Prenatal Care

Prenatal Care
Initial Prenatal Evaluation
Subsequent Prenatal Visits
Ancillary Prenatal Tests
Initial Prenatal Evaluation
Goals
To define the health status of
the mother and fetus.
To estimate the gestational
age of the fetus.
To initiate a plan for
continuing obstetrical care.
The initial plan for subsequent care may range from re
Typical Components of Routine Prenatal
Care
First Visit 1520 2428 2941
Weeks Weeks Weeks
History
Complete
Updated
Physical examination
Complete
Blood pressure
Maternal
weight
Pelvic/cervical
examination
Fundal height
Fetal heart
rate and
position
 First Visit 1520 2428 2941
Weeks Weeks Weeks
Laboratory tests
Hematocrit or
hemoglobin
Blood type and Rh
factor
Antibody screen A
Pap smear
Glucose tolerance
test
Maternal serum B
AFP screening
Cystic fibrosis B or B
screening
Urine protein
Urine culture
Rubella titer
Syphilis test C
Gonococcal culture D D

A Performed at 28 weeks, if indicated. C High-risk women should be retested at the beginning

B Test should be offered. of the third trimester.
D High-risk women should be screened at the first
prenatal visit and again in the third trimester.
 First Visit 1520 2428 2941
Weeks Weeks Weeks
Chlamydia culture D D
Hepatitis B surface
antigen
Human B
immunodeficiency
virus (HIV)
Group B E
streptococcus
culture
Rhogam if D- A
negative
A Performed at 28 weeks, if indicated.
B Test should be offered.
C High-risk women should be retested at the beginning
of the third trimester.
D High-risk women should be screened at the first
prenatal visit and again in the third trimester.
E Rectovaginal culture should be obtained between 35
and 37 weeks.
Prenatal Record
Prenatal Record
Definitions
Normal Pregnancy Duration
History
Psychosocial Screening
Physical Examination
Laboratory Tests
High-Risk Pregnancies
Definitions
Nulligravida: a woman who is not now and
never has been pregnant.
Gravida: a woman who is or has been
pregnant, irrespective of the pregnancy
outcome.
Primigravida: With the establishment of the first
pregnancyand
Multigravida: with successive pregnancies
Nullipara: a woman who has never completed
a pregnancy beyond 20 weeks' gestation. She
may or may not have been pregnant or may
have had a spontaneous or elective abortion(s).
Definitions
Primipara: a woman who has been delivered
only once of a fetus or fetuses born alive or
dead with an estimated length of gestation of
20 or more weeks.
Multipara: a woman who has completed two
or more pregnancies to 20 weeks or more.
Parity is determined by the number of pregnancies
reaching 20 weeks and not by the number of fetuses
delivered.
That is, parity is not greater if a single fetus, twins, or
quintuplets were delivered, nor lower if the fetus or
fetuses were stillborn.
Definitions
G Gravida, or total # of
pregnancies
P Para, or outcomes of
pregnancies
F Full term
P - Preterm
A - Abortion
L Living child

Example: G3P3 3003

Normal Pregnancy
Duration
The mean duration of
pregnancy calculated from
the first day of the last
normal menstrual period is
very close to 280 days, or 40
weeks.
Normal Pregnancy
Duration
Expected date of delivery
(Naegele rule):
date of the first day of the LMP + 7
days; counting back 3 months.

