenatal history; (2) review the family history, concentrating on potential heritable disorders; (3) identify psychosocial factors that have an impact on the family’s adjustment to a newborn, and (4) lay the foundation for a long-term physician-family relationship.
Often, the family physician will already be providing care for family members but will not be providing prenatal care for the current pregnancy. In such cases, a prenatal pediatric visit allows the opportunity to review medical and psychosocial issues relevant to the pregnancy and to prepare for subsequent neonatal and well-child care.
Although this article is written largely for the family physician who does not provide obstetric care, most of the information will also be relevant to family physicians who include a prenatal pediatric visit in their routine prenatal care.
The format and content of the prenatal interview vary but should include the basic steps of reviewing the prenatal and psychosocial histories and discussing parental concerns regarding hospital and home .
The visit is scheduled with both parents during the latter part of the third trimester. The interview should last 30 to 45 minutes, allowing an opportunity for the parents to review their concems. Parents have reported being highly satisfied with this type of interview, because it gives them a chance to discuss their anxieties before the arrival of the infant . Although prenatal classes are widely available, Pridham and Schutz found that the educational resource rated highest by expectant parents was the prenatal discussion with their physician.
Early morning and late afternoon appointments are usually more relaxed, without the pressures of a busy waiting room. Since the examination room may be rather cold and imposing, the physician’s personal office may be a more appropriate setting.
Some physicians arrange to conduct these visits with small groups of expectant parents. This method conserves the physician’s time and generates a lively discussion of concems and questions shared by those attending.
The pediatric prenatal visit starts with a routine medical and family history, focusing on conditions that may affect the fetus or the perinatal course. Having established rapport in this way, the family physician can move on to the psychosocial history, concentrating on issues related to bringing a new family member into the household.
If the pregnancy has been followed by the family physician, a review of the prenatal history is, of course, unnecessary. Table 1 provides a summary of information to be obtained when the family has been newly referred.
The prenatal history should include the estimated date of confinement, information obtained by the obstetrician, such as the results of uterine sonograms and any complications of pregnancy (e.g., diabetes mellitus, preeclampsia). Questions about the outcome of previous pregnancies and any difficulties with conception of the current pregnancy may yield information pertaining to both medical issues (e.g., recurrence of Down syndrome) and psychosocial problems (e.g., risk of vulnerable child syndrome).
Inquiries about the health of both parents are important, particularly those regarding conditions that may adversely affect the fetus or newborn. For example, when a parent has a history of congenital hearing loss, the infant should be screened for the presence of hearing loss in the nursery. A mother with Graves’ disease may give birth to a hyperthyroid or hypothyroid infant, or a mother with systemic lupus erythematosus may have an infant with congenital heart block.
In some cases, parents may omit a significant item from their medical histories, but the astute clinician may observe a physical finding, such as the “stare” of Graves’ disease or the butterfly rash of lupus, that will lead to tactful questions about an important medical condition,
Any drug use, including prescription and nonprescription medications, should be reviewed. Substance abuse, including smoking and alcohol use, needs to be addressed, In addition to obtaining the history, the physician can use this inquiry as an opportunity to discourage the parents from smoking, especially around the infant. Psychosocial History
The social history should include the parents’ occupations, their plans for work or child care after the birth, their routine living patterns and some estimate of their financial status.
If the family physician has not met the family previously, an important question to ask is:”Was this a convenient time for you to become pregnant?” The physician may discover that the expected child is being viewed as the solution to marital turmoil, that abortion was considered earlier in the pregnancy or that one of the parents has significant depression due to the pregnancy. The responses to whether this was a planned pregnancy may uncover a situation in which the infant may be at high risk for abuse.
Questions about the emotions surrounding the pregnancy are even more important in the case of the pregnant teenager. The physician should ask whether or not the mother will be returning to school and who made the major decisions about the pregnancy.
With the decline of the extended family in American society, it is also important to find out what support systems will be available for the expectant parents, particularly when neither parent has had much previous child care experience. This is a good opportunity to prepare the parents for the inevitable changes in their marriage, family relationships and sexual life that will come with the birth. One survey4 has suggested that parents felt they had received inadequate preparation from physicians in these particular areas. Many parents fail to anticipate the fatigue they are likely to experience on arrival of the newborn at home. Counseling about these and other issues is even more critical in the case of families that are anticipating multiple births.
Obtaining a good psychosocial history involves both interviewing skill and observation of interaction between the two parents. If children are brought into the interview, the physician has the opportunity to observe parent-child interaction. Parents need to be counseled about changes in their interaction with the older children (e.g., a decrease in time spent with these children, a probable increase in confrontations). The physician should also warn the parents of the possible behaviors an older child may develop after the birth-attention-seeking, direct aggression and regression, or maturity and independence . Hospital Concerns DELIVERY PLANS
Most parents have fears, anxieties and expectations about the actual birth of their infant. If parents have not yet attended prenatal classes, the family physician may encourage this during the prenatal pediatric visit.
Delivery plans should be discussed. If the pregnancy is high risk or if cesarean section has been planned or mentioned by the obstetrician, the role of the family physician should be explained. A visit to the high-risk nursery may also be in order if it appears that the infant will spend time there. Parents who choose birthing rooms should be counseled that plans may have to be changed if complications develop. Parental anxieties about a previous stillborn infant can be addressed.
Single adolescents need extra reassurance regarding their hospital concems. Prenatal classes taken by both the expectan t mother and the father or another partner are extremely useful and highly desirable. One study suggested that teenage mothers who had a supportive companion during labor experienced fewer perinatal problem s (e. g ., cesarean section, meconiumstained fluid). These mothers were more comfortable during delivery and smiled and talked to their newborns sooner after delivery.
