Initial Encounter

Establishing rapport is the single most important aspect of the initial encounter

Several visits may be required to complete all sections of the assessment.
Complete sections as indicated by the presentation and circumstances of the woman.
Address the woman's needs and withdrawal symptoms before moving on to next sections.
Address the woman in a culturally-appropriate, non-judgemental manner.
Offer help as needed or wanted.
Refrain from trying to "cure" the woman.

Screening and assessment

History*

Medical	· Chronic and acute medical concerns · Medications: prescribed and OTC · Gynecological and obstetrical history (GTPAL, last menstrual period) · HIV, Hepatitis A, B, C (HAV, HBV, HCV), sexually transmitted diseases (STDs) · Family history of substance dependence · Psychiatric history (diagnosis, previous treatment, abuse history, eating disorders) · Previous emergency visits, hospitalizations
Drug Use	· How much alcohol do you drink? (See the alcohol section for T-ACE) · Do you smoke? If yes, how many cigarettes per day? · Have you ever used cocaine, marijuana or any other recreational drug? (Modify based on drugs used in your community) · What's your drug of choice? Route(s) of use? · Have you ever used drugs by injection? (See infectious disease concerns with injection drug use)
Mood	· How has your mood been during this pregnancy? (See the postpartum section for information on Postpartum Depression)
Woman and Child Safety	· A woman may not readily admit to violence. Disclosure is a voluntary act. If you have any suspicion about woman abuse, consider using the following questions: o Have you been hit, kicked, pushed or otherwise hurt by someone within the past year? If so, by whom? o Do you feel safe in your current relationship? o Is there a partner from a previous relationship who is making you feel unsafe now? · You may also wish to ask about relational aspects of a woman's substance use: o Do you ever use alcohol or drugs in response to your partner's treatment of you? o Do you ever use alcohol or drugs to help cope with fear? o Do you ever feel pressured or manipulated by your partner to use alcohol or drugs? o If you quit using, what would your partner do? Would you be supported? · Child safety: (See the child protection section) o Do you have any children living with you? o Where is/are your child(ren) now? o When you are using, who is usually with your child(ren)? o Has your partner ever threatened or abused your child(ren)?

*Consider using the ALPHA (Antenatal Psychosocial Health Assessment) Form: http://dfcm19.med.utoronto.ca/research/alpha

Needs

Ask to identify her most pressing needs: "Right now, how can I help you most?"

Health:	How do you feel? Are you feeling pain anywhere? Do you feel sick in any way?
Food:	Are you hungry? Do you need something to eat and drink?
Clothing:	Do you have other clothes? Can I get you a change of clothes?
Housing:	Where are you staying? How long can you stay there? Who lives with you?
Safety:	Do you feel safe there?
Family:	What help do you have in this pregnancy? Any children? Others?
Partner:	Do you have a partner? What is your relationship like?
Referrals:	Do you want to talk with Social Work? Legal Aid? Public Health?

Explore the Pregnancy

Patient-centred Model (FIFE)

Feelings:	How do you feel about being pregnant? How do you feel about the new baby?
Impressions/Ideas:	How do you think you got to this place in your life? What are your ideas about where to go from here?
Functioning:	How does the pregnancy affect your everyday life? How will it affect your life later or after the birth?
Expectations:	How can I help? How can we work together?

The overlap of violence, mental health problems and problematic substance use in pregnancy (PSUP) must be recognized. As many as 2/3 of women with PSUP have concurrent mental health problems. In addition, many women with PSUP are victims of physical and sexual abuse either as children or adults. Establishing a therapeutic relationship and sensitive interviewing techniques are required before screening for these co-morbid conditions.

Physical Exam

Ask for permission to examine her and explain what you are doing. Ensure safety, privacy, confidentiality.

Vital signs, fetal heart rate
Weight
Abdominal exam: symphysis fundal height, hepatosplenomegaly
Gynaecological exam can be deferred until second visit unless at patient's request or if urgently needed
Skin: needlemarks, cellulitis/abscesses, bruises/cuts/burns

Investigations

Bloodwork: Quantitative serum β-HCG, routine prenatal bloodwork (hepatitis B, syphilis, rubella), hepatitis C antibody, liver enzymes (AST, ALT), HIV serology
Urine: routine and microscopy (protein), culture and sensitivity
Ultrasound: for dates (if uncertain) and morphology
Consider utility of voluntary urine drug screening (UDS) (with consent) (See urine drug screening)

Pro: Can help clarify an unclear drug history; necessary if considering methadone maintenance therapy.
Con: If framed poorly, can create an adversarial relationship from the first meeting

Intervention

Deal with immediate needs and issues (See Needs)
Treat intoxication and withdrawal promptly (See appropriate protocols with different substances)

Appropriate for hospital admission/medical withdrawal?

Plan for follow-up soon after initial encounter
Be honest and open about any child protection responsibilities. (See section on child protection)

No legal requirement to report the unborn fetus to child protection agencies – consider earlier referral if children in her care

Consider transfer of care to level II/III centre and caregiver according to clinical needs.
If abstinence not achievable at present, focus on harm reduction.

When Interviewing Remember:

Watch for non-verbal cues
Be woman-centred

Explain alternatives and offer choices
Obtain consent for all procedures
Honour her decisions

Appearance of belligerence or anger may signify:

Previous negative health care experience
Illiteracy/limited intellectual functioning
Intoxication/withdrawal/fear/pain
Vulnerability/abuse/mental health problems

General Prenatal Care