Example
LMP: September 10
Expected date of delivery : June 17
Normal Pregnancy
Duration
It is apparent that pregnancy is
erroneously considered to have begun
about 2 weeks before ovulation if the
duration is so calculated. Nonetheless,
clinicians conventionally calculate
gestational age or menstrual age from
the first day of the LMP to identify
temporal events in pregnancy.
Embryologists and other reproductive
biologists more often employ ovulatory
age or fertilization age, both of which
are typically 2 weeks shorter.
Normal Pregnancy
Duration
It has become customary to
divide pregnancy into three
equal trimesters of
approximately 3 calendar
months.
First trimester up to 14
weeks
Second trimester through
28 weeks
Third trimester 29th- 42nd
Precise knowledge of the age of the fetus is imperative
History
Detailed information
concerning past obstetrical
history.
Crucial because many prior
pregnancy complications tend
to recur in subsequent
pregnancies.
History
The menstrual history is
extremely important.
The woman who spontaneously menstruates
regularly every 28 days or so is most likely
to ovulate at midcycle. Thus, the gestational
age (menstrual age) becomes simply the
number of weeks since the onset of the LMP.
If her menstrual cycles were significantly
longer than 28 to 30 days, ovulation
more likely occurred well beyond 14 days.
Similarly, if the intervals were much longer
and irregular, chronic anovulation is likely to
have preceded some of the episodes of
vaginal bleeding identified as menses.
History
Without a history of regular, predictable, cyclic,
History
Ascertain whether or not
steroidal contraceptives were
used before the pregnancy.
Because ovulation may not have
resumed 2 weeks after the onset of
the last withdrawal bleeding, and
instead, may have occurred at an
appreciably later and highly variable
date, using the time of ovulation for
predicting the time of conception in
this circumstance may be erroneous.
Psychosocial
Screening
The American College of Obstetricians and Gyne
 Psychosocial Prenatal
Screening Questions
Do you have any problems that prevent you from keeping your health car
Physical Examination
A thorough, general physical examination should be co
Pelvic Examination
The cervix is visualized employing
a speculum lubricated with warm
water.
Bluish-red passive hyperemia of
the cervix is characteristic, but
not of itself diagnostic, of
pregnancy.
Dilated, occluded cervical glands
bulging beneath the exocervical
mucosa, so-called nabothian
cysts, may be prominent.
Pelvic Examination
The cervix is not normally
dilated above the level of the
internal os.
Next, to identify cytological
abnormalities, a Pap smear is
obtained and specimens for
identification of Neisseria
gonorrhoeae and Chlamydia
trachomatis are obtained if
screening is indicated.
Digital Pelvic
Examination
Completed by palpation, with
special attention given to
The consistency, length, and
dilatation of the cervix;
The fetal presentation later in
pregnancy;
The bony architecture of the pelvis;
Any anomalies of the vagina and
perineum, including cystocele,
rectocele, and relaxed or torn
perineum.
Digital Pelvic
Examination
The vulva and contiguous
structures are carefully inspected.
All cervical, vaginal, and vulvar
lesions are evaluated further by
appropriate use of colposcopy,
biopsy, culture, or dark-field
examination.
The perianal region should be
visualized and digital rectal
examination performed.
Laboratory Tests
The Institute of Medicine
recommended that a national
policy of universal screening be
developed for human
immunodeficiency virus (HIV)
testing, with patient notification,
as a routine part of prenatal
testing.
If a woman declines testing, this
should be noted in the prenatal
record.
Laboratory Tests
All pregnant women should
also be screened for hepatitis
B virus infection.
In the absence of
hypertension, routine
urinalyses beyond the initial
prenatal visit were not
necessary.
 High-Risk Pregnancies
Risk Factor
Asthma
Symptomatic on medication OBG
Severe (multiple hospitalizations) MFM
Cardiac disease
Cyanotic, prior myocardial infarction, aortic stenosis, pulmonary MFM
hypertension, Marfan syndrome, prosthetic valve, American Heart
Association class II or greater
Other OBG
Diabetes mellitus
Class AC OBG
Class D or greater MFM
Drug and alcohol use MFM
Epilepsy (on medication) OBG
Family history of genetic problems
(Down syndrome, Tay-Sachs disease, phenylketonuria) MFM
 High-Risk Pregnancies
Risk Factor
Hemoglobinopathy (SS, SC, S-thalassemia) MFM

Hypertension
Chronic, with renal or heart disease MFM
Chronic, without renal or heart disease OBG
Prior pulmonary embolus or deep vein thrombosis OBG
Psychiatric illness OBG
Pulmonary disease
Severe obstructive or restrictive MFM
Moderate OBG
Renal disease
Chronic, creatinine 3 mg/dL, hypertension MFM
Chronic, other OBG
Requirement for prolonged anticoagulation MFM
Severe systemic disease MFM
 High-Risk Pregnancies
Risk Factor
Obstetrical History and Conditions
Age 35 years at delivery OBG
Cesarean delivery, prior classical or vertical incision OBG
Incompetent cervix OBG
Prior fetal structural or chromosomal abnormality MFM
Prior neonatal death OBG
Prior fetal death OBG
Prior preterm delivery or preterm ruptured membranes OBG
Prior low birthweight (< 2500 g) OBG
Second-trimester pregnancy loss OBG
Uterine leiomyomata or malformation OBG
Condylomata (extensive, covering vulva or vaginal opening) OBG
Initial Laboratory Tests
Human immunodeficiency virus (HIV)
Symptomatic or low CD4 count MFM
Other OBG
CDE (Rh) or other blood group isoimmunization (excluding ABO, Lewis) MFM
Subsequent Prenatal Visits
The timing of subsequent prenatal visits has been sch
Subsequent Prenatal
Visits
Women with complicated
pregnancies often require return
visits at 1- to 2-week intervals.

