1. Max Brinsmead MB BS PhD May 2015

2.  To date the pregnancy  But ultrasound is more accurate  To identify problems requiring pro active care  Antenatal care is an exercise in screening  To establish rapport  In order to prepare patients for childbirth and parenthood  Is difficult unless there is continuity of care

3.  Pregnancy dating  Past obstetric history  Past medical history  Social and Psychological Profile  Drug history  Family History

4.  Is important because… ▪ Both pre term and post term pregnancies are at risk ▪ As is being small or large for dates ▪ Many tests require dates for accurate interpretation  Begin with LNMP and cycle length ▪ Inaccurate indicator of conception in 1:3 women  Date when fetal movements are first felt ▪ 16 – 22w in Primigravida & 14 – 20w for Multipara  The EDD is calculated by Naegele’s rule ▪ Add 9 months and 7 – 10 days to LMP ▪ Or use an obstetric wheel

5.  A few women keep a menstrual calendar  Go back over important events  Coital history sometimes helps  “When did you first think you might be pregnant” ▪ Assisted conceptions ▪ Date of the 1 st missed period ▪ Date of the 1 st positive pregnancy test ▪ Fetal movements  Date of the first scan – and its EDD  Date of EDD from the 1 st examination

6.  Let the woman tell her own story ▪ This tells you about “where she’s coming from”  But the essential information is… ▪ Date and outcome of all pregnancies ▪ Gestation and birthweight ▪ Complications of pregnancy ▪ Onset and length of labour ▪ Mode of delivery ▪ Complications of the labour, birth or puerperium ▪ The baby  Facilitated by a form or aide memoire

7.  “Serious illnesses or operations” ▪ But especially those that may impact pregnancy  Trigger phrases that I use… ▪ Heart problems or rheumatic fever ▪ Asthma, bronchitis or other lung problems ▪ Kidney disease or bladder infections ▪ High blood pressure ▪ Blood clots or thromboses ▪ Nerves or depression ▪ Back or spine problems ▪ Serious accidents or blood transfusions ▪ Sexually transmitted infections ▪ Pap smears and gynaecological operations

8.  “Is this a planned pregnancy”  Age, education, occupation & religion  All about the partner (or father of the baby) ▪ The relationship – how long and how good ▪ His age, health, occupation and family ▪ Domestic violence  The in-laws and outlaws ▪ Especially relationship with the patient’s mother  Do you have all your previous children with you?  Pregnancy and birth plans  “Do you wish to meet with a counselor”

9.  Smoking, Alcohol, Prescribed and Other Drugs  Trigger phrases that I use… ▪ Do you smoke, how many, do you have to, have you ever stopped ▪ What is your favourite alcoholic drink, how often, how many ▪ Are you taking any other vitamins, minerals or supplements ▪ Have you ever injected yourself with drugs ▪ Do you use pot, marijuana or any other recreational drugs ▪ How about your partner

10.  Usually Hypertension, Diabetes & Twins ▪ But routine screening makes the latter 2 superfluous  Trigger phrases that I use… ▪ Do you know of any inherited conditions that run in the family like anaemia, birth defects, stillborn babies or babies that did not survive ▪ Have there been any early deaths from heart disease or strokes, blood clots or thromboses ▪ Anyone in the family who suffers from depression or nerves ▪ Epilepsy or any other handicaps ▪ Anyone in your family require Caesarean section

11.  Single out pregnancies that are abnormal, disordered or high risk…  In order to provide interventions that will optimise an outcome  So this is an exercise in screening  That starts with the history

15.  Sensitivity = the chance that the disease will be detected  Positive predictive value = the chance that a screen positive individual will have the disease

16.  Is there a good screening test available  Is there an intervention available  Is the disease worth detecting  Will screen positive patients comply  Will the test reach those applicable  Has the program been tested by RCT  Can the health system cope with the program

17.  Unless the answer that you get will help you in the care of your patient  And never do an examination or a test  Unless the result is going to influence what you do next  This is especially true for the physiological event that is Pregnancy and Childbirth

18.  Read the companion text to this Powerpoint :  www.brinsmead.net.au/mdoc/ModelANRecord.pdf www.brinsmead.net.au/mdoc/ModelANRecord.pdf