Tài liệu Obstetrics and Gynecology Clinics of North America 35, 2008 docx

OFFICE OBSTETRICS
CONTENTS
Foreword xi
William F. Rayburn
Preface xiii
Sharon T. Phelan
Components and Timing of Prenatal Care 339
Sharon T. Phelan
The primary objective for prenatal care has not changed in the past
100 years: to have the pregnancy end with a healthy baby and
mother. By identifying risk factors for pregnancy complications or
other maternal health concerns that need to be addressed, the
provider hopes to optimize pregnancy outcome. By using a series
of screening and diagnostic tests, as well as serially trending certain
components of the physical examination, the provider monitors the
ongoing ‘‘health’’ of the pregnancy. As the ability to screen and
intervene has improved over the last century, the issues to be
assessed have expanded to include not only medical aspects of care
but also barriers to access, psychologic considerations, and patient
education about general health, pregnancy, and childbirth.
The Prenatal Medical Record: Purpose, Organization
and the Debate of Print Versus Electronic 355
Sharon T. Phelan
The obstetric prenatal record is one of the best, most organized
medical record systems currently used in the United States. This
has allowed a standardization of care and documentation that has
benefited pregnant women over the past two decades. The
transition to an electronic record must maintain these advances
and, hopefully, strengthen them with the use of electronic prompts,
seamless transfer of information, and universal accessibility to the
records, regardless of the location of care.

VOLUME 35
Æ
NUMBER 3
Æ
SEPTEMBER 2008 vii
Nutrition During Pregnancy 369
Jean T. Cox and Sharon T. Phelan
Nutritional concerns in pregnancy are gaining increasing impor-
tance as problems with obesity, poor nutrition, and improper
weight gain during pregnancy have been shown to result in
morbidity for mother and infant during the pregnancy. More recent
studies show that the impact of poor nutrition in pregnancy
extends for decades to follow for the mother and the offspring.
Clearly, prevention of problems is the best approach. This article
discusses aspects of, and controversies concerning, prenatal weight
gain and specific nutrients, and special patient groups who may
benefit from intervention by a registered dietitian.
Promoting Healthy Habits in Pregnancy 385
William F. Rayburn and Sharon T. Phelan
Most women have an appreciation of what are generally
considered healthy habits including more exercise; eating a healthy
diet; avoiding cigarettes, alcohol, and drugs; using seatbelts; and
being current on preventive care, such as good dental status. Being
pregnant can be a strong motivator to change or modify behavioral
choices. This is an optimal time for a provider to build on this
potential motivator to effect change. Frequent follow-up visits
allow re-enforcement of attempted change. This constant encour-
agement and support helps to impress on the woman and her
family the importance of change.
Hyperemesis Gravidarum 401

T. Murphy Goodwin
Hyperemesis gravidarum occurs in 0.3% to 2% of pregnant
women, although populations with significantly higher rates
have been reported. In clinical practice, hyperemesis gravidarum
is identified by otherwise unexplained intractable vomiting and
dehydration. This article discusses the causes, presentation,
diagnosis, and management of hyperemesis gravidarum.
Perinatal Depression 419
Emily C. Dossett
Despite the fact that childbirth is often a time of joy for a family, the
occurrence of perinatal depression is very common. It is essential
for the depressed patient to be identified and treated during the
pregnancy or postpartum because the failure to treat can have
significant morbidity and even mortality for the woman and the
child. Despite various concerns several antidepressant medications
are generally safe and, after a careful risk/benefit analysis and
informed consent, indicated for the severely depressed pregnant or
lactating patient.
viii CONTENTS
Prenatal Diagnosis and Genetic Screening—Integration
into Prenatal Care 435
Valerie J. Rappaport
In the last 3 decades, perinatal medicine has made tremendous
advances in scientific knowledge and in the successful application
of this knowledge toward understanding the fetal aspects of
pregnancy. Evaluation of the health of the fetus and screening for
birth defects has become an important part of prenatal care. This
article provides an overview of birth defects and the various
screening methods for diagnosing birth defects before birth. It also
discusses the role of preconception genetic screening.

Recurrent Risk of Adverse Pregnancy Outcome 459
Lisa E. Moore
It is an unfortunate fact that all pregnancies do not end with
healthy babies and healthy mothers. Families who have experi-
enced an adverse pregnancy outcome require accurate information
about the risk of recurrence to plan future childbearing. This article
examines the recurrence risk of four complications of pregnancy:
gestational diabetes, preterm delivery, stillbirth, and preeclampsia.
Combined, these four complications are responsible for approx-
imately 24% of maternal and neonatal morbidity and mortality.
Prenatal Counseling Regarding Cesarean Delivery 473
Lawrence M. Leeman
In 1970, the cesarean delivery rate in the United States was 5.5% and
women receiving prenatal care only required the knowledge that
cesarean delivery was an uncommon solution to dire obstetric
emergencies. In 2008, when almost one in three women deliver by
cesarean, counseling on cesarean delivery must be part of each
woman’s prenatal care. The content of that discussion varies based on
the woman’s obstetric history and the anticipated mode of delivery.
Childbirth Education and Birth Plans 497
Joanne Motino Bailey, Patricia Crane, and Clark E. Nugent
Childbirth education is considered a key component to prenatal
care, although many women do not receive any formalized
preparation. There are multiple models of childbirth education
for both within health care settings, including Centering Preg-
nancy, and external programs, such as Lamaze and Bradley. As a
component of childbirth preparation, a birth plan can be a medium
to improve patient-provider communication regarding a desired
labor and birth experience and improve satisfaction with care.
Index 511

