Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Value of the Pre-Baby Visit
Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family. While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.
pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk predictablePregnancy brings mental and emotional changes in a for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.
In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.
The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.
The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a pre-baby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:
Asking about the history of previous pregnancies and the course of the current pregnancy so far.
Asking whether flu and Tdap vaccines were given.
Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.
Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”
More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!
The delivery method is not completely a choice but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!
Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.
You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though the mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!
Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!
Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories of how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!
Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at email@example.com.