The Prenatal Visit
by Howard S. King, MD
Parents are often encouraged to meet one or more pediatricians a month or two before they deliver their new baby.
Don’t expect universal support for the concept of a prenatal visit. One parent said that her brother belittled the idea of talking to a physician before her baby was born. He said, "It's how he handles your kid, not how he talks to you!"
Who is the patient? Is it the infant? He or she is not even born yet! Why meet? The fact that you and the parents are meeting makes a number of crucial statements.
Who is the patient?
Surprisingly, this is a basic question throughout the child's growth and development. Parents come in, appropriately, with a list of questions. But when they express concern about their baby, about whom are they really concerned? The questions may seem to be about their infant but, oftentimes, may reflect a different agenda. For example, they may disagree about the management of a particular problem, or the child may remind them either of themselves or some other relative in their current or past family. The questions may also reflect some insecurity with their decision-making or with themselves as to whether they will be competent parents.
Our challenge is to figure out what the real issue is and then, in an alliance with the parents, help them bring their concern to the surface. Helping parents helps children. We need to keep the family in focus at all times.
Forming a relationship
The mother-to-be has had periodic exams with her obstetrician. But now, delivery is imminent. Who will help her cope after her baby is born? As one mother put it, "It all seems so unreal!" The prenatal visit can be a bridge not only to working with a new professional but also to preparing for parenthood.
Parents often bring a long list of questions to the prenatal visit, including: "What are your attitudes about breast feeding?" "How do you feel about circumcision?" "What should I do if there is an emergency?" "How do you feel about silly questions?"
It is not just what we answer, it is how we answer that is crucial. Do we give parents adequate time, do we listen in a way that suggests we are addressing their unconscious concerns, are we listening with empathy, will we help them become competent decision-makers? Most important, do we enjoy listening to their "story"?
Being able to ask "silly questions" is a common concern of parents. With anxiety, and almost apologetically, they want to know how receptive we will be to their various questions. They ask, "Do you have someone in your office who can handle trivial questions?"
I urge them to ask anything. Behind every such question there is a parent who has good reason to be concerned, based on past experience. Or, there is a parent who was raised in an environment that may have demeaned her judgment and competence.
Not only should we attempt answer their questions with thoroughness and compassion. We should also try to make their experience with the "authority figure" of a physician a corrective experience, one in which they feel increasingly competent to trust their own judgment.
Spending sufficient time answering questions will not only be helpful to parents but also helps the child and family grow to their fullest potential.
The prenatal visit can also provide clues, ahead of time, for when we might anticipate a relationship problem with a parent. One mother said, "My husband comes from a family of doctors. He is always looking for a scientific explanation. He can be pushy ... abrasive. But sometimes it is very helpful." Such information helps us to meet the needs of parents and gets communication on the right track from the beginning.
Commitment to prevention
We convey a message when we ask about the parents' history, family history and prenatal fears. The underlying message is, "How can I help parents become competent, how can I help them prevent those problems they are concerned about from happening?
At the same time, we need to be sure that we are functioning within the parents' expectations. Do they want us to help them that way? Will they feel supported or will they feel threatened by a physician who cares about their personal and family functioning?
You are familiar with the standard prenatal visit, and with the kinds of questions that you routinely ask.
How you ask and what you ask about during the prenatal visit makes a statement of your intentions, and you are able to observe how comfortable parents might be with a relationship that explores psychological issues. Thus, asking a question with a preamble like, "May I ask you if ... " gives parents the opportunity to accept or decline as well as prepare them for situations in the future when they might be asked to reveal how they are feeling, or when there are tensions at home.
Also, asking parents what expectations they have about the role of a pediatrician may be helpful. The thoroughness of the interview, as well as how you follow up areas of concern, will reveal your intentions. One parent noted that "counseling" appeared to be my specialty. I said that while it was, some parents might be uncomfortable with a pediatrician who attempts to explore the emotional side of family functioning. I asked, "How would you feel about it?" She said, "I need emotional guidance. I've never been a parent before. I want someone who will teach us how to manage ..."
