(1)
Department of Family Medicine, University of California, Riverside, Riverside, CA, USA
Key Points
1.
Prenatal care is a process not an event.
2.
Excellent prenatal care represents a partnership between the provider, the patient, and her family.
3.
Key domains of intake information in prenatal care include pregnancy dating, baseline maternal health status, family health history, medical conditions impacted by pregnancy, medical conditions impacting pregnancy, and infection.
4.
Key domains of information during follow-up visits include normal growth and development, medical and/or obstetrical complications of pregnancy, and onset of labor.
Background
Prenatal care is generally the most prolonged and sustained component of pregnancy care. Such care is often delivered by a single provider who will follow the course of the pregnancy with nearly as much interest as the pregnant patient. Although the prenatal period is often filled with anxiety, it is generally more relaxed and almost always less pressured than the labor and delivery setting. For these reasons, prenatal care provides patients with an opportunity to educate themselves and participate in the process of preparing for a new infant.
Prenatal care can best be thought of as a process rather than a specific event. For patients who received preconception counseling, it is a continuation of the threefold process of education, risk identification, and risk reduction/intervention. For those patients who did not receive preconception counseling, it should be the beginning of such a process. Many prenatal care providers also participate in the delivery of their patients. In this regard, prenatal care provides an opportunity to establish or enhance a relationship that stretches from preconception through prenatal management to delivery. Excellent prenatal care represents a partnership between the provider and the pregnant patient (and her family) with ample opportunity for discussion, questions, and answers and active participation by each person involved.
Prenatal care is a cornerstone of modern obstetric care and has accompanied a reduction in the historic risk associated with pregnancy. Maternal mortality in 1935 was 582 per 100,000 pregnancies. By 1993, that figure had decreased to 7.5 per 100,000. Over approximately the same period, infant mortality decreased from 47 per 1000 to 8 per 100,000. Although many factors unrelated to prenatal care have contributed to these reductions, prenatal care has directly contributed to improved outcomes in a variety of areas: (a) fetal organogenesis (folic acid supplementation, glycemic control in diabetes), (b) infectious disease detection/treatment (e.g., chlamydia, bacteriuria), (c) infectious disease transmission prevention (e.g., syphilis, HIV), and (d) fetal growth (e.g., glycemic control in gestational diabetes).
Figure 2.1 in Chap. 2 provides a schematic outline for the interrelated factors involved in pregnancy. Factors present during the preconception period were reviewed in the prior chapter. With the advent of conception, additional factors come into play. Pregnancy itself introduces a variety of new conditions that can impact the health of both the mother and the infant. Although less well described, a variety of paternal factors can also affect the course and outcome of pregnancy. Although not specifically addressed in this chapter, there are a number of physician- and system-related factors that can, likewise, impact pregnancy. The process of prenatal care is cyclical and repetitive. Each visit allows providers to review what has already happened and to determine what has developed in the interval since the last visit. Each visit will focus on patient education, determination of normal growth and development, and compilation of critical information in a variety of important domains.
Key Domains of Prenatal Information
The first step in any prenatal assessment is to confirm that the patient is, in fact, pregnant. Many patients will arrive for a first prenatal visit with a confirmed positive pregnancy test result. Other patients will arrive for their first “prenatal” visit with a variety of less clear presentations. They may have missed their period but not have been tested. They may have self-tested but not trust the results (either positive or negative). Regardless of the nature of the uncertainty, all patients with uncertain pregnancy status should have their status confirmed via urine or serum human chorionic gonadotropin (hCG) testing. Following confirmation of pregnancy, all patients should have the opportunity to consider what the most appropriate next step should be. When uncertain regarding the desirability of a confirmed pregnancy, providers should be cautious in their choice of language. In particular, providers should avoid the use of language that implies a specific outcome such as “Congratulations, you’re pregnant!” or “We will need to get you started with prenatal care soon.” The use of open-ended questions such as “The test confirms that you are pregnant. What do you think you would like to do at this point?” will allow patients to more easily express their thoughts concerning subsequent management.
Initial evaluation during prenatal care is similar to the evaluation for preconception counseling. It is designed to focus on the patient’s baseline condition and any development in the time frame from the last menstrual period (LMP) through the first prenatal visit. (This is a time period during which patients may not recognize that they are pregnant and may include significant exposures to infectious or toxic agents.) At intake prenatal screening provides important information in six key domains:
1.
Baseline maternal health including prior obstetrical history, if any
2.
Family health (e.g., twins, Down syndrome, Tay–Sachs)
3.
Medical conditions impacted by pregnancy (e.g., cardiac disease, renal disease)
4.
Medical conditions impacting pregnancy (e.g., diabetes mellitus, hypertension, medications, toxic exposures)
5.
Infection
6.
Pregnancy dating
As discussed in the previous chapter, these domains of information can form the basis for patient education and intervention throughout the course of pregnancy (and beyond).
Following the initial prenatal screen, subsequent visits focus on interval developments and review of previously identified issues. It is often helpful to develop a prenatal problem list to organize ongoing issues under management. Such a list could include the problem, the date identified, interventions, if any, and the date resolved, if applicable. Follow-up prenatal care will focus on three key domains: (a) normal growth and development, (b) medical and/or obstetrical complications of pregnancy, and (c) onset of labor.
Frequency of Prenatal Visits
The frequency of visits during prenatal care is dependent on the complexity of the care being provided. For those patients with complex presentations, individualized decisions must be made concerning the frequency of prenatal visits. For patients with uncomplicated pregnancies, the currently recommended frequency for visits is as follows:
First prenatal visit: in the first trimester
Follow-up visits: every 4 weeks until 30 weeks gestation, then
every 2 weeks until 36 weeks gestation, then
every week until delivery at term, or
twice weekly from 40 weeks for assessment of
fetal well-being (see Chap. 18).
The First Prenatal Visit (See Table 3.1)
Table 3.1
First prenatal visit
Last menstrual period (LMP) |
Duration, abnormalities, fertility treatment, contraceptive use, and prior pregnancies
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