THE
PRENATAL
PEDIATRIC
VISIT
Morris A. Wessel, M.D.
Department of Pediatrics, Yale University School of Medicine, and Grace-New haven Comsiunitj
Hospital, New Haven, Connecticut
(Submitted March 25, 1963; accepted May 23.)
ADDRESS: (M.A.W.) Department of Pediatrics, Yale University School of Niedicine, 333 Cedar Street, New Haven, Connecticut.
PEDIATRICS, November 1963
SPECIAL
ARTICLES
926
E
XPECTANT PARENTS, as they anticipate the birth of their first child, oftenre-quest a prenatal interview with a
pedia-trician. They seek to initiate a professional relationship which they believe will
be
helpful when they assume the care of their
baby. Many sociologic changes in the last 25 years have diminished familial, corn-munity, and professional support which
formerly was available to new parents.
Couples, awaiting the birth of an infant, are frequently settled far away from family
and close friends. They depend to a great
extent on each other and on professional
services. This need for more professional service indicates a transfer of demand based on sociologic change, rather than a
lessened capacity of adults to assume
parental responsibilities. What was in former times a normative crisis, with carefully worked out traditional, familial,
and neighborly support, is now a life
ex-perience with decreasing mechanisms for
helping men and women during this
transi-tional phase of their life. Ruth Benedict, noting the lack of support offered by
con-temporary society, urged the development
of social institutions to help young people
assume new roles.1
Most women, as they approach
mother-hood for the first time, relinquish a job which has many satisfactions. They must give up relative personal freedom, eco-nomic reward, and social prestige. Contem-porary high school and college education prepares young women for careers rather than for parenthood. The change from the
somewhat well-demarcated responsibilities
of a position to the continual and
unpre-dictable demands of being a parent requires
extensive reorganization of a woman’s
out-look. The immediate rewards are not always
satisfying to a new mother. Some women
possess the capacity of moving quickly into
this new phase, while others take longer to
achieve a state of psychic equilibrium.2
Men, too, must reorient their thinking as
they prepare to assume the responsibility for
a child. They need time to develop skill in
assisting their wives in their new role of
motherhood.
The organization of medical practice has
undergone many changes which influence
professional care available during
preg-nancy, delivery, and early parenthood.
Spe-cialized obstetric and pediatric care increase
the availability of modern technical skills
which are unquestionably lifesaving to
many mothers and infants. At the same
time, women lose the psychologic
advan-tage of the continuous care and interest
of-fered by the trusted family doctor. The
ob-stetrician, by virtue of interest and training,
concentrates on a woman’s needs during pregnancy, labor, delivery, and postpartally.
Thereafter he relinquishes much of his
rela-tionship to the mother, as the pediatrician
assumes the dominant responsibility for
helping the woman in her new role. Thus,
while reorganizing her psychologic outlook
to include parenthood, a woman is asked to
relinquish a relationship to one physician
who has supported her through part of this
SPECIAL ARTICLES 927
with another physician, the pediatrician.
Recognizing the difficulty that women have in establishing a new relationship at this time, many pediatricians find it mutu-ally valuable to arrange a pediatric prenatal visit as a routine procedure. Obstetric
col-leagues are eager usually to refer patients. Many obstetricians are glad to know that
the contact with a pediatrician is estab-lished. There is, then, a mutual readiness
for any crisis which may arise. This is true
whether the crisis is a “normative crisis” common to all parents, or a “medical crisis” such as the birth of a premature infant, or
a critical illness in the newborn infant. Couples usually seek an appointment in
the eighth or ninth month of pregnancy. Husbands who are eliminated from
shar-ing in any direct way tile relationship
be-tween a woman and an obstetrician, usually
accompany their wives.
The initial portion of the interview
con-sists of becoming acquainted. Questions
such as, “How long have you lived in this
community? What kind of work do you do?” establish rapport and provide opportunity to gain impressions concerning the social, economic, and cultural background of the couple. The physician’s interest in the
couple’s life situation, their education and occupation, their housing and family rela-tionships, conveys a feeling that he is inter-ested in them as people, as well as in their infant, yet to be born. The pediatrician, knowing that the obstetrician is actively caring for the woman’s medical needs, is free to concentrate on her concerns related
to the baby. He “feels his way” as to how he can be of most help.