CONTENTS ix
Foreword
William F. Rayburn, MD, MBA
Consulting Editor
This issue, with Dr. Sharon Phelan as Guest Editor, provides a timely
update on topics of active interest in prenatal care. Pregnancy is a normal,
natural process for most women, with a profound impact on those it
touches. Although advances in prenatal care have improved the outcome
for mothers and their babies, problems can still arise at any time. This issue
of the Clinics highlights areas where problems can occur, their warning
signs, and ways to prevent these problems.
Health and happiness in pregnancy are largely dependent on proper guid-
ance and vigilance by a competent obstetrician, with a team of nurses, nurse
midwives, technicians, and allied health personnel. There are no better sub-
stitutes for such care, based on the physician’s acquaintance with the expec-
tant mother and her individual situation. Providers are developing a broader
appreciation of the many problems that expectant mothers face, with the
result that individual questions are answered with increasing understanding
and insight. Meticulous attention to detaildalong with technological
advancesdhave added increasing demands to the schedules of doctors
and nurses.
More than ever before, prenata l care is a systematic way to provide
comprehensive care and to screen for certain complications in an attempt
to anticipate or quickly intervene. With the routine use of more screening
and diagnostic tests, the traditional schedule of visits and the content of each
visit are continually being modified. Use of electronic prenatal records to
handle data management is gaining momentum, but there are certain issues
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Obstet Gynecol Clin N Am

35 (2008) xi–xii
and limitations that must be considered before completely adopting such
a record system.
Families who experience an adverse pregnancy outcome require accurate
information about healthcare maintenance and recurrence risks in order to
plan future childbearing. This issue cites multiple examples regarding how
pregnancy is a tim e when many women are motivated to alter unhealthy
behaviors, such as smoking, substance abuse, and poor nutritional intake,
and to seek assistance with lifestyle changes. For example, recent studies
show that the impact of poor nutrition during pregnancy extends for
decades to follow for both the mother and the child. Simple nausea during
pregnancy should be actively addressed with education, dietary modifica-
tions, and certain medications, while more severe presentations requ ire more
aggressive treatment, with the potential for hospitalization.
Childbirth education is another key aspect to prenatal care and multiple
models exist. As a component of childbirth preparation, a birth plan can be
a means to improve patient-provider communications about a desired labor
and the birth experience, as well as improved satisfaction with care. Of
special importance is the obstetrician’s role in providing information to help
weigh the risks and benefits of an attempted vaginal birth or to plan on an
operative birth.
Information in this issue represents the opinions of experts in obstetrics
and related fields. Portions of certain articles contain educational materials
from the American College of Obstetricians and Gynecologists. Views
expressed here are not absolute, however, and should be considered as flex-
ible guidelines based on medical advice and available local resources.
William F. Rayburn, MD, MBA
Department of Obstetrics and Gynecology
University of New Mexico School of Medicine
MSC10 5580

1 University of New Mexico
Albuquerque, NM 87131-0001
USA
E-mail address:
xii FOREWORD
Preface
Sharon T. Phelan, MD, FACOG
Guest Editor
For years, prenatal care has been recognized as a component of obstetri-
cal care; however, until the latter half of the twentieth century it has been
relatively limited. In the 1970s and 1980s studies showed that an investment
in earlier and more comprehensive prenatal care resulted in a cost savings by
decreasing preterm births and delivery complications. Over the past 20 years,
as technology and the Human Genome Project ha ve impacted medical care,
the scope of prenatal care has also changed.
Originally, obstetrical care was directed at minimizing maternal and
infant death associated with delivery and the immediate postpartum period.
Gradually, efforts to prevent the development of prenatal compli cations
(eg, pre-eclampsia) and screening for other maternal problems (eg, diabetes
and anemia) became more predominant. Now, more effort is directed to-
ward the fetus: screening and potentially intervening for fetal pathology.
This shift in focus of care involv es coordinating the use of more technology
and screening or diagnostic testing. The provider needs to be familiar with
cost-effective routine care, genetic and fetal screening tests, and must antic-
ipate recurrence of prenatal problems, both medical and operative.
Patient education becomes critical as pregnant women are more active in
the workplace, travel more, and participate in a variety of leisu re activities.
Women can enter pregnancy with unhealthy behaviors including obesity,
smoking, and substance abuse. This is a time in a woman’s life when she
should be motivated to adopt healthier behaviors with guidance from her

