Evidence-based Prenatal Care: Oxymoron or “Best Practice?”Francesco Leanza, MD FACTS 3/5/04

Objectives: To understand the historical context of

prenatal care To understand prenatal care from a population

health perspective To evaluate prenatal care from an evidence

based perspective To distinguish between standard of care and

evidence based practice

Levels of Evidence I Primary Reports of New Data Collection

– Class A: Randomized, controlled trial– Class B: Cohort study– Class C: Non-randomized trial with concurrent or

historical controls Case control study Study of sensitivity and specificity of a diagnostic test

Population-based descriptive study– Class D: Cross-sectional study, Case series, Case

report

Levels of Evidence II Reports that Synthesize or Reflect upon

Collections of Primary Reports– Class M: Meta-analysis

Systematic review Decision analysis

Cost-effectiveness analysis

– Class R: Consensus statement Consensus report Narrative review

– Class X: Medical opinion

Routine Prenatal Care Frequency of visits* Screening Counseling and Education Immunization and Chemoprophylaxis

Frequency of visits Low risk First trimester: 6-8, 10-12 Second trimester: 16-18, 22, Third trimester: 28, 32, 36, 38-41(4) POPRAS

– 4 extra visits at 24-28 weeks, 30, 34, 37– UA dip each visit, family ppd if + in mother– cumbersome form

Visit 1: 6-8 weeks Screening

– Risk Profiles– Height and Weight– OB H &P– Hemoglobin*– Rubella/rubeola– Varicella– ABO/Rh/Ab*– RPR

Visit 1: 6-8 weeks Screening

– Urine Culture*– Hepatitis B S Ag– HIV*– Domestic Violence Screening– STI screening: GC, Chlamydia– TB/ppd– POPRAS: Lead, UA Dip

Visit 1: 6-8 weeks Counseling and Education

– Lifestyle*– Nutrition– Warning Signs of PTL– Course of care– Physiology of Pregnancy– Testing for risks in pregnancy

Visit 1: 6-8 weeks Immunization and chemoprophylaxis

– Td booster– Nutritional supplements*– High risk groups

Visit 2: 10-12 weeks Screening

– Weight– Blood Pressure– Fetal Heart Tones– Chromosomal/Neural Tube Defect

Screening

Visit 2: 10-12 weeks Counseling & Education

– Fetal Growth– Review Lab results– Breastfeeding– Body Mechanics

Visit 3: 16-18 weeks

Screening– Triple Screen– OB U/S*– Fundal Height

Counseling and Education– Second trimester growth– Quickening

Visit 4: 22 weeks Counseling and Education

– PTL signs– Class– Family issues– Length of stay– GDM– RhoGAM

Visit 5: 28 weeks Screening

– PTL risk– Check cervix– Domestic abuse screening– Rh Antibody status

Visit 5: 28 weeks Counseling and Education

– Work– Preregistration– Fetal Growth– Awareness of Fetal Movement*– PTL Symptoms

Immunization and Chemoprophylaxis– ABO/Rh/Ab (RhoGAM)*– Influenza*

Visit 6: 32 weeks Counseling and education

– Travel – Sexuality– Provider for newborn– Episiotomy– Labor and Delivery issues– Warning signs/PIH

Visit 7: 36 weeks Screening

– Confirm fetal position– Culture for Group B Streptococcus

Counseling and Education– Postpartum Care– Management of late pregnancy symptoms– Contraception– When to call provider

Visit 8-11: 38-41 weeks Counseling and Education

– Postpartum vaccination– Infant CPR– Post-term management– Labor and Delivery update

Strip membranes

Summary So… Oxymoron or “Best Practice?” Standard of Care

– know what it is– what to do when you deviate

Resources for Best Practices– Texts– institutionally/regionally based– USPTF, Cochrane Data Base, ICSI

Resources ICSI- Institute for Clinical Systems

Improvement– www.icsi.org

• “Routine Prenatal Care”

Ratcliffe et al., “Family Practice Obstetrics”