As the couple become increasingly
corn-fortable in the interview, they talk more freely. Such a simple question as, “How ilave you been feeling?” directed to both
wife and husband offers a fertile field for gaining insight into the couple’s immediate experiences as they approach the birth of
the baby. Pregnancy involves intense
physi-ologic and psychologic upheaval, and the degree with which they are resolved by any
woman bears influence on the way in which
she cares for her infant. The woman who
feels miserable, depressed, overtly anxious,
or who suffers nausea, vomiting, or toxemic symptoms has a very different background
for approaching parenthood than does the woman who has “never felt better in my life” during pregnancy. Many women pres-ent, as a reflection of the intrapsychic
re-organization inherent in pregnancy, obvious
depression, nightmares, and intense anxiety
which respond well to the supportive rela-tionship offered by a sensitive physician.2
Women’s physiologic and psychologic
dis-comfort during pregnancy is well recog-nized, but the number of men who report
nausea, vomiting and cramps, sleeplessness and irritability, is surprising. This indicates that men, too, experience intense psychic reorganization as they anticipate
parent-hood. They benefit from the supportive in-terest of the pediatrician.
As the couple tell of their own symptoms, it is an appropriate time to obtain a family
history, of allergic, metabolic, neurologic diseases, blood incompatibility, and other
pertinent facts. One can sense areas of un-usual concern which are based on realistic past experiences of illness within the im-mediate family or among acquaintances. Once a comfortable relationship is estab-lished, couples usually ask specffic
ques-tions. Inquiries, in general, fall into one of three areas : questions concerning equip-ment for the baby, details regarding care
and health of the infant, and arrangements regarding telephone communication, night
coverage, frequency of visits, fees, and the like.
We discuss basic needs, focusing on gen-era! areas, such as arrangements for a place
for the infant to sleep or lie awake, for changing, feeding, and washing; and for transporting the baby, a collapsible carriage
or car bed is a necessity. Plans for diaper
service or a realistic means of washing diapers need to be discussed. Couples, for
example, living on the third floor should not depend on a washing machine in the base-ment during the first few weeks.
plans are considered. The couple’s
arrange-ments reflect the only way in which they
can demonstrate their readiness for
parent-hood. They must “buy the right things,”
“re-arrange the house in the right way,” etc.
The pediatrician as he listens, making an
oc-casional practical suggestion, provides
as-surances and support. This approval helps the couple establish confidence in their
capacity to assume the care of a child. Infant feeding is an important area for
discussion during the prenatal interview. Most women settle in their own minds
be-fore delivery whether they wish to nurse or formula feed. The psychologic
deter-minants leading to this decision represent
deep-seated forces which more often than
not are understood poorly by women them-selves. Husbands’ feelings, too, must be
con-sidered, since it is virtually impossible for
a mother to nurse her infant successfully if a father is unenthusiastic about the
pro-cedure.
Although a pediatrician may have definite
preferences as to breast or bottle feeding,
he makes the most effective use of his
pro-fessional role by supporting a woman in her ovn decision as to feeding method. To urge a woman to breast feed, when she feels un-comfortable as she considers nursing, may intensify already existing conflicts and weaken ratiler than strengthen a mother-infant relationship. The attempt at breast
feeding is usually unsuccessful, and infants are weaned in a few weeks. As he helps to choose appropriate bottles, nipples, and sterilizing equipment, a pediatrician
con-veys his desire to aid in the successful
es-tablishment of tile best possible feeding re-lationship for a particular woman and baby.
