Prenatal care involves regular checkups during pregnancy to monitor the health of the mother and baby and prevent or identify potential complications. The goals are to promote healthy pregnancies and deliveries through education, screening, identification of risk factors, and treatment or intervention if needed. Initial visits involve a full medical history, exam, lab work, estimation of due date, and education about nutrition, safety, and signs of concern to watch out for. Later visits focus on brief history updates, monitoring growth and fetal well-being through exams and testing, and addressing any issues that arise.

1. Prenatal Care
Simmons College
Graduate School for Health Studies

2. 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. 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.

4. 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.

5. Continuous communication and education

6. 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.

7. 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

8. 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.

9. – 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.

11. Prenatal Care: Complications
Prevented 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

12. Components of the
Initial 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.

13. Demographic Assessment
• Patient phone #’s and Emergency contact
• Marital status
• Education
• Occupation
• Partners name and occupation
• PCP
• Religion
• Insurance carrier

14. 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.

15. Gynecological History
• Menstrual history
• Last pap
• STD exposure
• DES exposure
• Genital tract disease or procedures
• Last contraceptive use/type

16. Medical/Surgical History
• Endocrine
• Cardiovascular
• Kidney
• Neurological
• GI
• Psychiatric
• Autoimmune
• Trauma
• Pulmonary
• Hematologic
• Breasts
• Surgical procedures
• Anesthesia
• Hospitalizations
• Allergies
• Medications
• Substance abuse

17. 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.

18. 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

19. 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.

20. • 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.

21. Genetic Screening:
For the nonpregnant patient, genetic consultation
is recommended in cases of unexplained
infertility.

22. 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.

23. 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.).

24. 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.).

25. Prenatal Care:
The Initial Physical Exam
Focus P.E. keeping in mind physiologic
changes of pregnancy!
Weight
Skin
Gums / Dentition
Blood pressure
Thyroid
Heart

26. – 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

27. 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

28. Laboratory Testing
• OB panel (cont)
– Rubella immunity.
• If negative must receive immunization postpartum
– RPR/VDRL
– HBsAg
• Even if previously vaccinated

29. 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)

30. Laboratory Testing
– Diabetes
• BMI
• Ha1c
– TB
– Toxoplasmosis
• Routine practice in France but not US
– Hepatitis C
– BV

31. 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

32. Laboratory Testing
– Spinal Muscular Atrophy
• Controversial. The Americaln Academy of Genetics
recommends universal screening. ACOG disagrees.
• Any h/o of SMA/SMA like illness

33. 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

34. 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.

35. 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

36. Education
• Nutrition
• Alcohol/Tobacco/Drugs
• Infection Precautions
– Influenza vaccination
– Tetanus/diphtheria/pertussis
– Toxoplasmosis risks
– Varicella
– Parvovirus
– Listeria

37. Education
• Work
• Sexual activity
• Medications
– Pregnancy categories since 1975
– Only a limited number were proven to be
teratogenic

39. Medications in Pregnancy
• Commonly used meds
– Acetaminophen
– NSAIDS
– Opioids
– Cold and Allergy
– Antibiotics
– Constipation and diarrhea
– Antiemetics and antinausea

40. Education
– GERD
– Sleep Aids
• Travel
– Available resources
– DVT risks in prolonged travel
– Infectious disease exposure

41. 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

42. Education
• Pesticides
• Hair Treatment

43. 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.

44. 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!

45.  Specifically, ask each client about:
 Pain
 Contractions or cramping
 Pelvic pressure
 Bleeding
 Leaking or Discharge
 Dysuria
 GI problems
 Presence and adequacy of fetal movements

46. 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.

47. 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

48. Prenatal Care:
Periodic Assessments
11-13 wks: Early Risk Assessment
15-22 wks: AFP, Quad screen
18 wks: ultrasound -- anatomic survey,
singleton vs. multiple gestation, dating
24-28 wks: one hour glucose tolerance
test/ CBC
28 wks: Rhogam if Rh(-)
36 wks: Group B Strep culture

49. Periodic Assessments
• Estimated Fetal weight
• >40 weeks: Fetal testing

50. Thank you!