Specific anxieties of parents involving religious restrictions on medical care in the hospital may be addressed. A Jehovah’s Witness may want to avoid blood transfusions, or a Jewish family may not want their male infant circumcised until the eighth day.
More parents are choosing out-of-hospital births (home or birthing-center births) that are attended by physicians, nursemidwives or lay midwives. Some parents may even choose to have an unattended birth, Such deliveries have increased significantly among the socioeconomically advantaged and well-educated population. Because of the small numbers of such births, however, few inferences can be drawn regarding the safety of planned, out-of-hospital births. In one study, 8 it was clear that women delivering out-of-hospital actually used more prenatal care. The same study showed a decline in physician-attended out-of-hospital births.
Parents planning home births must be counseled in a noncritical manner. Alienating the parents may drive them further away from medical care. Risks of home births should be reviewed carefully. The telephone numbers of the involved physicians should be given to additional family members or friends, with plans for someone other than the father to transport the mother and infant to the hospital should problems arise. The importance of vitamin K prophylaxis, particularly in breast-feeding infants, should be explained. The need for a newborn examination within 24 hours of the birth should be stressed to the parents, so that complications, such as late hemorrhagic disease of the newbom or meningitis in an infant with a myelomeningocele, can be avoided. If there is any possibility of blood group incompatibility, the parents should be advised to seek early medical attention.
Most physicians agree that the decision concerning circumcision should be made prenatally. Despite the 1975 statement of the AAP Ad Hoc Task Force on Circumcision that “there is no absolute medical indication for routine circumcision,” little change has been noted in the frequency of the procedure. In-depth counseling also has had no demonstrable effect.”
Why is circumcision so widely performed? In one study” “cleanliness and health,” social custom, a circumcised father and physical appearance were the most frequently cited reasons. Decreased risk of infection or cancer were cited much less frequently. According to Gellis, physicians have not been convinced that circumcision is of little benefit and have therefore been reluctant to discourage it.
Parents should be informed that circumcision may prevent cancer of the penis. However, this malignancy is rare, and good hygiene may contribute to its prevention in both uncircumcised and circumcised males. A recent report 14 suggests the possibility of increased urinary tract infections in the uncircumcised male. Because of these new studies, the AAP has released a new statement on circumcision, concluding that the procedure has potential medical benefits and advantages, as well as inherent disadvantages and risks. The AAP recommends that the decision is one best made by parents in consultation with their physician.
The possibility of the infant’s roomingin after the delivery can be mentioned. Parents should also understand the typical length of the hospital stay and the newbom screening procedures that may be mandatory in certain states.
Discussion of home concems involves two major areas-the practical aspects (‘Are things physically ready at home?”) and the emotional aspects (“Is the family ready for major changes at home?”).
The physician should ask parents about their plans for sleeping arrangements. If the parents seem extremely anxious about having separate sleeping accommodations for the infant, they may be reminded that they may disturb the infant’s sleep as much as the infant may disturb their sleep. In addition, the presence of the infant in the parents’ room will result in further disruption of the usual home patterns, especially the sexual relationship between the parents.
To ensure crib safety, parents need to know that crib bars should be no more than 2 3/8 inches apart, mattresses should be snug-fitting, and large pillows or crib toys with small parts should be avoided. Car seats should be discussed and parents reminded that th”first ride should be a safe ride.” The parents can be referred to car seat loan programs, or they may request a car seat as a gift. Parents should also be advised of the potential danger of family pets, which may become aggressive when the new infant appears to be invading their territory.
Parents should be informed that the more occlusive the diaper, the higher the likelihood of dermatitis. Newer disposable diapers with absorbent gelling materials (e.g., UltraPampers) have been associated with a lower incidence of diaper dermatitis . Home-laundered cloth diapers appear to have the highest frequency of dermatitis, which is probably related to higher bacterial counts and residual chemical irritants. A cost-comparison chart detailing the expenses of different types of diapers and diaper services from the physician’s area might be a helpful addition to any other printed material that is distributed during the prenatal visit.
Probably the most important home concern is feeding. Studies have shown that the decision to breast-feed or bottle-feed is made by nearly 50 percent of mothers before pregnancy. Physicians in general have been viewed as unhelpful in this decision.
It is important to present the advantages and disadvantages of both methods in an impartial fashion so that parents may choose the one that is best suited for their personalities and lifestyles (Table 2). Breast feeding is strongly recommended for fullterm infants in whom there are no specific contraindications.
Both the AAP’s 1978 commentary on breast feeding and the AAP’s policy statement on promotion of breast feeding stress that the decision to breast-feed is the result of many factors-education, cultural background and personality. To promote successful breast feeding, physicians and supportive health care personnel must be knowledgeable about infant nutrition, the physiology, value and technique of breast feeding, and the effects of maternal drug use on the nursing infant. Modifying the hospital routine to allow mothers easy access to their infants can be quite important to successful breast feeding. This can be accomplished by encouraging roomingin or cooperative care arrangements.
Mothers who choose not to breast-feed and those unable to breast-feed also require support. Physicians may have to dispel various myths to reassure their patients that breast feeding is not for everyone .
Family adaptation after the mother and infant come home should be mentioned. Will grandparents or others be available for assistance during the first few days? Recommending books on child care and child development is generally helpful.
A mild and transient form of postpartum depression (the “blues”) should be mentioned as a normal event for many mothers and fathers. Although depression does not always occur, parents need to understand this is not an unusual phenomenon. Any potential need for social service assistance can be explored.
Concluding the Interview
Many physicians reserve the final part of the interview to review their fee schedules, office hours and coverage of night and weekend calls. A written schedule of expected well-child visits and immunizations during the first year allows the family to plan accordingly.
COPYRIGHT 1989 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group