There are, on the other hand, many women desirous of nursing, whose
con-fidence is shaken by cultural, familial at-titudes, and all too often by nursing and medical personnel. The pediatrician’s inter-est in a woman’s wish to breast feed, and
his promise to be available at the time of
the initial feeding, develops confidence in
her capacity to breast feed successfully. Discussion of the details of the first few
feedings reassures women as they think
ahead. They should be told about the proper length of time for the breast
feed-ings. Women should be urged to seek the assistance of nurses so that they can have help in finding comfortable and relaxed
positions while u#{176}
Expectant couples have many questions regarding infant care in the hospital. They
feel more at ease when they know the
de-tails of when and where they will first see their infant, when tile first feeding occurs, and what the geographic relationship will be between mother and infant. In many hospi-tals, the lying-in routine provides for the father, mother, and infant to be together
for 20 or 30 minutes shortly after the birth of the infant and before tile mother leaves the delivery floor. Expectant couples look forward to this first visit as a family. In
areas providing optional rooming-in
facili-ties, the pediatrician discusses the details of patient care. The value of this plan de-pends, to a great extent, on the interest of
professional personnel in utilizing the bed-side arrangements as a means of improving the psychologic and physical comfort of the
‘8 The opportunity to gradually
as-sume responsibility for the care of an infant
appeals to many women. Husbands fre-quently anticipate with joy the prospect of donning a gown and holding their infant.
Some women, however, find that the
con-0 In many centers pediatricians and obstetricians
support nursing programs which include prenatal
“breast care” classes for expectant mothers. Women
are shown how to care for their nipples and are
taught to express manually colostrum from the breast. This latter technique is much easier to learn
and practice prenatally. The expression of colostrum towards the end of pregnancy has been shown by
Wailer to decrease the incidence of painful en-gorgement in the postpartal period, presumably by keeping the lacteal ducts open, and thus preventing stagnation and inspissation of secretion in the ducts
which could cause obstruction.’ Pediatricians, particularly those who carry supervisory responsi-bility for nursery policies and prenatal classes, are
in a strong position to provide additional help to
mothers who wish to nurse their infants. The writ-ings of r’4 Naish,5 and Barnes et al.6 are
SPECIAL ARTICLES
tinued presence of the baby evokes the
feel-ing that they must take more responsibility
than they are ready to assume either
phys-iologically or psychologically. They feel more comfortable utilizing the nursery for the care of their infants during the
lying-in period.
As the interview continues, expectant
par-ents, becoming more at ease, bring into the
conversation tlleir specific concerns and
anxieties. Tiley ask when their baby will be examined. Any couple awaiting the birth of
a baby wonder about the infant’s health.
There can, of course, be no guarantee that
a baby will be in perfect condition. As the husband and wife tell in their own words of unfortunate experiences of friends or
rela-tives, they benefit by sharing their thoughts with their pediatrician. It is as though they
say, “I told you my fears; you can worry
about them. Now I can relax.”
The pediatrician learns wilich areas are of greatest sensitivity for a particular couple. Past experiences, either personal or among
friends, such as a history of delivering a
premature infant who failed to survive or an infant with a fatal heart disease, or the birth of a defective infant, or an infant
rith a critical illness will, of course, increase
a couple’s concern. Every adult person
knows of a family where a tragedy of this
nature has occurred. Reassurance
consist-ing of comments such as “I hope your baby
will be in good llealth. The chances are, you know, definitely in our favor. I will
ex-amine the baby as soon as I can and tell
you how he looks to me,” can be helpful. When there is a specific reason for unusual concern, the pediatrician may offer to
ex-amine the infant in the delivery room
shortly after birth. One can, if the anxiety is intense enough, consider this a medical
emergency in the same category with many
house calls where the organic illness is
minimal, hut the parents’ anxiety necessi-tates the presence of the pediatrician.
Another area which should be discussed in the prenatal period concerns that of
household help for a mother during the first
weeks at IlOme. Women vary,
physiologi-cally, in their readiness to assume the im-mediate care of an infant. This variation occurs in both primiparous and multiparous women. An efficient, somewhat possessive baby nurse, may be a constant source of ir-ritation to a mother who is ready to assume
full responsibility for her infant. Yet, to another mother who needs more time to
reach a state of equilibrium, this type of
nurse is a great asset. Tile former mother may do vell with a part-time housekeeper
who cleans, prepares meals, and goes home,
while the latter may need round-the-clock
help for a few weeks. Some couples find that an ideal plan is for the husband to arrange his vacation at this time; or a
grand-mother or a sister may be able to help
out for a few hours each day. This may be all that is necessary. Care must be taken in
this prenatal discussion to aid the expectant
woman in achieving the kind of help which
will meet her needs.
