Avoidance of teratogens Safer sex*
Physical and emotional changes in pregnancy* Sexuality*
Self-help strategies for discomforts (for some) Fetal growth and development
Classes on nutrition, physical changes, exercise, psychological adaptation
Nutritional counseling (some or all) Preparation for screening and diagnostic tests Content and timing of visits* Need to report danger signs*
*Accepted by panel but not specifically reviewed.
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.
the woman discovers she might be pregnant and should be viewed as a continuation of preconception counseling. Home pregnancy test kits have a sensitivity and specificity of at least 95%; many can detect pregnancy by the fifth menstrual week. The most important aspects of the first prenatal visit include education, risk assessment, appropriate laboratory testing, and establishment of gestational age.
Education is an important component of prenatal care, particularly for women who are pregnant for the first time. Frequency of prenatal visits should be explained, with information about the physiologic changes that occur during
Box 21-4 Recommendations for Exercise in Pregnancy
1. Established exercise routines can be continued with mild to moderate intensity.
2. High-intensity or high-impact routines should be avoided or reduced.
3. The supine position should be avoided in the second and third trimesters.
4. Hyperthermia should be avoided.
5. Weight-bearing exercise should minimize strain because joints are more lax.
6. Routines should be designed to minimize risk of maternal trauma (falling).
7. Adequate nutritional intake to compensate for pregnancy should be assured.
8. Resumption of prepregnancy routines in the postpartum period should be gradual.
Modified from ACOG Technical Bulletin No. 189, 1994.
pregnancy. Preparation for the birthing process is a key theme around which to discuss care issues and choices such as breastfeeding. Structured educational programs to promote breastfeeding have unclear effectiveness. Pregnant women should be counseled about the risks of possible teratogens, including smoking, alcohol, and drug use, including exposure to medications, prescriptions, OTC drugs, and herbal remedies. Good handwashing is always encouraged because this is one of the best ways to avoid community-acquired infectious diseases. Appropriate immunizations such as influenza and novel influenza A (H1N1) virus should be offered. Common exposures such as workplace conditions and use of hot tubs and saunas should be explored. Exercise should also be encouraged if there is no obstetric contraindication (Box 21-4). Intercourse during pregnancy should be actively addressed because some women are reluctant to discuss this topic even with their physician. Sexual activity can generally continue during pregnancy except for few situations, such as placenta previa and preterm labor. Counseling regarding sexually transmitted diseases (STDs) and their avoidance should occur. Nutrition should be individualized, with an estimate of desirable weight gain given to the pregnant woman.
The estimated date of delivery (EDD) should be calculated by accurate determination of the last menstrual period (LMP). The first day of the LMP is a good clinical sign from which to calculate EDD, remembering that it must be adjusted for cycles shorter or longer than 28 days. The EDD can be calculated by Nagle's rule, that is, subtracting 3 months and adding 7 days to the first day of the LMP. EDD should then be extended by the number of days longer than a 28-day cycle or shortened by the number of days shorter. This approach should be considered if there is uncertainty about the LMP.
The physical examination during the first prenatal visit should include careful assessment of uterine size. If there is a discrepancy between menstrual age and uterine size, ultrasound should be considered early in the pregnancy to resolve the issue of dating. Recent evidence suggests that early sonography provides more accurate dating, which is important for timing screening tests and interventions and for optimal management of complications such as post-term pregnancies (Neilson, 2004). Late ultrasound, after 24 weeks, is not as sensitive for confirming gestational age. Additionally, any irregular bleeding or abdominal pain should prompt the practitioner to obtain sonographic confirmation of viability of the pregnancy as well as its normal intrauterine location.
A history and directed physical examination should be performed to detect conditions associated with increased maternal and perinatal morbidity and mortality. The first prenatal examination provides an opportunity for cervical cancer screening with a Papanicolaou (Pap) test in women who have not been screened recently. However, Pap tests performed in pregnant women may be less reliable. Risk factors should then identify other testing that might be done at this time, including blood glucose, sickle cell screening, Tay-Sachs screening, and surveillance for other infectious diseases.
Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the supportive evidence varies (Kirkham et al., 2005). Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. All women should be offered prenatal serum marker screening for neural tube defects and aneu-ploidy. Women at increased risk for aneuploidy should be offered amniocentesis or chorionic villus sampling (CVS). Counseling about the limitations and risks of these tests, as well as their psychologic implications, is necessary. Folic acid supplementation beginning in the preconception period and early pregnancy reduces the incidence of neural tube defects. Laboratory testing during the first prenatal visit consists of assessment of hemoglobin and hematocrit to identify anemia; blood D(Rh) type; serologic tests for syphilis, and rubella immunity; hepatitis B, and urinalysis. Testing for human immunodeficiency virus (HIV) infection should be offered and highly recommended because perinatal transmission can be decreased with appropriate medical intervention. During the pelvic examination, a Pap smear (if not done in past 6 months) as well as cultures for Neisseria gonorrhoeae and Chlamydia should be taken.
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