obstetrical provider. Couples often want to have more say relat ed to the
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Obstet Gynecol Clin N Am
35 (2008) xiii–xiv
birthing experience. The use of childbirth education program s and birth
plans can help a couple ha ve reasonable expectations of the birth progress.
Thus, the content and timing of prenatal visits have changed over the
past 20 years. The obstetrical provider must stay current on these changes
to provide optimal care.
Sharon T. Phelan, MD, FACOG
Department of Obstetrics and Gynecology
University of New Mexico
MSC 10 5510, 1 University of New Mexico
Albuquerque, NM 87131
USA
E-mail address:
xiv PREFACE
Components and Timing
of Prenatal Care
Sharon T. Phelan, MD, FACOG
Department of Obstetrics and Gynecology, University of New Mexico School of Medicine,
1 University of New Mexico, MSC 10 5580, Albuquerque, NM 87131, USA
History and public health implications of prenatal care
The concept of prenatal care has been part of the obstetrician’s care for
over 100 years. William’s Obstetrics, first edition, from 1907 states ‘‘pregnancy
should be considered a normal processes but (the provider should) keep strict
supervision and be constantly on alert for the appearance of untoward symp-
toms’’ [1]. The woman was to be encouraged to do outdoor exercise, eat an
abundant, nourishing diet, and loosen clothing, including dispensing with

her corset. She was also to be given guidance on sexual intercourse, breast
care, and bowel health. ‘‘Urine should be examined .once a month for the
first 7 months and at least twice a month.during the last 3 months .looking
for albumin and sugar . or decreasing volume’’ [1].
In the 1930s, the approach to care was designed to identify early the signs
and symptoms of pre-eclampsia and was very similar to our current tradi-
tional appointment schedule. Much of the focus was to improve maternal
mortality rates, which did decrease by 14-fold in the first half of the twenti-
eth century from 690 to 50 per 100,000 births. In the past 50 years the rate
has decreased further to eight out of every 100,000 births [1], so now the
emphasis ha s shifted more toward improving fetal outcome and preventing
maternal complications. Through much of the 1940s and 1950s a great deal
of emphasis was placed on minimizing maternal weight gain. It was thought
that this would decrease the incidence of hypertensive disorders. The patient
was instructed to gain only 20 pounds and might be given diuretics to assist
in meeting this goal. The only real change in the past 50 years has been to
add a number of screening and diagnostic tests and decrease the emphasis
on minimizing weight gain, but not to modify the visit scheduling approach.
The new tests were incorporated into the already established visit schedule.
E-mail address:
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This ‘‘traditional’’ approach to visit scheduling is currently being challenged
by the National Institutes of Health Expert Panel on Prenatal Care from
1989 [2], and other organizations, in favor of fewer but more focused visits.
In the mid-1980s the public health arguments for prenatal care caused
Medicaid coverage to extend to a large number of otherwise uninsured preg-
nant women [3,4]. It was clear that women who did not receive prenatal care

had worse outcomes. In turn, if a patient receives ‘‘adequate’’ care, her risks
of a low birth-weight infant go down significan tly [5], as well as preterm
births [6] and neonatal deaths [7]. Subsequent studies did challenge these
findings, stating that women without prenatal care usually had major
psycho-social or economic issues that increased their risk of obstetric com-
plications [8–10]. The six factors that most agree upon as having a direct
impact on the quality of prenatal care are: amount of insurance, delay in
telling others about the pregnancy, attitudes toward health professionals,
month of gestation in which the pregnancy was suspected, perception of
the importance of prenatal care, and initial attitude toward the pregnancy
[5]. Other studies show that whether the pregnancy was intended or not
(in addition to how important a woman felt prenatal care was) could pre-
vent even insured women from getting early and adequate care [11–17].
It should be noted that ‘‘adequate’’ prenatal care has been traditionally
judged on onset of care and number of visits, not the content of the care
[18,19]. Prenatal care can be organized into four general components:
(1) the initial intake history and physical examination, (2) periodic screening
or diagnostic testing, (3) serial examinations watching trends of various
objective measurements and patient’s emotional adjustment to pregnancy,
and (4) patient education. This article reviews each of these issues while
the following articles in this issue of Clinics will address most of these
components in greater detail.
Initial history and examination
In the past a great deal of emphasis was placed on the early examination,
primarily for dating the pregnancy. With ultrasounds being routinely done
to assist in pregnancy dating, the primary reason for the early examination
now is to identify significant maternal medical issues that require immediate
intervention or education. In fact, the ideal initial prenatal care visit occurs
before conception with a preconceptive visit. A preconceptive visit allows
modification of behavioral choices, medication, and optimizing medical