The challenge is, "When will a parent's or a pediatrician's question become a 'trigger question,' suggesting that the pediatrician should be alert to some hidden issue?" Here are some examples from my practice:
- "How old are you and your husband?"
One parent said, "My husband is 48, I am 33."
Why is there such a difference in age? It turned out that this was his second marriage, divorced at 24. What happened? Does it have any implications for this current marriage or their children?
- "How long have you been married?"
One parent said, "Five years." Was there any special reason why they took five years to start a family? "I wasn't sure I wanted to have a child ... I see myself as a selfish person. Would I want to give up my freedom? ... I have my own business ... [whereas] my mother was a 'sixties' person. She stayed at home, taking care of me and my siblings."
She is sharing her ambivalence. I praise her for her openness. I suggest that she may feel this way periodically, not to feel guilty for having such feelings, and that she can feel comfortable expressing them with me. I support the idea that, over time, she will be able to meet both her maternal and professional needs.
- I am asked, "How do you feel about breast-feeding? Will you be supportive?"
One mother said, "I'm not sure that I want to breast-feed even though my husband is lobbying for it. He thinks it is a great idea. I'm not sure I'll like it." I tell her that I'll support her whatever she decides. She shouldn't feel guilty, however, whatever happens.
- What kind of support system does she have in place?
Where do her parents live? If she is married, where do her in-laws live? Will they be supportive?
One mother replied that one of her parents lived locally, the other lived overseas. "Are they divorced?" She replied, "My parents were divorced when I was six years old. My father was abusing my mother at the time. I started living with my mother until my father kidnapped me when I was seven!" This same mother slept with her baby after the child was born. Her husband was concerned that she might be reenacting what had happened to her when she was young.
Another parent noted his in-laws were going to be living with them after the baby was born. He was worried that it would take them some time to regain their privacy.
Still another mother commented that both sets of grandparents live in another state, and she asked if I would be available to help her cope.
- "Do you have any fears about this new baby?"
"My husband has gripes about what happened to him growing up ... He blames his father for a lot of things ... He still has a lot of 'stuff' ...I worry how he will relate to our new baby. Especially since we know it is going to be a boy ..."
I tell her that there is bad news and good news. The bad news is that it is understandable she is worried that history might repeat itself. But the good news is that if we are alert, we can intercede. Furthermore, if her husband gets involved in parenting, he may discover that he has "a second chance." As he becomes more aware of his feelings he may be able to share what it was like growing up with his dad, learn more about his father's background and, perhaps, come to terms with these old grievances.
Another parent says, "My brother is schizophrenic. He appeared normal until he was sixteen years old." Will she worry if her little boy is shy at six or if he seems transiently moody at a later age? Will she be concerned about leaving him to go to work because she might predispose him to some long range problem?
Another parent was concerned that her child might inherit her husband's amblyopia, and she asked if I would be able to pick up this condition early enough.
- The contract
One parent introduced this topic by discussing a group practice she had interviewed prior to her coming to see me. She noted, "I was told I might have a different doctor each time. I worry about there not being continuity of care."
This gave me an opportunity to talk about what my practice was like, but I also encouraged her to let the group practice know how important continuity of care was for her. Continuity of care would seem to be a crucial issue in a pediatric practice which has as its goals enhancing the competence of parents and attempting to prevent emotional difficulties in children and families.
I also suggested that our ultimate goal is to help parents become good decision-makers. Thus, while some situations (like a high fever or injury) might require an immediate response on my part, our goal should be to help parents figure out why they were concerned about a particular issue. Our task is then to support them with finding a way to achieve their goals.
- The issue of separation
A parent was planning to go back to work when her infant was six weeks of age. She intended to breast feed until that time. "Should I give him a bottle before that?" "Why?" "I'm afraid it will be a tough transition ... I worry that he won't take a bottle." "Then what?" "I won't be able to go back to work!"
