Prenatal Care
Vern L. Katz
The time period from the recognition of a pregnancy until delivery is one of the greatest physical and psychologic transitions that a woman undergoes in her lifetime. During these months, the obstetrician, family physician, or midwife serves a much larger role than just health care provider. The clinicians’ role during this time is not only to assess the health of the mother and fetus, prescribe interventions, and try to influence behaviors but also to advise and help patients as they undergo this challenging psychologic passage. This chapter outlines the principles of prenatal care and addresses specific concerns of a woman’s general health during gestation.
Prenatal care has consisted of adherence to ritual and taboo for generations. Greek authors suggested that Spartan women exercised in pregnancy to give birth to better warriors. Roman physicians argued that strong and violent movements induced rupture of membranes. In the early twentieth century, hanging clothing to dry on a clothesline was said to increase the risk of the umbilical cord wrapping around the baby’s neck. In the United States, the first organized prenatal care programs began in 1901 with home nurse visits. The first prenatal clinic was established in 1911. The goal of early prenatal care was to diagnose and treat preeclampsia in order to decrease maternal mortality. It is not surprising that this focus on maternal and infant health occurred as a direct outgrowth of the woman suffrage movement.
The current emphasis on prenatal care stems from historic pronouncements and retrospective analyses concluding that women who receive prenatal care have less fetal, infant, and maternal morbidity and mortality. However, a conclusive scientific foundation is lacking for the content of prenatal care and the relationship of its components to good outcomes. As technology flourishes and resources dwindle, it has become increasingly important to obtain scientifically based evidence demonstrating which components of prenatal care are clinically appropriate, cost-effective, and deserving of preferential funding. At this time, the optimal content and delivery of prenatal care remains the subject of discussion and debate. Given the increasing number of tools of prenatal assessment, the current consensus is that the best prenatal care is individualized for the specific needs of the mother.
Prenatal care has two areas of emphasis. The first is directed at ensuring appropriate fetal growth and development. This is accomplished through counseling with regard to health behaviors of the mother as well as physical and laboratory evaluations. The second area of emphasis is more complex and involves assessment of the physical and psychologic adaptations of the mother during her pregnancy. Most aspects of pathology occur when there is either insufficient maternal adaptation or too much. Preeclampsia and diabetes are good examples of such pathologies, respectively. The two areas of attention—maternal and fetal well-being—are obviously intertwined. For the clinician facing complex problems, it sometimes helps to untangle these two themes to better address diagnosis and therapy. An example is the pregnant woman diagnosed with cancer or the mother with epilepsy. The evaluation of risk:benefit ratio of tests and treatments must be seen looking at both maternal and fetal health. This chapter will emphasize normal changes in pregnancy, and later chapters will build on this discussion to focus on pathology.
Over the three trimesters of pregnancy, a woman must develop new aspects to her identity. Her self-image develops an additional sense of femininity beyond what was developed at puberty, and a maternal self-concept must develop as well. Reba Rubin, in her works on the maternal experience, describes a new mother’s psychologic tasks as the woman grows into her new role. These tasks include:
Accepting a new body image, which is often in conflict with accepted societal views of attractiveness
Accepting the child who is growing inside her
Reordering her identity with her mother, her friends, and the father of the pregnancy
Symbolically finding acceptance and safety for her child (i.e., making a new home).
For many women with good social support, these tasks are anticipated and desired roles that bring a sense of fulfillment. For other women, some or all of these tasks are unanticipated and difficult. The obstetric provider, in multiple ways, helps the mother through these transitions while at the same time ensures the physical health of both patients (mother and fetus). Many aspects of prenatal care have grown from their original role of health promotion to ritualized traditions that have acquired symbolic value in helping women and their families adapt to these psychologic transitions. For example, studies have found that for women of average weight, the practice of weighing a woman during each visit has minimal medical value. Yet, if the nurse forgets to weigh a patient, that woman usually remarks quite quickly about having her weight taken. Another example is the routine ultrasound. This is now a demand ritual. At this visit, a mother will usually bring several female family members or friends to see the sonogram. The new mother not only uses the sonogram to bond with her child but also shows the baby to the other women around her for their acceptance. Throughout the world, cultures and subcultures view prenatal care differently, but most all hold it with respect. A woman might miss her annual Pap smear, but she rarely misses a prenatal visit.
