A 19-year-old woman who came in for her annual exam told me that she'd had two sexual partners in the past six months. When I told her that I wanted to do gonorrhea, chlamydia and HIV tests, she responded with frustration and said, "I don't need them. I know I don't have any of those problems."
Several options occurred to me. I could insist; I could simply write "declines STD testing" on her chart; I could do the tests without her knowledge; I could request that she allow me to do them, provide my rationale, but accept her decision if she said no. I chose the last path, because I feel that I have a responsibility to my clients. She obviously made her appointment with me because she felt I had a certain amount of expertise, experience and skill that would benefit her. However, she is responsible for her own health and ultimately will chose what she feels is best for her body.
There's a fine line to walk when providing health care. The philosophical underpinnings of nurse-midwifery ask us to plan care with women, not for women. We want and we ask women to take responsibility for their own health to the extent that this is possible.
The relationship that care providers have with any woman seeking prenatal care involves education '- providing enough information so the woman can join in her own care. We used to practice according to a model based more upon tradition than evidence. If an older and wiser mentor did it a certain way, we were apt to carry on the practice. We tested urine at each visit on every client because it seemed to make sense and because our teachers said it was a good idea. We performed routine cervical exams every week during the last month of pregnancy but could not really specify why. We shaved the perineum and gave women enemas in labor because that was simply the way it was done.
Since the advent of evidence-based medicine, however, we've started paying attention to outcomes. We've learned that none of these practices improved the outcome of pregnancy and that, in the case of shaves and enemas, we were performing these rituals only for the convenience of the person attending the birth. Babies delivered by midwives without intervention did just as well or better. When baby delivered quickly, before we could do a shave, mothers did not get infections. Women hated enemas because they caused unnecessary discomfort. Our clients became more vocal in voicing their dissatisfaction and in asking for the rationale behind some obstetrical practices.
With the emergence of evidence-based medical care, we began to develop national, regional and clinical guidelines for the care we provide. Today, rural, urban, privileged and underserved women will get the same tests when they come in for prenatal care.
Overview of laboratory testing
- At your first visit, several tubes of blood are collected for a complete blood count (CBC), which provides hemoglobin level, platelet count, red blood cell count and evaluation, and white blood cell count and evaluation. The hemoglobin level is rechecked at least twice more during the pregnancy and more frequently if indicated.
- Rubella titer, hepatitis B status detection and a test for syphilis (VDRL or RPR) are also performed.
- HIV testing is strongly recommended in pregnancy.
- Some care providers collect blood for thyroid testing. Depending upon race and genetic background, a woman who has arrived for her first pregnancy visit may be offered screening tests for sickle cell disease (if she's African or African-American) or cystic fibrosis (if she's Caucasian). Women of Ashkenazi Jewish descent or French-Canadian descent should be tested for Tay-Sachs disease.
- A Pap smear for cervical changes and tests for gonorrhea, chlamydia and vaginal infection may also be performed if a mother has not had one within the past year or if she is at increased risk for sexually transmitted infections. In addition, urine is collected to test for infection, protein and ketones.