Prenatal Counseling Regarding Smoking, Work and Common Patient Concerns

Although the prenatal record has not changed much in the past few years, there is increasing debate regarding whether certain facets of typical prenatal care stand up to an evidence-based review.¹ Issues of frequency and timing of visits for low-risk women and certain screening procedures are being challenged as not cost-effective and having an unacceptable occurrence of false-positive results. Routine urine dipstick for proteinuria and glucosuria is one standard activity that is undergoing scrutiny.² Even the standard use of prenatal vitamins with iron supplementation is being questioned.

Given these challenges to ongoing prenatal care procedures, the initial assessment assumes even a greater importance in the delivery of effective obstetric care. The determination of risk status for a pregnancy may take on a greater importance as the potential number of visits may decrease. Previous obstetric history continues to be the best indicator of increased risk in a current pregnancy. Issues such as previous preterm delivery or intrauterine fetal death will necessitate evaluation for possible causes, possible intervention with this pregnancy, and close monitoring for evidence of a reoccurrence of the complication. In the primigravida, other information will be used to assign an increased risk status to a prenatal patient. These might include a pregnant teenager who has dropped out of school, the factory worker on an assembly line, the older woman (older than 35), and those with identified preexisting medical problems.

This also means that early identification of modifiable risks needs to be performed and efforts to change the woman's behavior must be made. Some of these risks include smoking, abuse of other substances, and work place concerns.

Although studies have shown the risks of smoking during pregnancy and that providers generally ask about smoking (93%), and advise the woman to quit (90%), far fewer provide any other assistance (28%).³ After the initial visit there appear to be little further inquires or intervention performed. It has been thought that this lack was because of the understanding that comprehensive programs were required for smoking cessation to be successful. Studies have shown this is not the case.^{4, 5, 6, 7} A relatively short 5- to 15-minute intervention at the initial prenatal visit with follow-up at each subsequent visit can improve the quit rate by 30–70%. This program has been endorsed by the American College of Obstetricians and Gynecologists and promoted by the Robert Woods Johnson Foundation. It is based on the principles of change and motivational interviewing. By using the pneumonic of five As, it attempts to aid the provider in the implementation of the steps.

Ask

Asking takes approximately 1 minute. Although most patients are simply asked if they smoke, better success and understanding of the smoker's status is accomplished by asking the question in a standard fashion such as to receive a yes or no answer to the following: (A) I have never smoked or have smoked fewer than 100 cigarettes in my life time; (B) I stopped smoking before I found out I was pregnant and I am not smoking now; (C) I stopped smoking after I found out I was pregnant and I am not smoking now; (D) I smoke some now, but I have decreased the number of cigarettes I smoke since I found out I was pregnant; and (E) I smoke regularly now, approximately the same as before I found out I was pregnant.

If a person answers yes to questions A through C, then the patient should be praised. In the case of a yes response to questions B or C, reassessed should be performed at subsequent visits. If a patient answers yes to questions D or E, then the provider proceeds to the next step. In all cases the chart should be labeled regarding the smoking status.

Advise

Advising takes approximately 1 minute. A simple direct statement regarding quitting should be made. One example would be, “My best advice for you and your baby is to quit smoking.” Additional advice should be personalized and relevant to the patient, depending on her situation. Studies have shown that positive messages (such as your clothes will smell better or you can save money) work better than negative consequences (preterm delivery or small for gestational age infant). Often the patient can provide reasons why she should stop.

Assess

Assessment takes approximately 1 minute. One needs to determine if the patient is willing to stop smoking within the month. Setting a quit date helps to establish a definitive goal and focus her commitment. Depending on the arrangements that need to be made, this can be a day or two or even a few weeks away. If the patient agrees to quit, then the provider should move to the next step in the five As.

Assist

Assistance takes approximately 3 or more minutes. This is the key step and the most time-consuming. The provider may want to do this or may have an identified staff member who is trained to help a patient through this step. Assisting involves identifying potential barriers to quitting and possible supports. Counseling then helps the patient access the supports (e.g., family members that do not smoke) and be prepared for the problems (e.g., cravings, negative moods, trigger events, and family members who smoke). Pregnancy-specific self-help materials and offering the support of the office staffing have been found to improve quit rates by reenforcing the counseling performed at the visit. As with any behavior modification, follow-up is key to support the change and help in cases of relapse.

Arrange

Arranging takes approximately 1 or more minutes. The management of follow-up is easy during pregnancy because prenatal care involves frequent scheduled visits. At each follow-up, repeated assessments should be performed regarding cessation success or occurrence of a relapse.

Although the five As is a brief intervention that will work for many patients, the woman who is a heavy smoker may benefit from a more intensive program if available and even pharmaceutical intervention.

If the pregnant woman is not interested in quitting, then the provider can go through the five Rs with the patient, having to identify the following relative to smoking cessation: (1) relevance, reasons for smoking; (2) risks, negative consequences from the patient's point of view; (3) rewards, benefits of quitting for self, pregnancy, and family; (4) roadblocks, barriers to quitting are identified; and (5) repetition, this process is repeated at each visit.