concerns before conception. Medications or illnesses that impact
a pregnancy typically have their greatest impact in the first 12 weeks of
the pregnancy, often before the patient’s acknowledgment of the pregnancy.
The damage will have already been done if behaviors or medications were
not modified before the conception. Patients at increased risk for ectopic
pregnancy should be seen earlier in the pregnancy to insure implantation
is in the uterus.
340 PHELAN
In the uncomplicated pregnant patient the initial visit commonly can be
delayed until 10 to 12 weeks, after the major risk of spontaneous abortion.
This visit consists of a comprehensive history, de tailed examination, initial
prenatal laboratory work, and introduction to patient educational
resources. This visit is designed to assess health of the mother and
(by proxy) the fetus, date the pregnancy, and initiate a plan for individu-
alized care. Many providers divide this into two sessions, with the first be-
ing the history followed a few days or a week later with the physical
examination. Between the visits the patient has the appropriate lab work
done (Box 1). At the second session the history, laboratory results, and
any pertinent physical findings are discussed and a prenatal care plan
established.
Initial history (whether done before or after conception) should include
the issues listed in Box 1. One needs to conceptualize that this history is
not only assessing for maternal risks but also is a ‘‘fetal histo ry,’’ assessing
for fetal risks of genetic or environmental concerns. To do this effectively
a detailed personal, family, and partner medical and genetic history must
be obtained. Poor maternal behavioral choices or potential teratogen expo-
sure for mother, father, and others in the home or workplace need to be
elicited by the provider. These issues could be as obvious as substance abuse
or more subtle, such as a first year kindergarten teacher with exposure to
multiple viruses or a chemotherapy nurse at the local cancer center. Certain

ethnic groups should be offered additional screening for genetic concerns,
such as Tay-Sachs or sickle cell anemia. Detailed personal and family repro-
ductive history may also raise concern of other genetic disorders, such as
Fragile X syndrome. Exposures to some medications (certain antiseizure
medications or antihypertensives or anticoagulants) or high serum glucose
levels are potential teratogens and the patient or couple may benefit from
additional counseling and fetal assessment earlier in the pregnancy. These
situations are discussed further in the article by Rappaport elsewhere in
this issue.
A detailed menstrual history will allow the provider to determine how
reliable this data point is for gestational dating [22]. To be used as a primary
dating criteria, the woman should be certain of the date of onset of the last
menses, it should have been normal in flow, not be associated with hor-
monal contraceptive use, and she should have regular 28 to 30 day cycles.
If these criteria are not met, the provider should consider using an ultra-
sound for establishing the due date or clinical examination.
In addition to the medical history, a prior surgical history should also be
taken. The patient’s history may alert the provider to increased risk of cer-
tain maternal problems or complications. With the increasing obesity
among pregnant women, the risk of back problems or excessive weight
gain with increased risk of macrosomia or gestational diabetes is increasing.
A patient with prior gynecologic or obstetric history may be at increased
risk for recurrent obstetric complications (see the articles by Moore and
341COMPONENTS AND TIMING OF PRENATAL CARE
Box 1. Components of the initial prenatal assessment
History
Gynecologic and menstrual history, with emphasis on last
menstrual period (LMP) timing
Obstetric history with any complications noted because of risk
of recurrence

Detailed maternal review of systems
Occupation and potential concerns (briefly assess other
household members)
Socioeconomic, educational, and cultural concerns
Psychologic health and risks of depression
Safety issues in home, including domestic violence
Any religious beliefs that could impact care
Medical and surgical history of mother
Family medical history, including the father of the baby
Any issues since conception, such as exposures to infection
or other toxins
Behavioral issues of exercise, weight, smoking, alcohol,
or recreational drug use
Genetic screening of patient, partner, and relatives
Allergies
Nutritional issues
Physical examination
Vital signs, including current weight, height, blood pressure
Comprehensive physical, including dental status, thyroid
enlargement, cardiovascular and pulmonary status, breasts,
abdominal examination, and extremities
Pelvic examination for uterine size, pelvic masses, and vaginal
discharge
Obstetric assessment with fetal heart tones and uterine size if out
of pelvis
Laboratory testingdbaseline
Blood type, Rh, and antibody screen
Hematocrit or hemoglobin or complete blood count [20]
Syphilis screen
HIV screening

