The Prenatal Visit

OBJECTIVES OF THE PRENATAL VISIT

Several objectives can be served by the prenatal visit.

1. Establishing the physician-parent relationship. The prenatal period is a good time to start building the therapeutic alliance that should last throughout the child's pediatric care. Pediatricians who meet with the parents before the delivery demonstrate how much they value this relationship. A prenatal visit introduces the parents to the concept of a medical home for the child's future health and developmental needs.
2. Gathering basic information. The most important information to collect concerns the general assets and needs of the parents and their worries about the expected infant. Pertinent areas to discuss in addition to the family medical history are the parents' own experiences being reared, their background with other children and medical care, complications and concerns with this pregnancy, and possible problems with their newborn. Knowledge about the parents' occupations and education may be useful. Some other matters to cover are basic information on the expected date of delivery, feeding plan (breast or formula), parents' views and current scientific information about circumcision, and other issues about the care of the newborn. Additional issues to consider are the age of the parents and the nature and extent of supporting family and friends. Factors that may be contributing turmoil and stress or stability and contentment to the parents, such as employment, housing, and the likely effect of the arrival of the infant on the family, may be discussed.
3. Providing information and advice. The pediatrician can describe the anticipated behavior of the neonate and the routine care provided in the nursery. It may be helpful to ask, "Have you considered breastfeeding the baby?" This can be followed with an offer of information about the benefits of breastfeeding along with a gentle endorsement and an offer of continuing support. A decision on the method of feeding should not be requested during this prenatal visit, but the parents may be encouraged to learn more about breastfeeding. A description of the pediatrician's role at that time and in the months and years to come informs the parents of the ways in which the pediatrician will be available to help them do as much as possible for themselves as well as provide assistance for them whenever needed. Anticipatory guidance can begin at this point. Parents should be encouraged to participate in childbirth classes if they are not already doing so. If an early discharge is foreseeable, plans for either a home visitor or an early office appointment may be established.
4. Building parenting skills. One of the pediatrician's most complex but gratifying tasks is to help parents mature into more competent caregivers. This process can begin before the birth of the child by discussing the parents' concerns and planned strategies.

The prenatal visit can take several possible forms depending on the experience and preferences of the parents, the competence and availability of the pediatrician, and the provisions of the health care system.

The Full Prenatal Visit
The optimal form of visit is a regularly scheduled office visit with both parents present. During this visit, the four objectives listed above are pursued. This type of visit is most appropriate for a first pregnancy, for young parents, when there are pregnancy complications or other anticipated problems of consequence for the newborn, when parents are unusually anxious for any reason, or before an adoption. Many parents do not take the opportunity to have such a prenatal visit when offered. Extensive clinical experience by seasoned practitioners, however, attests to the value of this visit in ways that are difficult to measure precisely. The establishment of a mutual commitment to a sound and rewarding professional relationship usually results from this visit.

The Brief Visit to Get Acquainted
A brief encounter lasting 5 to 10 minutes between the physician and parent at the physician's office allows a superficial meeting of the two parties. The visit may include an introduction to other members of the staff and a short tour of the facility. This arrangement is appropriate for the parent who is still in the process of selecting a pediatrician and is not yet ready for more extensive involvement. There is not enough time to cover all the desirable elements of a visit as listed above, but the pediatrician can personally offer an opportunity for scheduling a longer visit on another occasion.

The "Basic Contract" Visit or Telephone Call
This prenatal contact involves the prospective parent calling the physician's office and either the physician or the support staff describing the basic practice arrangements, assuming the physician is accepting new patients. (This should also be part of the two longer visits.) Discussion usually focuses on the office hours, the telephone hours, fees, hospital affiliations of the physician, coverage for night, weekend, and emergency care, and what arrangements can be made if the infant is born at a hospital where the pediatrician is not on staff. During the telephone call, the parents are requested to provide the following basic identifying information: name, address, telephone number, origin of referral, place and expected date of delivery, and type of insurance coverage. The pediatrician or the support staff also invites them to make an appointment to discuss any substantial concerns. If a sheet or booklet describing the practice is available, it can be mailed to the prospective parents. In this common arrangement, the physician's services are offered but they may or may not be accepted.

No Prenatal Contact
If no prenatal contact has been made, all of the objectives listed above can be addressed in the newborn nursery or at the first postnatal office visit. Although a sound therapeutic alliance can be formed at this time, a prenatal contact is advantageous in the event of problems in the newborn period.

Group Prenatal Visit
The concept of the group well-child visit can be extended to the prenatal visit. Arranged either as a large group (eg, a monthly meeting in the evening) or a small group of three to five parents, the group prenatal visit encourages mutual support among pregnant women and spouses while providing a forum for information similar to traditional individual sessions. It has the added advantage of saving clinician time and expense. Participation by a pediatrician in a prenatal class provides an alternative setting.

RECOMMENDATIONS

1. Every practice needs to establish a policy on prenatal visits. The services offered can be flexible and designed to meet the needs of parents. In some cases, a full prenatal visit is necessary. For others, a briefer encounter is sufficient.
2. When appropriate for a particular practice, a policy on charges for prenatal visits should be established and communicated both to third-party payers and families. It may be necessary to persuade some insurance companies of the cost-to-benefit ratio of prenatal visits in certain cases.
3. This policy on prenatal visits should be made known to local obstetricians and to prospective parents who telephone pediatricians to inquire about available services. Health maintenance organizations and managed-care insurance companies should be encouraged to accept the long-term advantages of prenatal visits. It is important to encourage prospective parents to begin a congenial relationship with their pediatrician through a prenatal visit.