Primary and Preconception Care
Philosophy
Care for preconception, pregnancy, and postpartum should be integrated and accessible, focus on the majority of personal health care needs, represent a sustained partnership between patient and provider, and occur within the context of family and community. For many women, pregnancy care occurs as a part of the continuum in a long-term relationship with the health care provider. The first visit may be a preconception visit or may occur after the woman is pregnant. If a woman is seen for a preconception visit, many issues need not be readdressed when she becomes pregnant.
Content of the Preconception Visit
The preconception visit is a focused visit for the woman who is planning to become or is considering becoming pregnant in the near future. The content of this interval visit includes a complete history; when appropriate, a complete physical examination; risk assessment and intervention; selected laboratory testing based on the patient’s age and the results of the foregoing evaluation; ongoing management of medical conditions; and a plan of care. A purposeful discussion of contraception, sexually transmitted disease prevention, and timing of conception is appropriate. Timely administration of routine immunizations, educational counseling, and advice complete the visit.
Risk Assessment
A goal specific to the preconception interval visit is the systematic identification of potential risks to pregnancy and the implementation of early intervention as necessary. These risks fall into several categories, described in the following sections.
Unalterable Factors
Unalterable factors are preexisting factors that cannot be altered in any medical way by clinical intervention. These include the patient’s height, age, reproductive history, ethnicity, educational level, socioeconomic status, genetic composition, and to some extent her body mass index (BMI). Genetic and family histories, although unalterable, may lend themselves to screening and evaluation. A detailed family history should be obtained, including inquiry of thromboembolic disease, recurrent miscarriage, neonatal or early infant death, congenital cardiac disease, mental retardation, or other major disease affecting health in family members.
Factors Benefiting from Early Intervention
Conditions that should or could be modified before pregnancy is attempted include poor nutrition; an underweight or obese BMI; and poorly controlled medical diseases such as diabetes mellitus, asthma, epilepsy, phenylketonuria, hypertension, and thyroid disease.
Some prescription medications that are known teratogens should be discontinued and appropriate substitutions made. These include medications such as isotretinoin (Accutane), warfarin sodium (Coumadin), certain anticonvulsants, and angiotensin-converting enzyme inhibitors. However, many medications are safe, such as medications for asthma and most antihistamines. Some medications such as antidepressants need to be evaluated for the risk:benefit ratio.
Determining the status of a patient’s immunity to rubella, varicella, and hepatitis is appropriate during the preconception visit. If needed, the influenza vaccine is safe. In high-risk populations or endemic geographic areas, patients should be assessed for active tuberculosis with skin testing and chest x-ray.
Social Risk Factors
Inquiry should be made regarding occupational hazards involving exposure to toxins such as lead, mercury and other heavy metals, pesticides, and organic solvents (both liquid and vapors). Hazards in the home, such as exposure to toxoplasmosis or toxic chemicals (asbestos, pesticides), are important to identify. If a woman uses well water, it should be assessed for acidity, lead, and copper.
Family violence is a particularly important household hazard. Nonjudgmental, open-ended evaluation should be applied. Judith MacFarland has recommended questions such as “Are you in a relationship in which you are being hit, kicked, slapped, or threatened?” “Do you feel threatened?”
“Have you been forced to do things against your will?” These questions should be asked again at the first prenatal visit. Some studies have suggested that a written questionnaire, in addition to oral questions, will allow for greater identification of domestic abuse. Approximately 20% of all pregnant women are battered during their pregnancy. About one half of women who are physically abused prior to pregnancy continue to be battered during pregnancy. For some women, the violence begins with pregnancy. All such patients require information regarding their immediate safety and referrals for counseling and support.
“Have you been forced to do things against your will?” These questions should be asked again at the first prenatal visit. Some studies have suggested that a written questionnaire, in addition to oral questions, will allow for greater identification of domestic abuse. Approximately 20% of all pregnant women are battered during their pregnancy. About one half of women who are physically abused prior to pregnancy continue to be battered during pregnancy. For some women, the violence begins with pregnancy. All such patients require information regarding their immediate safety and referrals for counseling and support.
Risky Health Habits
The use of illicit drugs or abuse of alcohol represents a significant health hazard to pregnancy. Alcohol is a known teratogen. There is no consensus on the correlation between the quantity of alcohol consumed and the manifestation of adverse fetal effects. Therefore, the best advice to women who wish to become pregnant is to stop drinking. The T-A-C-E screen for alcohol abuse has been well studied. The letters stand for four questions asked in a nonjudgmental manner:
T—“How much do you drink to feel drunk?” (tolerance)
A—“Does your drinking annoy anyone?”