a
Rubella screen for immunity
Hepatitis B surface antigen screen
Chlamydia and gonorrhea screen
Consider Pap smear if due but not just as a routine
Urine for protein, glucose, and asymptomatic bacteriuria,
342 PHELAN
Leeman elsewhere in this issue). Other surgeries can impact care, such as
prior splenectomy (need to be sure immunizations are current), cholecystec-
tomy (can still has cholestasis), cardiac surgery (for subacute bacterial endo-
carditis coverage and possibl e cardiac echo on fetus), and bariatric surgery
(may have mechanical and psychologic difficulties with adequate nutrition)
to mention a few.
Personal and family psychosocial issues can also have a major impact on
pregnancy. More studies are showing that severe stress in a pregnancy does
have a negative impact. For this reason, information regarding safety in the
home (see the article by Dossett in this issue), barriers to care (as discussed
above), educational or language barriers to following through with care, or
possible religious restrictionsthat may impact care (Muslims requiring a female
attendant or Jehovah Witness refusing blood products) need to be elicited.
This type of detailed history can be a time-consuming undertaking, so
having a patient complete a personal history form or having a staff member
take the initial history may be a more efficient use of everyone’s time. The
provider can then review the information and modify care as indicated. For-
tunately, most women are relatively healthy as they enter a pregnancy.
The initial physical examination also needs to be comprehensive, as the
initial obstetric examination is often the first physical examination the patient
has had in years. By looking for signs of chronic illness (thyroid disease or
hypertension) or poor be havioral choices (obesity or smoking) the provider
may initiate early intervention. Patients are often very willing and moti vated

to change behaviors and be compliant with medical interventions during
a pregnancy. This is an opportunity for intervention that should not be passed
up. (See the article by Rayburn and Phelan in this issue).
There are core laboratory tests that all providers generally agree upon
(see Box 1). Other testing may be population-specific, such as early diabetes
Offer genetic screening and implement at gestationally
appropriate times, such as cystic fibrosis screening or first
trimester genetic screening.
Depending on population or medical history, may also get
additional testing, such as hemoglobin electr ophoresis, thyroid
screen, early 1-hour 50-gm glucola challenge, purified protein
derivitive for tuberculosis, toxoplasmosis (if maternal
prevalence is >1.5 per 1,000) [25] and hepatitis A and C screen.
a
Recommended by the American College of Obstetricians and Gynecologists
that this is done routinely [21]
Data from Lockwood CJ, Lemons JA. editors. Guidelines for perinatal care.
6th edition. American Academy of Pediatrics and American College of
Obstetricians and Gynecologists; Washington, DC: 2007. p. 87–111.
343
COMPONENTS AND TIMING OF PRENATAL CARE
screen or hemoglobulin electrophoresis screening for sickle cell or thalasse-
mia. Public health departments in some states require additional testing,
such as sexually transmitted infection screening in the third trimester or
tuberculosis screening for all patients. Depending on ethnicity, genetic his-
tory, and gestational age, there are a number of genetic tests that should
be offered at this visit or subsequent visits. Because the decision to recei ve
additional genetic testing can be difficult, with various psychologic ramifica-
tions, written information regarding the availability of the testing, timing of
the testing, and the implications of a positive test can be given to the patient

ideally before the need for a decision regarding testing.
At the end of this initial assessment, a plan regarding prenatal care
visits, screening tests, and interventions should be made. This plan should
include how to monitor the pregnancy, based on the identification of any
risk factors in the intake history, and physical, implementation of behav-
ioral changes as needed, timing of routine assessments, and patient
education.
The patient is also usually very anxious to know her due date at this time.
The average pregnancy is 280 days long [23]. In the past, Naegle’s rule (LMP
þ 7 days À 3 months þ 1 year ¼ EDC or expected date of confinement) was
the typical way of calculating the EDC if the LMP was felt to be reliable.
Currently, many providers use a gestational wheel to calculate not only
a current gestational age but the EDC. This is generally fine, but a provider
needs to realize that these wheels have an error of plus or minus 3 to 4 days.
There are now computer programs for hand held devices or incorporated
into the ultrasound report programming that are more accurate and, hence,
may be preferable to use to avoid patient confusion. Patients will ‘‘bond’’ to
the first date given and do not understand the varia tion, especially if subse-
quent dates mean that the patient has to be ‘‘pr egnant longer.’’
Patient education is an essential part of prenatal care. At the initial visit,
general information regarding routine prenatal care schedule and promo-
tion of good behavioral choices, including dental care, nutrition, wearing
a seat belt, continued exercise, avoiding substance exposure, and sexual
activity are some of the topics for the initial visit. Referring a patient to
purchase one of the patient-centered prenatal books is one approach.
However, before recommending a specific title, you may want to review
the content to be sure it is fairly consistent with your practice style.
Some practices develop their own educational material and provide it for
patients. This can be a particularly good idea if the patient clientele has
unique needs, are non-English speaking (although many of the prenatal

