Prenatal Care
Simmons CollegeGraduate School for Health Studies
Prenatal Care: Goals & Benefits
1. To prevent, identify, and/or ameliorate maternal or fetal abnormalities that adversely effect pregnancy outcome, including socioeconomic and emotional factors as well as medical/obstetric considerations.
2. Anticipatory guidance during the pregnancy, labor and postpartum period and intervention to prevent or minimize morbidity.
3. To promote adequate psychological support from partners, family, and caregivers, especially during the 1st pregnancy. This promotes successful adaptation to the pregnancy and the challenges of raising a family.
Initial patient assessment
• Early, accurate estimation of gestational age• Identification of patients at risk for
complications• Ongoing evaluation of both mother and fetus• Anticipation of problems and interventions to
decrease morbidity.
Continuous communication and education
Prenatal Care: Definition
A continuum of family health care from the preconceptual period through the first postpartum year.
Commences with an extensive Hx and P.E. An estimation of gestational age and
determination of the EDC is made. Routine lab tests are drawn.
Initial Prenatal Assessment
• Ideally should be initiated by 10 weeks.• Guidelines set up by ACOG mainly for testing.• Care Provider: There is no statistical
significance perinatal morbidity of patients cared by midwife/general practitioner/ob/gyn in the US
Centering Care
• Group prenatal care is alternative means of delivering prenatal care
– A facilitator which is usually a nurse practitioner or nurse midwife guides the women through group discussion, education, skill building preparation for childbirth and parenting role as well as non medical issues as relationships and other social issues.
– Women at the same gestational age share appointments which can last as long as 2 hours.
• The women themselves are responsible to document weight, blood pressure, urine dip.
– Only privacy is at the initial appointment, if health concerns that require privacy arise and vaginal exams.
Prenatal Care: ComplicationsPrevented or Minimized
Anemia due to Fe or Folic Acid deficiency
UTIs and Pyelonephritis PIH Preterm labor and
delivery IUGR
STDs and their effect on the newborn
Rh isoimmunization Breech presentation at
birth Hypoxia or fetal death
from postterm birth
Components of theInitial Prenatal Visit
Overview:Patient may present at any gestational age.Why did they choose your practice?Review of where infant will be delivered, on-call
arrangements, after-hours protocols, etc.Role of MD / NP / CNM.
Demographic Assessment
• Patient phone #’s and Emergency contact• Marital status• Education• Occupation• Partners name and occupation• PCP• Religion• Insurance carrier
Obstetrical History• Number of pregnancies– Full term, preterm, Miscarriage, Abortion, Ectopic,
Living children, Multiple gestation
• For each pregnancy– Date of delivery, Gestational age, Location, sex of
child, mode of delivery, anesthesia, length of labor, outcome, details and complications.
Gynecological History
• Menstrual history• Last pap• STD exposure• DES exposure• Genital tract disease or procedures• Last contraceptive use/type
Medical/Surgical History
• Endocrine• Cardiovascular• Kidney• Neurological• GI• Psychiatric• Autoimmune• Trauma
• Pulmonary• Hematologic• Breasts• Surgical procedures• Anesthesia• Hospitalizations• Allergies• Medications• Substance abuse
Domestic Violence
• ACOG and AMA recommend providers to routinely assess pregnant women for domestic violence.– Markers include: bruising, improbable injury,
depression, late prenatal care, missed prenatal visits, cancelled appointments.
Genetics History
• Age at delivery• Ethnic background• Thalassemia• Neural Tube defects• Congenital heart defects• Down syndrome• Tay-sachs disease• Canavans Disease• Sickle cell disease
• Hemophilia or blood disorders
• Muscular dystrophy• Cystic fibrosis• Huntingtons disease• Mental retardation or autism• Genetic disorders• Birth defects• Recurrent misscarriages
Genetic Counseling
– The following patients require formal genetic counseling!• Having given birth previously to a child with, or a family
history of, birth defects, chromosomal abnormality, or known genetic disorder.• Having given birth previously to a child with prenatally
undiagnosed mental retardation.• Having given birth previously to a baby who died in the
neonatal period.
• Multiple fetal losses.• Abnormal serum marker screening results.• Consanguinity.• Maternal conditions predisposing the fetus to
congenital abnormalities.• A current pregnancy history of teratogenic exposure.• A fetus with suspected abnormal ultrasound findings.• A parent who is a known carrier of a genetic disorder.
Genetic Screening:
For the nonpregnant patient, genetic consultation is recommended in cases of unexplained infertility.
Psychosocial Assessment:How do they feel about the pregnancy?Who is accompanying the pregnant woman during
the initial visit?Previous pregnancies / children.Pregnancy options. (if appropriate)Living situation now and when baby is born.
Calculation of EDC
– Estimated day of confinement/delivery• Crucial for pregnancy management.• Naegele’s Rule: Subtract 3 months from LNMP, add 7
days to the 1st day of the LNMP, and add one year. Assumes a 28 day menstrual cycle.• Ultrasonography
– Crown-rump measurement of ultrasound (error of 7 days) and the biparietal diameter and femur length measurements later on (error of 10d up to about 22 wks.).
Gestational Age
• Approximate estimation– Uterine size in first trimester– Time of quickening (16-20 weeks).– Fundal height– Time fetal heart tones auscultated (electronic
doppler: 10-12 wks., nonelectronic fetoscope: 18-20 wks.).