C—“Has anyone told you to cut down?”
E—“Do you drink in the morning to feel better?” (eye-opener).
Smoking cigarettes is associated with adverse pregnancy outcomes, including low birth weight, premature birth, and perinatal death. Smoking by both the pregnant woman and members of the household should be avoided during pregnancy and, preferably, not resumed postpartum. The relative risk of intrauterine growth restriction (IUGR) among pregnant smokers has been calculated at 2.2 to 4.2. Because of the morbidity associated with smoking, various methods to assist women to quit smoking should be encouraged prior to pregnancy. Numerous interventions are available. Use of the transdermal nicotine patch in pregnancy is thought to be preferable to smoking. One benefit of using a nicotine patch is the elimination of exposure to other toxins such as carbon monoxide inhaled in cigarette smoke. Its theoretic risk is that it creates a constant blood level of nicotine, as opposed to the vacillations that occur with smoking. Depending on the timing of the prescription, it may be a very appropriate intervention. Similarly, all illicit drugs have the potential of harming the pregnancy.
Other behaviors that should be avoided are those that promote exposure to sexually transmitted and other infectious diseases. These include unprotected sexual intercourse in a nonmonogamous relationship and the sharing of needles between addicts.
Interventions
The final phase of the preconception visit involves specific interventions derived from the information obtained during the history, physical examination, and risk assessment phases. The specific interventions may include immunization against rubella, varicella, or hepatitis; changes in prescribed medications; behavior modification; genetic screening for such conditions as Tay–Sachs disease, cystic fibrosis, thalassemia, and sickle cell anemia; and nutritional and physical activity recommendations.
During the physical examination, evaluation of the thyroid and breasts is important. Signs or symptoms of thyroid disease should prompt laboratory evaluation with TSH and free T4. If a woman is 35 years of age or older, a screening mammogram should be ordered, since as much as two and a half years may pass before she will be able to have one (mammograms have significantly decreased sensitivity during pregnancy and for up to 6 months after lactation). If a woman has a family history of premenopausal breast cancer, a mammogram may be considered at younger ages. Additionally, if there is a body habitus or history suggestive of polycystic ovary disease, this condition should be evaluated (Chapter 38). If a Pap smear has not been done within a year, this test should be repeated at this time. Abnormalities of the Pap smear are more easily addressed prior to pregnancy. Additionally, it is valuable at this visit to examine the patient’s skin. The incidence of melanoma is increasing faster than any other malignancy in the United States. The obstetrician has the unique opportunity to assess and teach at this visit regarding this cancer. An inquiry about periodontal disease and, when appropriate, assessment of dental hygiene is important. Periodontal disease is associated with a significant risk of preterm birth. Periodontal disease may be treated at any time in pregnancy but is best addressed preconception.
Folic acid as a supplement can reduce the occurrence and recurrence of neural tube defects and may reduce the risk of other birth defects as well. Women who have had a previous pregnancy affected by neural tube defects should take 4 mg of folic acid per day, starting 4 weeks prior to conception through the first trimester. For all other women of reproductive age who have the potential to become pregnant, 1 mg of folic acid should be prescribed. Unfortunately, prenatal vitamins contain only 0.4 to 0.8 mg.
Some patients purposely initiate a preconception visit to determine whether or not a preexisting medical condition is an absolute contraindication to pregnancy. Pulmonary hypertension, for example, although rare, is associated with up to a 50% maternal mortality and a greater than 40% fetal mortality. It is possible to obtain epidemiologic studies that provide statistics on the morbidity and mortality for mother and fetus for most disease states. These cannot, however, provide specific data for any one patient with her own unique set of medical, demographic, and social variables. Many patients who make these inquiries will benefit by reading the relevant medical materials themselves and by obtaining more than one opinion. Consultation with other medical specialists may be necessary. For example, women with orthopedic problems often inquire about vaginal delivery. Another common concern is advanced
maternal age. Specific risks of increased rates of aneuploidy and miscarriage should be discussed. Women over age 40 have been found to have higher rates of low birth weight, fetal demise, preterm birth, and operative delivery.
maternal age. Specific risks of increased rates of aneuploidy and miscarriage should be discussed. Women over age 40 have been found to have higher rates of low birth weight, fetal demise, preterm birth, and operative delivery.