Women experiencing a second pregnancy often seek an opportunity to discuss with their pediatrician their concerns about the care of an older child during the lying-in period and the first months at home with the
new baby. The first born youngster, who is usually of toddler or nursery school age, may demonstrate behavioral changes during pregnancy. Whether or not a young
child senses the fact of the pregnancy, the motiler’s own psychic involvement and her
attitudes toward tile first child convey tile
impression that something is happening. The child reacts by becoming increasingly
more restless and demanding. He may be-come openly aggressive. The mother, often weary and physiologically uncomfortable,
is uneasy at this change in her child’s
be-havior. She may be torn between “babying him as much as possible” and “withdrawing a little” hoping this will help him “grow up before the baby arrives.” She may try to complete toilet training, discontinue the bottle, and put him into a big bed, etc., all at the same time. This parental pressure may intensify the child’s disturbing be-havior.
930
these behavioral changes. They wonder how
they will ever manage to assume the care of another infant. The sharing of this
feel-ing with the pediatrician provides
oppor-tunity to gain understanding of the child’s behavior. His encouraging expression of confidence in a woman’s ability to function
effectively with a larger family aids in the
reorganization of her outlook to include ad-ditional responsibilities.
There are specific suggestions which a pediatrician can offer. Many 3 and 4-year-old children are concerned as to the physi-cal process of birth. A simple discussion of the biological facts is in order. Older chil-dren are frequently ready for a detailed
discussion of the biological facts of con-ception and delivery.
The pediatrician helps the mother arrive at plans which strengthen the child’s
Ca-pacity to adjust to the events surrounding
the birth of the baby. Children should
know how long their mother expects to be absent. They should meet the substitute par-ent who will take care of them during the
lying-in period. Telephone and mail contact
are valuable means of maintaining the
rela-tionship. All too frequently, the parents
re-frain from calling, fearing that it will
up-set the child at home. This reflects the
be-lief that a child who cries is worse than a child who doesn’t. Just as a wife enjoys
a phone call from a husband who is out of town for a few days, so also do children benefit by a conversation by phone when separated from their mother. These sug-gestions, which appear simple and
straight-forward, frequently are overlooked. They represent practical means of aiding a child
to use his own resources as he handles
adjustments inherent in the birth of a new sibling.
SUMMARY
Various topics of discussion which occur
between expectant couples and a pedia-trician have been presented. The subject
matter in the interview varies in individual circumstances. The relationship which can be established prenatally with the pedia-trician offers a valuable supporting force as
expectant couples approach parenthood. The pediatrician finds it easier to provide
professional service after the birth of the baby when the relationship between phy-sician and parents is well established during
the pregnancy.
REFERENCES
1. Benedict, R.: Continuities and discontinuities. Psychiatry, 1:161, 1938.
2. Bibring, G. L. : Some considerations of the
psychological process in pregnancy. Psycho-anal. Study Child, 14:115, 1959.
3. WaIler, H. : Clinical Studies in Lactation.
Lon-don, William Heinemann, 1938.
4. Wailer, H. : Incidence, causes and prevention
of failure of breast feeding. Brit. Med.
Bull., 5:181, 1947-1948.
5. Naish, C.: Breast Feeding. London, Oxford,
1948.
6. Barnes, G. R., Jr., et a!.: Management of breast
feeding. J.A.M.A., 151:192, 1953
7. Jackson, E. B. : Theoretic considerations and parental observations relating to unified
hos-pital care of mother afl(1 infant. Proceedings
of Third American Congress on Obstetrics
and Gynecology, 1947, pp. 8-17.
8. Jackson, E. B. : Pediatric and psychiatric
as-pects of Yale rooming-in-project. Conn. Med.