Although the five As have not been formally studied with other substances of abuse, the approach is consistent with the research on changing behavior. It would be reasonable to try a similar approach to change after the standard screening methods for problems with, for example, alcohol, based on a screen with CAGE, TACE, or a similar screening tool.

Pregnancy is a very teachable moment, with most women very motivated to change behaviors to improve the health of the infant. Cessation can provide short-term benefits for the pregnancy and also long-term benefits for the woman and her family.

With most women of reproductive age in the workforce, it is important to ascertain a woman's work environment for potential reproductive hazards. Although Occupational Safety and Health Administration (OSHA) regulations have decreased the workplace hazards for all employees, there are a few areas that are important to the pregnant woman.⁸ Exposure to various chemicals and solvents in a well-ventilated environment rarely is a problem. However, if the woman is exposed to them in a confined, poorly ventilated area, this may cause concerns. The woman or her employer can contact OSHA (www.osha.gov) for more specifics on the agent of concern. There are also ergonomic concerns for pregnant women, particularly regarding carpal tunnel syndrome, back pain, lifting, and swelling of the lower extremities. Finally, ready access to water, bathrooms, and ability to take breaks is more important to the pregnant employee. Depending on the job responsibilities for a patient, the provider may want to counsel the patient on some strategies to minimize problems at the workplace. For an uncomplicated pregnancy, there are few job modifications or restrictions necessary. However, women with complications or high-risk pregnancy may benefit from such changes.⁸

Because pregnancy is a common event, there are concerns that women may be discriminated against because of a pregnancy or potential of pregnancy. The Pregnancy Discrimination Act is an amendment to Title VII of the Civil Rights Act of 1964. Discrimination on the basis of pregnancy, childbirth, or related medical conditions constitutes unlawful sex discrimination under Title VII. In other words, women who are pregnant must be treated in the same manner as other applicants or employees with similar abilities or limitations.⁹ There are four areas that may legally impact the pregnant employee.¹⁰ The Health Insurance Portability and Accountability Act was passed in 1996. This act means that if a pregnant woman changes jobs and insurance plans during the pregnancy, she is to have insurance coverage for care that relates to her pregnancy as long as she had insurance at your former job.

Family and Medical Leave Act (FMLA) allows an employee who meets certain requirements the ability to take up to 12 weeks of unpaid leave within a given year. To take family leave, a woman must work for a company that has at least 50 employees, must have worked for the employer for at least 12 months, and must have worked at least the equivalent of 60% full-time employment during that previous year.

When she returns to work, an employee must be given the same or equal job. She also must be given the same benefits she had when she left. Because a few states provide more benefits than the federal FMLA, a patient should be encouraged to contact the state department of labor for more details.

Pregnancy Discrimination Act (PDA) is a federal act that requires employers (with 15 or more employees) to treat workers disabled by pregnancy or childbirth the same as workers disabled by illness or accident. The PDA also makes it illegal to hire, fire, or refuse to promote a woman because she is pregnant.

OSHA requires employers to provide a workplace free from known hazards that cause, or are likely to cause, death or serious physical harm. This is irrespective of gender or age.

If the number of prenatal visits are decreased, most of the decrease occurs early in pregnancy. Given that, it is important to address the common concerns and problems of early pregnancy at the initial screen. One of the most frequent symptoms of pregnant women (70–80%) during the first half of the pregnancy is “morning sickness” or nausea–vomiting of pregnancy (NVP). The spectrum of this symptom can range from only an inconvenience for some to requiring prolonged hospitalization with intravenous fluids and feeding for others (0.5%).¹¹ Fortunately, most women have a mild form with nausea with or without emesis between 6 and 12–14 weeks' gestation. However, even nausea can have significant impact at the workplace even if a woman is not experiencing emesis. There are a number of approaches that provide relief for many and these should be shared with a pregnant woman proactively, along with the reassurance that this is not dangerous for the pregnancy. These include dietary modifications, including frequent small meals containing high-carbohydrate, low-fat foods, with protein being dominant,¹² a bland, dry diet such as crackers (soda crackers or graham crackers), especially after a period of a fast such as first in the morning and making sure to stay well hydrated with continuous intake of cold, clear fluids such as water and carbonated beverages. Also, avoiding spicy foods or foods that have a strong odor, especially when cooking, is helpful.^{12, 13, 14}

Over-the-counter medications such as vitamin B₆ (25 mg three times per day) will often help. In addition, a patient can add half a tablet of over-the-counter sleep-aid medicine (12.5 doxylamine) to the vitamin B₆.¹⁵ This mimics the preparation Bendectine that used to be available in the United States and a preparation that is currently available in Canada. Also, dimenhydrinate (50 mg orally every 4–6 hours) may help.¹⁶

Alternative methods of therapy including acupuncture, ginger tea or powder, mint tea, stimulation of the P6 (Neiguan) point, and medical hypnosis have been shown to have variable success with NVP.¹⁷

Therapies that are more aggressive than these strategies should merit a visit and evaluation by the provider to rule out more problematic concerns.

Now, even more so than previously, the initial assessment for risks, screening, and behavior modification is assuming a greater role in the delivery of prenatal care, particularly at the initial visit.