Family Planning Pre-Pregnancy

Occupation and nature of working activities

Understanding work environment and task they perform. If there is high risk of injury or exposure to chemicals (some pesticides, paints and paint thinners or teratogens or can affect fertility) as can radiation

• Will pregnancy impact their ability to work (is their job labour intensive)

• Understanding financial situation and maternity leave implications

Reduce exposure to teratogens and related chemicals.

Refer to social worker or welfare counsellor for work and financial planning assistance

Exercise and nature of exercise undertaken

Is the patient physically active. It is necessary to understand their fitness level, health of cardiovascular system and the types of exercise they are doing

Would pregnancy impact or limit hobbies and interests (for example high impact sports and scuba diving)

Does the patient have any plans to stay active during pregnancy

Has the patient had rehabilitation between pregnancies. If so, what type of rehab and for how long

Refer a pelvic health trained/rehabilitative osteo/ exercise physiologist

Lifestyle activities

Smoking – can decrease fertility by up to 50% 1 Education regarding risks of foetal and maternal effects of smoking while pregnant. Referral to appropriate quitting strategies and encourage support from partner/family

Health history

Overweight/obesity: Almost half of all Australian women of reproductive age are overweight or obese. These women have an increased risk of sub fertility or infertility. They are also at increased risk of developing serious health problems whilst pregnant 2

• Some pre-existing medical conditions can affect fertility, not just those of the reproductive system. The majority of these conditions are immune or auto immune

• Vaccination history: patients considering pregnancy should ensure they have had Hep B, varicella (chicken pox) and MMR vaccines. Patients who have received live vaccines should avoid falling pregnant for 28 days

If weight/obesity is affecting a patient’s fertility, it is important to have a team based, supportive approach. This should include nutritional advice, exercise programs and counselling

GP for appropriate screening of pre-existing medical conditions, vaccination status review and blood test

High blood pressure, pulse or body temperature prior to pregnancy should trigger referral to a GP and/or cardiologist prior to conception

• Be sure to take baseline vitals: BP, pulse, RR and temp

General assessment domains for questioning

Mental health history

Concerns/flags to be attentive to and why important

• History of mental health conditions increases the risk of antenatal/postnatal depression (especially major depressive disorder) and post-partum psychosis (especially bipolar)

• Some medications used to treat mental health conditions are also teratogens that can impact pregnancy prospects

Referral pathway options AND/OR management strategies

• Complete Edinburgh depression scale

• Referral to Perinatal Anxiety and Depression Australia for information panda.org.au

Referral to GP, for mental health plan if necessary to see a psychologist

• Ensure patient understands not to cease any medication use without GP or specialist consultation

Medication/ pre-natal supplements

• Teratogens (compounds which lead to malformations of an embryo)

Some prescription medications are teratogens. Medications in the following categories can affect foetal development:

Anti-convulsant - Blood thinners

Anti-biotics

Anticancer drugs

ACE inhibitors

SSRIs

Tranquilizers - Hormone therapies

Aminopterin - Isotretinoin

Thalidomide - NSAIDs

Lack of folic acid, vitamin D, iodine or iron can impact the conception experience, particularly for patients with a history of spine-bifida and neural tube defects. Risk of reflux and hyperemesis can exist without appropriate pre-natal vitamins

• Consult their GP or specialist

• Consult the Royal Hospital for Women with questions regarding prescription medications and pregnancy and breastfeeding: http://www.seslhd.health.nsw.gov.au/royalhospital-for-women/services-clinics/directory/ mothersafe

• A document listing the current Australian guidelines for vitamin supplementation for pregnant patients can be found here: https://www.hps.com.au/wp-content/ uploads/2019/04/Vitamin-and-mineralsupplementation-in-pregnancy-C-Obs-25Review-Nov-2014-Amended-May-2015.pdf

• Prescribing medicines in pregnancy database: https://www.tga.gov.au/products/medicines/ find-information-about-medicine/prescribingmedicines-pregnancy-database

• If women have further questions regarding supplementation, they should consult their GP or dietitian

Nutrition/diet and digestion

• Patients with inflammatory bowel disease should avoid conceiving during active flare ups as their condition can often remain active throughout the pregnancy, increasing risk of miscarriage, premature delivery and low birth weight 3

Patients who plan on becoming pregnant should eat a well-balanced diet, high in vitamins, and continue any supplements they may have been taking prior to conception

• Dietitian referral

• GP referral

• Education on risks of alcohol on foetal development. If the patient has signs of alcoholism, they should be referred for counselling support

• Alcohol consumption- can affect foetal neurological development and increase risk of foetal alcohol spectrum disorder4

Caffeine consumption- limited to 200mg when pregnant 5

• Encourage reduced caffeine consumption in preparation for pregnancy Other

Understanding

Referral

1 Practice Committee of the American Society for Reproductive Medicine, 2008, Smoking and infertility. Fertility and sterility, 90(5), S254-S259

2 Boyle JA, Dodd J, Gordon A, Jack BW, Skouteris H, 2022, Policies and healthcare to support preconception planning and weight management: optimising long-term health for women and children, Public Health Res Pract, 32(3):3232227. doi: 10.17061/phrp3232227. PMID: 36220563

3 Hashash JG, Kane S, 2015, Pregnancy and Inflammatory Bowel Disease, Gastroenterol Hepatol (N Y), (2):96-102. PMID: 27099578; PMCID: PMC4836574

4 Wilhoit LF, Scott DA, Simecka BA, 2017, Foetal Alcohol Spectrum Disorders: Characteristics, Complications, and Treatment. Community Mental Health J, 53(6):711-8

