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!