Example,
Luke and co-workers (2003) found
that a specialized prenatal care
program that emphasized
nutrition and education and
required return visits every 2
weeks resulted in improved
outcomes in twin pregnancies.
The World Health Organization conducted a
multicenter randomized trial with almost
25,000 women comparing routine prenatal
care with an experimental model designed
to minimize visits
Women were seen once in the first
trimester and screened for certain risk
factors.
Those without any anticipated
complications80 percent of the
women screenedwere seen again at
26, 32, and 38 weeks.
(Compared with routine prenatal care, which
required a median of eight visits, the new
model required a median of only five visits)
No disadvantages were found in
women with fewer visits.
Prenatal Surveillance
At each return visit, steps are
taken to determine the well-
being of mother and fetus
Typical Components of Routine Prenatal
Care
First Visit 1520 2428 2941
Weeks Weeks Weeks
History
Complete
Updated
Physical examination
Complete
Blood pressure
Maternal
weight
Pelvic/cervical
examination
Fundal height
Fetal heart
rate and
position
 First Visit 1520 2428 2941
Weeks Weeks Weeks
Laboratory tests
Hematocrit or
hemoglobin
Blood type
and Rh factor
Antibody A
screen
Pap smear
Glucose
tolerance test
Maternal B
serum AFP
screening
Cystic fibrosis B or B
screening
Urine protein
Urine culture
Rubella titer
Syphilis test C
Gonococcal D D
A Performed at 28 weeks, if indicated. C High-risk women should be retested at the beginning
culture
B Test should be offered. of the third trimester.
D High-risk women should be screened at the first
prenatal visit and again in the third trimester.
 First Visit 1520 2428 2941
Weeks Weeks Weeks
Chlamydia culture D D
Hepatitis B surface
antigen
Human B
immunodeficiency
virus (HIV)
Group B E
streptococcus
culture
Rhogam if D- A
negative
A Performed at 28 weeks, if indicated.
B Test should be offered.
C High-risk women should be retested at the beginning
of the third trimester.
D High-risk women should be screened at the first
prenatal visit and again in the third trimester.
E Rectovaginal culture should be obtained between 35
and 37 weeks.
Prenatal Surveillance
Certain informationfor
example, assessment of
gestational age and accurate
measurement of blood
pressureis especially
important.
Fetal
Heart rate(s)
Sizecurrent and rate of
change
Amount of amnionic fluid
Presenting part and station
(late in pregnancy)
Activity
Maternal
Blood pressurecurrent and
extent of change
Weightcurrent and amount of
change
Symptomsincluding headache,
altered vision, abdominal pain, nausea
and vomiting, bleeding, vaginal fluid
leakage, and dysuria
Height in centimeters of
uterine fundus from
symphysis
Maternal
Vaginal examination late in
pregnancy often provides
valuable information:
Confirmation of the presenting
part.
Station of the presenting part
Clinical estimation of pelvic
capacity and its general
configuration
Consistency, effacement, and
dilatation of the cervix.
Assessment
of Gestational Age
Precise knowledge of
gestational age is important
because a number of
pregnancy complications may
develop for which optimal
treatment will depend on
fetal age.
Assessment
of Gestational Age
It is possible to identify this
with considerable precision
through
an appropriately timed,
carefully performed clinical
examination coupled with,
knowledge of the time of onset
of the last menstrual period.
Fundal Height
Between 20 and 31 weeks, the height
of the uterine fundus, measured in
centimeters, correlates closely with
gestational age in weeks.
Obesity, however, may distort this relationship.
The fundal height should be measured
as the distance over the abdominal wall
from the top of the symphysis pubis to
the top of the fundus.
The bladder must be emptied before
making the measurement.
At 17 to 20 weeks, fundal height was 3
cm higher with a full bladder.
Fetal Heart Sounds
The fetal heart can first be
heard in most women
between 16 and 19 weeks
when carefully auscultated
with a DeLee fetal
stethoscope.
Ultrasound
When gestational age cannot
be clearly identified,
sonography is of considerable
value.
Ultrasonography performed
between 8 and 16 weeks was
slightly more accurate
(compared to the LMP
calculation), by
approximately 2 days, for
Subsequent
Laboratory Tests
If the initial results were normal, most
tests need not be repeated.
Maternal serum screening at 16 to 18
weeks (15 to 20 weeks is acceptable) is
recommended for detecting open
neural-tube defects and some
chromosomal anomalies
Hematocrit (or hemoglobin)
determination, along with syphilis
serology if it is prevalent in the
population, should be repeated at
about 28 to 32 weeks.
Subsequent
Laboratory Tests
Cystic fibrosis carrier screening
should be offered to couples with
a family history of cystic fibrosis
and to Caucasian couples of
European or Ashkenazi Jewish
descent planning a pregnancy or
seeking prenatal care.
Ideally, screening is performed
before conception or during the first
or early second trimester.
 Ancillary
Prenatal Tests
Ancillary Prenatal
Tests
Gestational Diabetes
All pregnant women should be
screened .
Laboratory testing between 24
and 28 weeks is the most
sensitive
Chlamydial Infection
Women at high risk for C
trachomatis infection should be
screened during the first
prenatal visit .
Ancillary Prenatal
Tests
Gonococcal Infection
Pregnant women with risk
factors or symptoms be
cultured for N gonorrhoeae at
an early prenatal visit and
again in the third trimester.
Fetal Fibronectin
Forecast preterm delivery in
women with contractions .
Routine screening not needed.
Ancillary Prenatal
Tests
Group B Streptococcal (GBS)
Infection
Obtained in all women between
35 and 37 weeks.
Special Screening for Genetic
Diseases
Offered based on maternal age,
family history, or the ethnic or
racial background of the
couple.
Adequate vs
Inadequate Prenatal
care