5 Australian guidelines, Healthdirect, https://www.healthdirect.gov.au/caffeine

Clinical issue to explore (biological)

Accesses obstetric/ medical checks advised in the pre pregnancy phase

Period pain

Educate on the availability of pre-genetic screening for issues that could impact conception particularly if there is a known history of adverse pregnancy outcomes such as repeated miscarriage or known familial genetic conditions

• If a patient reports significant pain either during menstruation or ovulation, they may have an underlying medical condition. Reproductive conditions often go undiagnosed or are not found until a patient tries to become pregnant for the first time

Referral to GP for onward referral to specific specialists as required including genetic counsellor

• Refer to GP for pelvic ultrasound and gynaecologist

Gynaecological health generally, including menstrual cycle

• No gynaecological history can leave flags undetected. Full gynaecological screening includes:

- Menarche

- Menstrual cycle duration

- History of changes to cycle (absence, change in duration, increased menstrual pain)

- Blood flow

- Associated symptoms (any bowel or bladder changes that are cyclic)

- Contraceptive history (some hormone-based contraceptives can affect fertility for several months post cessation)

- Previous pregnancies (and their outcomes)

- Previous sexually transmitted diseases

- Pain (with menstruation, non-menstrual cyclic pain, intercourse, bowel motions and urination)

• Referral to GP for onward referral to gynaecologist

Clinical issue to explore (biological)

Childbearing history (caesareans, tears, episiotomies, number of children, miscarriages, and method of conception)

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Understanding a patient’s obstetric history can influence their desires, beliefs and attitudes towards further pregnancies. This area should be discussed with a level of sensitivity and openness

• When taking a birth history, be sure to take the history in chronological order (especially in cases with multiple children) to avoid confusion and missed info

• Apply the GTPAL principle:

- G= gravidity,

- T= term pregnancies,

- P= preterm deliveries,

- A= abortions or miscarriages,

- L= live births

• Pregnancy: previous incompetent cervix

• Births: term of pregnancy, Braxton Hicks, length of labour, length of active labour, interventions, positioning, medications, tears, health of baby at delivery

• Dyspareunia is common after third and fourth degree tearing and therefore may impact method of conception for subsequent pregnancies

• Referral to GP for onward referral to specific specialists as required

Breast feeding patterns/issues (previous pregnancies if relevant)

• Breastfeeding exclusively for the first six months can result in amenorrhoea, but the patient should consult personalised contraceptive advice from their GP

Breastfeeding is very variable and different for each mother

• Issues with breastfeeding with previous children, can impact a patient’s choice to breastfeed with new pregnancies

Patients with pre-existing medical conditions that require prescription medications should also consider if this medication can impact breastfeeding

• It is important to be aware that a patient can still be breastfeeding and conceive

• Referral to Lactation consultant

Pelvic floor integrity, pain, or cramping

• Leaking/incontinence (stress/urge or mixed), prolapse (heaviness or dragging)

History of kidney, bladder and/or urinary conditions

Dyspareunia (pain with intercourse), arousal and/ or penetration

• Referral to pelvic floor health practitioner (osteopath or physiotherapist)

• Referral to urologist

Abdominal pain and abdominal surgical history

Intended method of conception and length of time attempts made

Adhesion formation impacting fertility

If they have had surgery: what was it for, when was it performed, was it successful, were there any complications, does it require regular monitoring

• Consider the patient’s relationship status and sex of their partner (if they have one)

• Are they planning on conceiving naturally or with IUI or IVF

If the patient has been trying to naturally conceive, how long have they been trying for. If they are under 35 and have been trying for one year, consider referral to assess fertility. If they are over 35 and been trying for six to 12 months, they should have their fertility assessed

Referral to GP for onward referral to specialists as required

• Fertility testing (male partners should also be tested). Referral to GP for onward referral as required

Clinical issue to screen (psychosocial)

Stress levels

Trauma

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management

strategies

Social support, partnership status and living situation

• Patients with high day to day stress levels can take up to 30% longer to conceive 6

The pelvis is a very sensitive and personal area, especially around the topic of trauma. Pelvic trauma can include, crush and musculoskeletal injuries, surgical trauma, episiotomy, tearing from previous births and sexual abuse

Patients may be uncomfortable discussing these topics, as well as uncomfortable being touched around the pelvis: full informed consent should be given prior to placing your hands on any patient

• If discussion of this area is clearly quite uncomfortable for the patient, do not force it. Explain to them why you are asking these questions and let them share as much as they want. Developing rapport is vital in these situations

Patients with history of significant pelvic physical trauma should be referred for imaging and fertility discussed

Understanding a patient’s biopsychosocial situation will help get an understanding of how to approach the topic of pregnancy. Is the patient single or in a partnership, if they are in a partnership, is their partner male or female. Knowing this will guide discussion to appropriate conception options

• Also understanding who the patient lives withalone, with parents, roommates or other family. It is important to understand who is in the patient’s life and will help them through their pregnancy

• Understanding living situations can also be a factor: do they have a permanent place of residence and is that residence safe for the patient and her soon to come child

• Psychologist referral

• Mindfulness and meditation exercises

Sexual abuse: police, mental health professional

Referral to psychologist or mental health professional

• Referral to GP for onward referral to obstetrician/ gynaecologist

Referral to psychologist, welfare worker or social worker

Psych/counselling

Police

Family violence organisations (safe steps 1800015188 – VIC)

• 1800 RESPECT - National

The Orange Door https://www.orangedoor.vic.gov.au