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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