books are available in Spanish), or have specific cultural views that impact
on the education. Finally, providing a patient with Web resources, such as
the American College of Obstetricians and Gynecologists (ACOG) is useful.
If not given some direction patients may ‘‘surf’’ the Web and come across
sites that are not scientifically based in their information and cause more
anxiety than needed.
344 PHELAN
Subsequent prenatal visits
The remainder of the prenatal care visits need to be scheduled at intervals
that allow serial monitoring for common complications, conduct specific
time-sensitive screening (ie, diabetes screening), administration of immuni-
zations or Rhogam, or provide education. Box 2 outlines data to trend
and subsequent laboratory testing.
Trending of fundal growth, maternal blood pressure, and weight [27]
often alert the provider to issues of abnormal fetal growth, poor nutrition,
or developing hypertensive concerns. Typically the fundal height in centime-
ters equals estimated gestational weeks from 20 to 34 weeks. This is altered
in the situation of obesity but serial growth should still be approximately
a centimeter a week [25]. A full bladder can alter measurements by 3 cm
[28]. An oblique or transverse lie can result in smaller measurements than
expected. Excessive or inadequate fundal growth may be the first indication
of a potential fetal problem and will likely trigger an ultrasound assessment
of fetal growth and fluid volumes [29]. Determination of fetal position in the
last month of pregnancy allows the potential to offer a version for an abnor-
mal position at term or plan an operative delivery if indicated [30].
Formalized maternal monitoring of fetal movement (fetal kick counts)
can provide reassurance to the mother and the provider in the third trimes-
ter regarding fetal well being. The patient can be asked to count to a certain
number of movements within a specified time interval. If the fetus moves less
than the requirement, the patient should have further fetal assessment. The

optimal number of movements or time interval or frequency of assessments
has not been determined. A commonly used criteria is 8 to 10 discrete move-
ments within 2 hours every 1 to 2 days [24].
Finally, key educational points shou ld be raised at the relevant and
appropriate times during the pregnancy. For example, the patient needs to
know the signs of preterm labor from 26 to 34 weeks in contrast to 34 weeks
on, where an understanding of the role of fetal movements in assessing fetal
well being becomes more relevant along with labor precautions and poten-
tial symptoms of developing pre-ec lampsia. Many practices either conduct
their own childbirth education classes that cover this material and more
specifics about the labor process, or refer patients to such childbirth classes
(see the article by Bailey, Crane and Nugent elsewhere in this issue).
For approximately 50 years, these ongoing visits have been every 4 weeks
until 28 weeks estimated gestational age (EGA), then every 2 to 3 weeks un-
til 36 weeks into the pregnancy, and then weekly until delivery. This is the
pattern of care still listed by ACOG in the Guidelines for Perinatal Care
[31]. This tradition is being actively challenged on many fronts.
The National Institutes of Health Expert Panel on Prenatal Care 1989, rec-
ommends less frequent visits for the uncomplicated nulliparous or parous
patient [2]. This type of scheduling is being advocated by many European
professional societies. In fact, even more restricted prenatal care was
345COMPONENTS AND TIMING OF PRENATAL CARE
Box 2. Subsequent visits: data to trend and interval lab testing
History
Symptoms of potential preterm contractions: bleeding, increased
vaginal discharge, excessive pelvic pressure
Symptoms of pre-eclampsia or potential hypertension
Fetal movement:
Onset in second trimester around 18 to 20 weeks,
Fetal kick counts (FKC) in the third trimester (>8–10 FKC every

2 hours or similar threshold) [24]
Safety at home
Risky maternal behaviors: update success with smoking
cessation, abstinence from drugs, improved diet, and so forth.
Physical examination
Weight and interval weight gain
Blood pressure
Fundal height in centimeters
Fetal heart tones and rate
Fetal presentation from 36 weeks and on.
Optional issues are cervical examination during the last few
weeks of pregnancy with potentially sweeping membranes to
promote labor.
Laboratory testing
Diabetes screen, either by:
50-gm 1-hour glucose challenge test: early if high risk for
diabetes and again at 24 to 28 weeks of gestation (most
sensitive) [25,26] or
Risk factors (age <25, not a member high risk ethnic group,
body mass index <25, no history of glucose intolerance, no
diabetes in a first degree relative, no history of obstetric
complication associated with diabetes mellitus, such as
macrosomia [25]
Repeat hematocrit or hemoglobin around 26 to 30 weeks [20,25]
Rhogam workup and administration around 26 to 30 weeks
Gonorrhoea, chlamydia, and syphilis screening depen ding on
population
Group B Streptococcus (GBS) screening at 35 to 37 weeks [25]
Urine for protein and glucosedof questionable value [25]
346 PHELAN

recommended by the United Kingdom National Instutute for Clinical
Excellence in 2003 [32]. This panel recommended abandoning the early pel-
vic examination, pelvimetry, regular weighing unless it will change manage-
ment, no GBS cultures, no urine dips each visit, and other items. Although
many of their recommendations are unlikely to be accepted by the providers
or patients in the United States, they also recommend the number of prena-
tal visits be greatly decreased [32]. This approach advocates for fewer total
visits that are strategically scheduled to allow testing, intervention at key
times in the pregnancy, and ideally more time for patient ed ucation [33].
As more pregnant women are in the work force each prenatal visit can
mean missing half a day of work, this can place a hardship on the patient
and employer. For women not employed outside the home, there are still
many demands, responsibilities, and barriers to making it to frequent
appointments, such as transportation or childcare [34]. The patient also
appreciates fewer visits with more accomplished at each visit regarding
ongoing assessment, testing, and education. Tables 1 and 2 compare the
traditional and a suggested modification for both a nulliparous and multip-
arous patient [33,35].
This modified approach is appropriate for the uncomplicated patient.
It still provides closer surveillance of the first time mother in the third tri-
mester to assess for complications of pre-eclampsia or fetal growth con-
cerns. The nulliparous patient commonly needs more reassurance and
education regarding the common end-of-pregnancy complaints, labor signs,
and labor process, and thereby finds benefit with the more frequent visits the
last month of the pregnancy [36]. The reduction of total number prenatal
visits does not result in an increase in the use of other medical services or
unscheduled visits [37].
Testing done in pregnancy is reflective of the pressures on health care
delivery, including increa sing technology, patient expectations, third party
payers, and concerns of medical liability [38]. Extensive testing has become

