Followup Prenatal Visits

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According to the report of the Expert Panel on Prenatal Care (Rosen et al., 1991), low-risk primigravid women should have at least 10 prenatal visits; low-risk multiparous women should have at least eight visits. Again, however, data suggest that antenatal visits could be reduced without adverse effect to the mother and child (Carroli et al., 2001). Women with psychosocial issues or pregnancy complications should be seen more frequently. In the first two trimesters, prenatal visits may be 5 to 6 weeks apart if no problems have been ascertained. Frequency of visits should increase after 30 weeks, with weekly visits after 37 weeks. Specific recommendations are noted in Table 21-4. Routine visits for low-risk women should be scheduled at times that recommended laboratory testing could be accomplished. Prenatal screening for chromosomal abnormalities is available in the first trimester between 10 weeks, 2 days and 13 weeks, 6 days. Structural defects of the fetus (in particular neural

Table 21-4 Expert Panel Recommendations for Visits throughout Pregnancy

Activity

Week/Trimester

Check for any exposure to infection."

Physical Examination

Blood pressure

24+

Weight

Each visit

Fundal height/growth

16+

Fetal lie/presentation/engagement/heart rate"

24+

Cervical examination

41*

Laboratory Tests

Hemoglobin/hematocrit

24-28

Rh sensitivity!

26-28

Diabetic screen

26-28

Repeat syphilis!

Third trimester

Repeat gonococcal and HIV!

36

Serum alpha fetoprotein

14-16

Ultrasound*

When indicated

Health Promotion Activities

Teratogen avoidance

Each visit

Safer sex"

Each visit

Maternal seatbelt use

Each trimester

Smoking cessation!

Each trimester

Work/nutrition counseling!

Each visit

Signs of preterm labor

Second/third trimester

Physical/emotional changes"

First/third trimester

Sexuality counseling"

Last half of pregnancy

Fetal growth/development

Each visit

Self-help for discomforts!

Each visit

General health habits

Each visit

Breastfeeding

26+

Infant car seat safety

Each visit

Childbirth/parenting classes

32

Family roles adjustment

38

Information about laboratory tests"

Before testing

Birth plan"

Third trimester

Labor (when to call/where to go)"

Third trimester

From Rosen M, Merkatz I, Hill J. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol 1991;77:785.

"Accepted by panel but not specifically reviewed.

+That week and each week thereafter.

!For some.

HIV, Human immunodeficiency virus.

tube defects) and karyotypic abnormalities in the form of alpha-fetoprotein based tests (Quad screen, see below) can be obtained at 16 to 18 weeks. Screening for gestational diabetes is recommended at 26 to 28 weeks of gestation, as well as screening for anemia with a hemoglobin or hematocrit. Antibody screening, Rh0(D) immune globulin (RhoGAM) prophylaxis for D-negative mothers, and repeat testing for infectious diseases for at-risk mothers are recommended at this time.

At 36 weeks' gestation, rectocervical cultures for group B streptococci (GBS) should be obtained. If cultures are positive, antibiotic prophylaxis during labor is given. For women without a penicillin allergy, penicillin (5 million units, then 2.5 million units IV every 4 hours) is administered during labor. If there is a penicillin allergy, sensitivities to clindamy-cin and erythromycin should be obtained and one of these agents used. If the organism is resistant to these antibiotics, women with a serious penicillin allergy should receive van-comycin; women with a minimal reaction from penicillin (e.g., rash) should receive a first-generation cephalosporin intravenously during labor (ACOG, 2002a, Schrag et al., 2002). Women with GBS bacteruria or a prior child affected with GBS sepsis should be treated during labor without screening cultures.

The clinical components of routine prenatal visits are controversial. Most guidelines recommend routine assessment with fundal height and maternal weight and blood pressure measurements, fetal heart auscultation, urine testing for protein and glucose, and questions about fetal movement. The assessment of uterine growth and size should be performed at every prenatal visit. Documentation of fetal heart tones is also recommended with each prenatal visit. Before 12 weeks' gestation, the size of the uterus is estimated by bimanual pelvic examination. The ability to assess the presence of fetal heart tones using Doppler ultrasound before 12 weeks is variable. After 12 weeks and before

40 weeks 30 weeks

20 weeks 16 weeks 12 weeks

40 weeks 30 weeks

20 weeks 16 weeks 12 weeks

Fundal Height Measuring Weeks Ahead

Figure 21-2 Fundal growth at various weeks of gestation.

20 weeks, adequate uterine growth is assessed by location of the uterine fundus in the lower abdomen (Fig. 21-2). Fetal heart tones should be reliably heard during this period. At 20 weeks of gestation, most women have a palpable fundus at the umbilicus. After 20 weeks, fundal height is measured using the distance from top of the symphysis pubis to top of the fundus. The number of completed weeks of gestation should equal this measurement in centimeters (±2 cm). This measurement should be performed as accurately as possible. The most common reasons for inconsistency between menstrual age and fundal height is an inaccurate menstrual-age assignment and inaccurate measurements caused by maternal obesity. Larger-than-expected fundal height may also be caused by multiple gestation, uterine fibroids, polyhydramnios, or a large-for-gestational-age (LGA) fetus. Smaller-than-expected fundal height should warrant an exploration for etiologies such as oligohydramnios, IUGR, and fetal demise.

By 30 weeks' gestation, the fetus is large enough that it can be palpated through the maternal abdomen. Position of the fetus should be documented at this and subsequent visits. This is easily done in most women by Leopold's maneuvers (Fig. 21-3). The first maneuver involves palpation of the uterine fundus to identify the fetal part that is there. The palpating hands then glide downward laterally to perform the second maneuver, location of the fetal back. In the third maneuver the hands are cupped around the presenting part

Leopold Maneuver

Figure 21-3 Leopold's maneuvers for determination of fetal position.

A, First maneuver: palpation of the uterine fundus to identify the fetal part.

B, Second maneuver: location of the fetal back. C, Third maneuver: cupped hands to determine the presenting part and station. D, Fourth maneuver: palpation of the cephalic prominence to determine the degree of flexion.

Figure 21-2 Fundal growth at various weeks of gestation.

Figure 21-3 Leopold's maneuvers for determination of fetal position.

A, First maneuver: palpation of the uterine fundus to identify the fetal part.

B, Second maneuver: location of the fetal back. C, Third maneuver: cupped hands to determine the presenting part and station. D, Fourth maneuver: palpation of the cephalic prominence to determine the degree of flexion.

at the level of the symphysis pubis to determine the presenting part as well as its degree of descent into the pelvis. If the presenting part is cephalic, the fourth maneuver will determine its degree of flexion. The examiner now turns 180 degrees to face the mother's legs, and the cephalic prominence is palpated. Another aid in ascertaining the position of the fetal back is the location of the fetal heart tones by Dop-pler sonography or auscultation. These sounds are best heard through the fetal back; in the left lower uterus in left occiput anterior, transverse, and posterior positions of the fetal head; and the right lower uterus in right occiput positions. The evidence supporting the previous practices is variable but continues as the standard of care (Kirkham et al., 2005).

By the end of gestation, the practitioner as well as the woman should know the presentation of the fetus. This avoids emergent management when she presents in labor with a nonvertex presentation. Internal digital cervical examination can also verify presentation of the fetus and may be done when needed. Unless indicated, however, routine cervical examination to determine cervical readiness for labor need not be done until 41 weeks' gestation.

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