It is also important to discuss how and when to discontinue contraceptive measures. Patients using medroxy-progesterone acetate (Depo-Provera) injections may experience a delay of several months in the return of regular ovulatory menstrual cycles. An intrauterine device (IUD) may be removed at any time in the cycle. It should be removed as soon as conception is considered, since removal during pregnancy (although preferable to leaving in place) is associated with a higher rate of pregnancy loss. Likewise, birth control pills and other hormone-based contraceptives should be discontinued prior to attempting conception. Many physicians believe that discontinuing the use of hormone-based contraceptives for one to two cycles allows better growth of the endometrium. Although definitive evidence is lacking, the thought is that this may be associated with better implantation of the fertilized egg. If a woman discontinues hormone-based contraception, she needs to be reminded that ovulation may occur in a variable time period after stopping the contraception. Thus, risky behaviors should be avoided at the time of discontinuation.
The patient should be advised to seek early prenatal care by making an appointment after missed menses or on confirmation of pregnancy by a home pregnancy test. Unfortunately, in the United States, only 75% of pregnant women receive prenatal care beginning in the first trimester. Ongoing barriers to prenatal care access include lack of money or insurance to pay for care, system undercapacity for appointments, and inadequate transportation.
Initial Prenatal Visit
This visit represents the first detailed assessment of the pregnant patient. The optimal timing of this visit may vary. For women who have not undergone the comprehensive preconception visit, prenatal visits should begin as soon as pregnancy is recognized. For these women, much of the content of the preconception visit will need to be addressed at this time—for example, screening for domestic abuse and alcohol use. All other women should be seen by about 8 menstrual weeks (6 weeks after conception) gestation. For all patients, the appropriate content of prenatal care and the first prenatal visit is contained in the antepartum record published by the American College of Obstetrics and Gynecology (ACOG). Identifying data, a menstrual history, and a pregnancy history are obtained. Past medical, surgical, and social history are recorded, along with symptoms of pregnancy. The patient’s current medications, including over-the-counter (OTC) and herbal supplements should be evaluated. A focused genetic screen, infection history, and risk status evaluation are performed or reconfirmed.
Diagnosis of Pregnancy
The two aspects of pregnancy diagnoses include confirmation of an intrauterine pregnancy and assessment of viability. Evaluation of the signs and symptoms associated with the presumptive diagnosis of pregnancy, while a useful adjunct, has been largely superseded by the widely available urine pregnancy test and ultrasound. The detection of greater than 35 mIU of human chorionic gonadotropin (hCG) in the first morning void has a very high specificity for pregnancy. OTC pregnancy tests can confirm a pregnancy prior to the missed period. Other tests for confirming the presence of pregnancy include a positive serum β-hCG and demonstration of the fetal heart by either auscultation or ultrasound. Using a transvaginal probe, an intrauterine pregnancy may be confirmed (gestational sac–intradecidual sign) at the time a β-hCG reaches 1,500 IU. Fetal cardiac activity should be seen by postconception week 3. Ultrasound imaging is not routinely indicated to diagnose pregnancy but is often used in the evaluation of a patient who is unsure of her last period, at increased risk for ectopic pregnancy, or showing signs of miscarriage. In conjunction with early quantitative serum β-hCG assessments, these conditions can be clearly differentiated from a normal intrauterine pregnancy and timely therapy initiated (Chapter 5).
Gestational Age
The Nägele rule is commonly applied in calculating an estimated date of confinement (EDC). The clinician should remember that this is an approximate rule. Using the date of the patient’s last menstrual period minus 3 months plus 1 week and 1 year, the rule is based on the assumptions that a normal gestation is 280 days and that all patients have 28-day menstrual cycles. Although several studies have found the average length of gestation for primiparous women to be 282 to 283 days, for convention, 280 days is the currently accepted average gestation. After adjustment for a patient’s actual cycle length, natality statistics indicate that the majority of pregnancies deliver within 2 weeks before or after this estimated date. During prenatal care, the week of gestation can be obtained based on the calculated EDC. When the last menstrual period is unknown or the cycle is irregular, ultrasound measurements between the 14 and 20 weeks gestation provide an accurate determination of gestational age (Chapter 9). Care should be taken not to change the EDC unless the ultrasound differs by 10 or more days from the menstrual dates. Once dates are appropriately confirmed, continued alterations of EDC based on fetal size are problematic and ill advised.