a community standard. However, laborato ry testing commonly done during
pregnancy is under review for its evidence-based cost-effective contribution
to prenatal outcomes.
One such test is the urine assessment for glucose, protein, and nitrite at
each visit. These were initiated to screen for gestational diabetes, pre-
eclampsia, and asymptomatic urinary tract infections. Because most patients
are screened for gestational diabetes by risk factors or the 1-hour 50-gm
glucose challenge [25], the finding of glucosuria rarely adds any accurate
information. Most positive tests are false-positives because of a large glu-
cose intake be fore visit and are not indicative of diabetes. If the initial urine
analysis is negative it is unlikely that the patient will develop significant
renal disease during the pregnancy, except for hypertensive-related pathol-
ogy. The blood pressure is the best screen for new onset renal disease or
the development of pregnancy-related hypertensive disorder [25]. If hyper-
tension develops, then an assessment of proteinuria with protein/creatinine
347COMPONENTS AND TIMING OF PRENATAL CARE
ratio or a timed urine collection for protein is more accurate [39]. After the
initial screen for asymptomatic bacteruria at the initial visit, patients only
need to be screened for urinary tract infections if they are symptomatic or
in a high-risk group, such as preterm labor, twins, gestational diabetes,
Table 1
Comparing traditional and modified scheduling of prenatal care visits for nulliparous women
Nulliparous
Traditional prenatal care Modified prenatal care
Visit time Testing Visit time Testing
NOB ideally
8–10 weeks
prior
Routine NOB
labs, offer first

trimester
screening
NOB at
10–12 wks
Routine NOB
labs, offer first
trimester
screening
12 wks Document FHT
by doppler
dd
16 wks MMS, order
dating/anatomy
ultrasound
if to be done
at 20 wks
18 wks MMS, order
dating/anatomy
ultrasound if
to be done at
20 wks
20 wks Ultrasound
for anatomy
and visit
d Ultrasound only
24 wks d 24 wks d
28 wks Diabetes screen
and Rhogam
workup and
administration

28 wks Diabetes screen,
Rhogam workup
and administration
30 wks Initiate childbirth
education
dd
32 wks d 32 wks Initiate childbirth
education
34 wks d 34 wks Only if concerned
at 32 wk visit
36 wks GBS screening,
discuss
contraceptive
choice
36 wks GBS screening,
discuss
contraceptive
choice, fetal
position
37 wks dd(none if blood
pressure okay)
38 wks d 38 wks d
39 wks d 39 wks d
40 wks d 40 wks d
41 wks Consider induction 41 wks Consider induction
42 wks Induction 42 wks Induction
Total number
of visits
14–16 d 9–11 d
Abb reviations: FHT, fetal heart tones; MMS, multiple marker screening; NOB, new

obstetric.
Data from Refs. [2,31–35].
348
PHELAN
known renal disease, or sickle cell disease/trait [25,40–43]. Fewer than 2% of
patients without bacteriuria at the initial screen will develop a symptomatic
urinary tract infection.
Ultrasounds have become a standard of care, despite studies showing that
the routine use of ultrasounds do not significantly improve obstetric outcome.
An ultrasound in the first trimester is optimal for dating but an ultrasound
scan in mid-second trimester is best for anatomy. It is possible to have a single
scan around 20 weeks and confirm dating while getting a good anatomic sur-
vey. Unless the patient opts for terminating the pregnancy in the case of lethal
or potentially lethal anomalies, there is little cost benefit to society for patients
to have a ‘‘routine’’ ultrasound screening. If there is no particular reason for
an earlier scan (ie, rule out an ectopic pregnancy or first trimester screening),
the first scan can be delayed to the second trimester [25,35,44]. Having said
Table 2
Comparing traditional and modified scheduling of prenatal care visits for parous women
Parous
Traditional prenatal care Modified prenatal care
Visit time Testing Visit time Testing
NOB Ideally prior
to 8–10
weeks
Routine NOB labs,
offer first trimester
screening
At 10–12 wks Routine NOB labs,
offer first trimester

screening.
12 wks Document FHT dd
16 wks MMS, order
dating/anatomy
ultrasound if
to be done
18 wks MMS, order dating/
anatomy ultrasound
if to be done
20 wks Ultrasound and visit d Ultrasound only
24 wks d 24 wks d
28 Diabetes screen and
Rhogam workup
and administration;
discuss
contraception if
considering PPTL
28 Diabetes screen,
Rhogam workup
and administration;
discuss contraception
if considering PPTL
30 wks ddd
32 wks d 32 wks d
34 wks ddd
36 wks GBS screening 36 wks GBS screening
37 wks ddd
38 wks ddd
39 wks May sweep membranes 39 wks May sweep membranes
40 wks May sweep membranes dd

