Monday, October 9, 2017

Routine Prenatal Care

The objective of prenatal care is to optimize the outcome for both mother and baby. This is achieved through a series of visits with the mother during which history, physical examination, laboratory and other measurements, and patient education all are essential parts.

On the first visit, the last menstrual period is ascertained to date the current pregnancy. In addition, the patient is questioned about previous pregnancies, ethnic background, current problems, current medications, and medical, social, psychosocial, nutritional, and family history. Also on the first (or an early) visit, the mother is given a screening physical examination and a full pelvic examination including estimation of uterine size and clinical pelvimetry. Her weight and height are recorded, and blood pressure measured. Urine is examined for protein and glucose and may also be screened for bacteriuria. Standard blood studies include complete blood count, Venereal Disease Research Laboratory test (VDRL) for syphilis, rubella antibodies, hepatitis B surface antigen, blood type and Rh, and red cell antibodies.

During these early visits, education of the mother continues on such topics as promoting healthy behaviors, general knowledge of pregnancy, nutritional information, and information on the structure of prenatal care. This educational portion of the visit is supplemented by written materials appropriate to individual needs.
Referral to medical, social, or financial resources may begin at this time.

The frequency of prenatal visits is tailored to individual requirements.
  • The first visit is generally between 6 and 8 weeks of gestation.
  • The second visit, 6 weeks later, is at gestation greater than 10 weeks, when fetal heart tones can be detected. 
  • The next visit, approximately 6 weeks later, is when the mother is offered expanded maternal serum screening for neural tube defects and some chromosomal anomalies. 
  • At 18 to 20 weeks of gestation a fetal and obstetric ultrasound study is done. 
  • The mother will be seen again approximately 4 to 6 weeks later, and again at 28 weeks of gestation, when blood glucose concentration is measured 1 hour after a standard dose of oral glucose, a CBC is repeated, and the mother is evaluated for the need for Rh immune globulin. 
  • Visits continue at 4-week intervals until 36 weeks of gestation, then at 38 weeks, and weekly thereafter.
The Concept of Risk Assessment
Risk assessment in obstetrics was introduced before more specific tests of fetal evaluation were developed. The concept is that certain maternal or fetal conditions make it more likely that the pregnancy outcome will be worse than in the average mother. It is still used as an indication for screening and for deciding which mothers are more likely to benefit from specific tests such as fetal heart rate monitoring, ultrasound imaging, amniotic fluid volume, amniocentesis, etc. The combination of a number of tests of fetal condition and pulmonary maturity has lead to the important concept of optimal timing of delivery in the at-risk pregnancy

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