Physical Examination
A targeted physical examination during the first prenatal visit includes special attention to the patient’s BMI, blood pressure, thyroid, skin, breasts, and pelvis. On pelvic
examination, the cervix is inspected for anomalies and for the presence of condylomata, neoplasia, or infection. A Pap smear is performed, and cultures for gonorrhea and chlamydia are taken, if indicated. A small amount of bright red bleeding may occur after these manipulations, and the patient can be assured that this is normal. On bimanual examination, the cervix is palpated to assess consistency and length as well as to detect the presence of cervical motion tenderness. Size, position, and contour of the uterus are noted. The adnexa are palpated to assess for masses. The pelvic examination may include evaluation of the bony pelvis—specifically, the diagonal conjugate, the ischial spines, the sacral hollow, and the arch of the symphysis pubis. This evaluation need only be performed once during the pregnancy.
examination, the cervix is inspected for anomalies and for the presence of condylomata, neoplasia, or infection. A Pap smear is performed, and cultures for gonorrhea and chlamydia are taken, if indicated. A small amount of bright red bleeding may occur after these manipulations, and the patient can be assured that this is normal. On bimanual examination, the cervix is palpated to assess consistency and length as well as to detect the presence of cervical motion tenderness. Size, position, and contour of the uterus are noted. The adnexa are palpated to assess for masses. The pelvic examination may include evaluation of the bony pelvis—specifically, the diagonal conjugate, the ischial spines, the sacral hollow, and the arch of the symphysis pubis. This evaluation need only be performed once during the pregnancy.
Laboratory Evaluation
Several laboratory tests are routinely done at the first prenatal visit.
Blood Tests
Hematologic testing includes a white blood cell count, hemoglobin, hematocrit, and platelet count. Full red cell indices are advised for women of Asian descent to evaluate for thalassemia, a serologic test for syphilis (RPR, rapid plasma reagin or VDRL), a rubella titer, a hepatitis B surface antigen, a blood group (ABO), and Rh type and antibody screen. HIV testing should be recommended to all pregnant patients and documented in the chart. Routine assessment for toxoplasmosis, cytomegalovirus, and varicella immunity is not necessary but may be obtained if indicated. The National Institutes of Health and ACOG recommend offering all white women testing for cystic fibrosis status. Women with histories suggestive of thrombophilia, or a personal or family history for thromboembolic disease, should be evaluated at this time. Women with a history suggestive of thyroid disease should also be evaluated. Although TSH is normally used to evaluate for thyroid disease, TSH may be affected by other pregnancy hormones and not accurately affect thyroid status. Thus, a free T4 should always be obtained when evaluating thyroid disease in pregnancy.
Appropriate screening for genetic carrier status, if not performed at the preconception visit, includes but is not limited to Tay–Sachs disease, Canavan disease in women of Jewish ancestry, α- and β-thalassemia in women of Asian and Mediterranean descent, and sickle cell disease in women of African descent. Women with a suggestive history of mental retardation should be screened for fragile X syndrome.
Urine Tests
All women should have a clean-catch urine sent for culture. Asymptotic bacteriuria occurs in 5% to 8% of pregnant women. Urinary stasis is present during pregnancy secondary to physiologic changes in the urinary system, including decreased ureteral peristalsis and mechanical uterine compression of the ureter at the pelvic brim as pregnancy progresses. Bacteriuria combined with urinary stasis predisposes the patient to pyelonephritis, the most common nonobstetric cause for hospitalization during pregnancy. Urinary tract infection is also associated with preterm labor, preterm premature rupture of the membranes, and preterm birth. Asymptomatic bacteriuria is identified by using microscopic urine analysis, urine culture (>100,000 colonies per milliliter), or a leukocyte esterase–nitrite dipstick on a clean-catch voided urine. Group B streptococcal (GBS) colonization of the urinary tract will not always induce a positive leukocyte esterase reaction. Thus, full urine culture at the first visit is indicated, even with negative leukocyte esterase.
Cultures and Infections
The use of routine genital tract cultures in pregnancy is controversial. While it is clear that chlamydia, gonorrhea, GBS disease, herpes infection, and potentially bacterial vaginosis can be detrimental to the ultimate health of the fetus or newborn, the indications for and timing of cultures for these infections are debated. The ACOG recommends assessment for chlamydiosis and gonorrhea at the first prenatal visit for high-risk patients. The high-risk patient is defined as less than 25 years of age with a past history or current evidence of any sexually transmitted disease, a new sexual partner within the preceding 3 months, or multiple sexual partners. Any abnormal discharge should be assessed with a wet prep or Gram stain. Symptomatic patients should be treated. Symptomatic bacterial vaginosis may be treated in the first trimester.