Prenatal Care: The Initial Physical Exam
Focus P.E. keeping in mind physiologic changes of pregnancy!WeightSkinGums / DentitionBlood pressureThyroidHeart
– Lungs– Breasts– Abdomen– Pelvic exam:• Focus on pelvic soft tissue, bony pelvis, pelvic inlet,
midpelvis, pelvic outlet, pelvimeter, cervix, and uterus.• Cervix: Os, lacerations, length, appearance• Uterus: size, shape, consistency, position
– Peripheral vascular
Laboratory Examination
• OB panel– Blood typing and antibody screen• Rh(D) negative women should receive anti(D)-
immune globulin after a bleeding episode or prophylactically at 28 weeks.
– Hct/Hgb/MCV.• MCV of <80 warrants hemoglobin electrophoresis
Laboratory Testing
• OB panel (cont)– Rubella immunity. • If negative must receive immunization postpartum
– RPR/VDRL
– HBsAg• Even if previously vaccinated
Laboratory Testing
– GC/CT.– HIV• Universal screening for each pregnancy• Use “opt out” approach
• Additional testing for at risk clients– TSH• Symptoms of thyroid disease• Personal or family h/o• Predisposition (other endocrine disorder, goiter,
iron deficiency)
Laboratory Testing
– Diabetes• BMI• Ha1c
– TB– Toxoplasmosis• Routine practice in France but not US
– Hepatitis C– BV
Laboratory Testing
– Cystic fibrosis• Should be available to all couples but in particular
to those at high risk. (Caucasian, European, Ashkenazi Jewish)
– Fragile X• Intellectual delay or disability, autism.
– Tay Sachs• Eastern European/Ashkenazi Jewish ancestry• Southern Lousiana Cajun, Eastern Quebec French
Canadian descent
Laboratory Testing
– Spinal Muscular Atrophy• Controversial. The Americaln Academy of Genetics
recommends universal screening. ACOG disagrees.• Any h/o of SMA/SMA like illness
Patient Education
• In first appointment it is appropiate to discuss patient responsibilities and expected course of pregnancy.
• Those with higher risk pregnancy should be aware of higher expectations and plan of care
Prenatal Care: Visit Schedule Recommendations from the American College of
Obstetricians and Gynecologists:An extensive initial visit during early pregnancy.Revisit every 4 weeks until 28 weeks gestation.Then, revisit every 2 weeks from 28 - 36 weeks
gestation.Revisit weekly from 36 weeks gestation until
delivery.
Education
In subsequent visits, the provider will explores any problems the client may have, documents the growth of the fetus, and tries to identify potential complications.
How to reach provider, coverage arrangements, role of office staff.
Seat belts. 3 point belt. Lap belt across the hips and below the
uterus/ shoulder belt between breasts and lateral to uterus.
ACOG recommends airbags to remain on
Education
• Nutrition• Alcohol/Tobacco/Drugs• Infection Precautions– Influenza vaccination– Tetanus/diphtheria/pertussis– Toxoplasmosis risks– Varicella– Parvovirus– Listeria
Education
• Work• Sexual activity• Medications– Pregnancy categories since 1975– Only a limited number were proven to be
teratogenic
Medications in Pregnancy
• Commonly used meds– Acetaminophen– NSAIDS– Opioids– Cold and Allergy– Antibiotics– Constipation and diarrhea– Antiemetics and antinausea
Education
– GERD– Sleep Aids
• Travel– Available resources – DVT risks in prolonged travel– Infectious disease exposure
Education
– Air travel• Fetal Heart rate not affected.• Commercial travel safe up to 36-37 weeks• Restrictions on high risk pregnancies• Hydration, movement, clothing and seatbelts• High Altitude
– Common concerns• Caffeine• Mercury
Education
• Pesticides• Hair Treatment
Plan
• Danger Signs -- When to Call:– Abdominal or pelvic pain or cramping.– Frequent uterine contractions or painless
tightening from weeks 20-36.– Vaginal bleeding.– Passage of watery discharge.– Significant decrease in fetal movements.– Severe headache or blurring of vision.– Persistent vomiting.– Chills or fever.
Prenatal Care: History at Revisits
A brief interval history to uncover new problems and to follow-up on existing ones should be conducted at each prenatal revisit.
It is recommended that all clients be screened for domestic violence at each prenatal visit!
Specifically, ask each client about: Pain Contractions or cramping Pelvic pressure Bleeding Leaking or Discharge Dysuria GI problems Presence and adequacy of fetal movements
Additional prenatal revisit history:Ask if any new or complications of other problems
have arisen since the last visit.Those with medical conditions or known
complications should be asked specific questions regarding those problems.
Women desiring sterilization should be counseled well ahead of delivery.
Prenatal Care:Physical Exam at Revisits
• At each subsequent prenatal visit, obtain the following physical data:– Weight– BP– Urine dipstick– FHT assessment– Fetal size: check fundal height beginning at 22 wks.
gestation; a discrepancy of > 2-3 cm is c/w a size-for-dates problem.
– Fetal position: Leopold’s maneuvers
Prenatal Care:Periodic Assessments
11-13 wks: Early Risk Assessment15-22 wks: AFP, Quad screen18 wks: ultrasound -- anatomic survey,
singleton vs. multiple gestation, dating24-28 wks: one hour glucose tolerance
test/ CBC28 wks: Rhogam if Rh(-)36 wks: Group B Strep culture
Periodic Assessments
• Estimated Fetal weight• >40 weeks: Fetal testing
Thank you!