I suggested that while it might be a little difficult for her infant, it would be harder for her. She was going back to work, primarily for financial reasons. I felt it might be helpful for her to anticipate the sadness she might feel when she went back. I said she would work it out and her husband and I could help her when the time came. I also encouraged her that her infant would take a bottle when she set her mind to it.
It was important, however, to consider reviewing her and her husband's past history to be sure there were no hidden issues which might make her more vulnerable to the issue of separation. If there was, it might be useful to differentiate those situations from the present where the parents seemed to be functioning in a normal way and appeared capable of healthy adaptation.
- What plans do they have for child care?
If parents don't bring this up, it is important to do so, not only to understand what kind of arrangements they have made but also how they feel about it.
One parent said, "I heard that infants pick up a lot of colds. Is there any way you can prevent that?" This same parent was also trying to cope with her in-laws who felt she should be staying at home with her child. They would say to her, "We got along without a lot of luxuries ... Are you sure you need to work?"
Helping parents work out their ambivalence about working, evaluate the positive or negative feedback they get from people around them, diminish guilt, feel they will be competent to manage -- are important tasks for the pediatrician.
- Reassurance about physical problems.
One father was worried his child might inherit his serious allergy problem. A mother worked in a potentially hazardous industry. "Do you think my child might be predisposed to some type of abnormality?" We need to be prepared to help parents get specific information about such issues.
- Potential feeding problems
One parent asked about adding cereal to a bottle. "They say it helps a child sleep through the night." I suggested that she consider not doing that. I did acknowledge that sleep problems are a common concern during the first year of life. But, regardless of the etiology, I attempted to convey that hunger was rarely a contributing factor.
I said I would help them manage any sleep problems that might emerge, and also tried to have them reconsider the tendency to use food or extra feedings to cope with pain or stress.
- Reassurance about family issues
One parent said, "All of us had horrible colic. My mother said, 'We never slept.' Do you think I'll have the same problems with my infant?"
Another parent called herself "the worrying type." She seemed very anxious. It turned out that her mother had tuberculosis and was hospitalized for a year shortly after she was born. She, in turn, was placed with her aunt during her first year of life. One could hardly be surprised that she expected the worst. But, by linking up with a counselor and talking about that experience, along with continued support, she turned out to be a very effective mother.
Finally, one parent mentioned that she grew up in an alcoholic family. She was worried about her brother who seemed to be treating his child the way she and her brother were treated by their abusive father. She asked, "How do you help a sibling change his ways?"
- The role of fathers
Fathers usually come in for the prenatal visit. At that time, I encourage them to either accompany the mother to the periodic checkups or even come in by themselves. I believe that mothers are helped to get in touch with their feelings and memories as they get involved with the evolving development of their infant. Fathers, who have a harder time with this in our culture, deserve the same opportunity to do so. Reflecting back and forth over time may give them that chance whenever they bring up concerns about their young infant.
It is worth reminding the father that even if the mother is not concerned about a particular issue, he can call you himself. This is not meant to demean the mother's judgment but rather to help him be comfortable with expressing his own fears and anxieties. One father asked, "When should I call?" I said, "Whenever you need to!" "I'm afraid I'll go overboard"" I said, "I'm not worried. You'll gain more and more confidence over time. If you don't, it's my job to help you figure out why."
- Finally, "What should I read?"
This is a common question at the prenatal visit.
While I encourage parents to read anything they think would be helpful, I try to make a few points:
I urge them to be skeptical about everything they read. I want them to trust their own intuition and judgment.
I suggest that within each of them is their own "book." They will write this "book" over time as they listen to their own questions, raise issues, and filter back answers through their own senses. If they can do that, the confidence that may result from mastering current issues will be available to them in future situations.
I pass out a booklet of my own at the prenatal visit. While it has much useful information, I tell them the most useful item is in the title, "Parents Have Rights Too!" The message I want to convey is that parents have to consider their own needs simultaneously with responding to those of their infant. Giving parents permission to consider themselves can validate their ambivalence and help them carry on with the inevitable sacrifices that being a parent requires.