Tuberculosis skin testing in high-risk populations or in certain geographic areas should be done if the patient has not been vaccinated with BCG vaccine. BCG vaccinations are not given in the United States.
Discussions with the Patient
The first prenatal visit is a time for the caregiver and patient to exchange expectations, to answer questions, and to set the stage for what will occur throughout the rest of normal prenatal care. The timing and content of future visits and the timing and rationale behind further laboratory testing should be explained. The patient should be given educational resources and materials that are written at the appropriate reading level. She and her partner are encouraged to ask questions about what they will read and to share the concerns they have about the pregnancy. It is important to reinforce that there is no such thing as a meaningless, “dumb,” or trivial question. Emergency and routine phone numbers should be given to the patient in writing. Social services and community resources, such as Women,
Infants, and Children (WIC) programs, may be identified for the patient on an as-needed basis. Discussion regarding sexual activities, physical activities, and nutrition are usually initiated at this time. Instructions on safe and unsafe OTC medications (i.e., acetaminophen vs. ibuprofen) are also initiated. Instruction on the use of seat belts and domestic abuse is also recommended. For women with previous pregnancies, a discussion of issues and problems from that pregnancy and the past delivery experience should be entertained at this time. Many fears and tensions can be alleviated with simple discussions now and obviate anxieties that may linger and build over pregnancy. A note in the chart to further discuss a particular point at a later time may also be helpful.
Infants, and Children (WIC) programs, may be identified for the patient on an as-needed basis. Discussion regarding sexual activities, physical activities, and nutrition are usually initiated at this time. Instructions on safe and unsafe OTC medications (i.e., acetaminophen vs. ibuprofen) are also initiated. Instruction on the use of seat belts and domestic abuse is also recommended. For women with previous pregnancies, a discussion of issues and problems from that pregnancy and the past delivery experience should be entertained at this time. Many fears and tensions can be alleviated with simple discussions now and obviate anxieties that may linger and build over pregnancy. A note in the chart to further discuss a particular point at a later time may also be helpful.
Finally, the patient should be made aware of the warning signs and symptoms of infection (fevers, chills, dysuria, and hematuria) or threatened pregnancy loss (bleeding, cramping, passage of tissue). Should any of these occur, the patient should seek immediate medical attention. At the completion of the first visit, the next prenatal appointment is made.
Routine Antepartum Surveillance
The rationale and guiding principles of prenatal care are listed in Table 1.1. It is at this point in the patients’ care that individualization should occur. For women in high-risk categories—such as those with previous preterm birth, chronic medical diseases, family history of problems, and the like—an individualized frequency of visits should be established and documented. For example, a woman with a previous unexplained second-trimester loss that was suspicious but not diagnostic for incompetent cervix might be observed weekly between 17 and 24 weeks, or a woman with chronic hypertension might be seen every 2 weeks throughout the first and second trimesters. In contrast, a woman with previous uncomplicated pregnancies might be seen every 6 weeks in the first and second trimesters and every other week in the last 8 weeks. The traditional timing of 14 prenatal visits was established empirically in the 1930s and has never been validated. In the mid 1980s and 1990s, several randomized trials demonstrated that for low-risk women, 6 to 8 total prenatal visits were equally effective in achieving good pregnancy outcomes. A systematic review and the current standard of care allow for individualized scheduling of visits. Fourteen visits for a low-risk woman would be more than necessary. Table 1.2 lists the traditional timing of visits. From this outline, each woman’s needs may be individualized and the prenatal course altered, based on necessary assessments and interventions. A U.S. Public Health Service report delineated the interventions and tests deemed minimally necessary in a normal pregnancy and the suggested the timing for each (Table 1.3).
TABLE 1.1 Rationale for Routine Prenatal Care | ||||||
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Content of Subsequent Prenatal Visits
The two components of each prenatal visit are the assessments of fetal growth and health and the evaluation of maternal well-being. Maternal health is assessed first with the taking of an interval history, risk assessment and identification, and intervention as necessary. Fetal assessment is via physical examination and inquiry of fetal movements. It is important that the assessments be recorded in an ongoing database. The final aspect of the visit is education, advice, and support of the patient and her family.
TABLE 1.2 The Traditional Timing and Number of Prenatal Visits | ||||||||||||
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TABLE 1.3 Timing of Prenatal Care Based on Specific Interventions (in weeks) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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