41 wks Consider induction 41 wks Consider induction
42 wks Induction 42 wks Induction
Total number
of visits
14–16 d 7–9 d
Abbreviation: PPTL, postpartum tubal ligation.
Data from Refs. [2,31–35].
349
COMPONENTS AND TIMING OF PRENATAL CARE
that, from an evidence based view, patients expect one or two ultrasounds
during the pregnancy and see it as a bonding experience and an opportunity
to get their first ‘‘baby’’ pictures. Some independent commercial endeavors
have started to provide this type of nonmedical ultrasound, complete with
a picture album. ACOG actively discourages this type of ultrasound, stating
the concern that it provides a false sense of reassurance and often little reliable
medical information.
Patient education
Patient educational issues are discussed in more depth in a subsequent
articles in this issue of the Clinics, but basic issues should be addressed early
in care and re-enforced as indicated. There are safety issues, such as the use
of seat belts, minimal use of hot tubs (less than 10 minutes) or saunas (less
than 15 minutes) [21]; use of medications, immu nizations [45,46], avoidance
of substances, and domestic violence; comfort issues (back pain, symphyseal
pain [47], varicose veins, hemorrhoids, heartburn , dental care [48] and round
ligament); and activity issues revolving around work and leisure that need to
be discussed early during care. Toward the end of the pregnancy, issues of
breast feeding, family planning desires [49], circumcision, umbilical cord
blood banking, circumcision, and childcare need to be raised. Women
who report receiving sufficient health behavior advice as part of their prena-
tal care are at lower risk of delivering a low birth-weight infant [50].

Back pain is a common complaint during pregnancy, As the lordosis
increases in the second and third trimester, so does the occurrence of back
pain. The presence of obesity or a history of back problems increases the
incidence. The patient needs to be taught better back mechanics and lifting
techniques. Although most times the patient can be reassured, if there are
neurologic deficits found on examination, a referral to a neurosurgeon
may be indicated [38]. Otherwise, conservative measures of heat, good
body mechanics, pain medication, and potentially a muscle relaxant will
provide some relief.
Leisure time physical activity is associated with a reduced risk of pre-
term delivery [51] (see the article by Rayburn and Phelan in this issue).
There continues to be discussion regarding the role of work and poor ob-
stetric outcomes. Some data support that very physical activity jobs may
increase the risk of poor outcomes, and yet very physical exercise is as-
sociated with a better outcome. The provider needs to know what type
of work-related activities and exposures that the patient has and counsel
accordingly.
Heartburn and indigestion are common complaints, especially in the first
trimester and again in the third trimester. During the first trimester, much of
the indigestion is associate with the common nausea and vomiting of preg-
nancy (see the article by Goodwin in this issue). The complaints in the
third trimester are commonly because of the pressure of the enlarging uterus
350 PHELAN
in combination with the muscular relaxation of the intestinal tract. These
concerns can often be handled with dietary changes and antacids, but one
can use proton pump inhibitors if necessary.
Summary
Prenatal care should allow consistent screening and monitoring of both
the mother’s and fetus’s development and health. Providing this care in
a supportive, informative fashion in a way that is sensitive to the multiple

demands placed on all patie nts today helps with the patient establishing
trust in her provider and confidence in her own ability to do what is best
for her infant. At a time when there is so much misinformation, much of
which is frightening to the patients and promotes fear and anxiety through-
out the pregnancy, it is crucial for the provider to encourage ready commu-
nication and education as well as medical care through the entire pregnancy
and postpartum.
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353
COMPONENTS AND TIMING OF PRENATAL CARE
The Prenatal Medical Record: Purpose,
Organization and the Debate of Print
Versus Electronic
Sharon T. Phelan, MD, FACOG
University of New Mexico School of Medicine, Department of Obstetrics and Gynecology,
1 University of New Mexico, MSC 10 5580, Albuquerque, NM 87131, USA
Objective and purpose of the prenatal record
The primary objective of the prenatal record is to have a standardized
way to systematically record the large amount of information that needs
to be obtained during a pregnancy. In the late 1800s and early 1900s, text
books recommended simple note cards for the obstetric provider to keep
track of their patients. Even in the 1980s information from each prenatal
visit was often recorded in a series of progress notes with cryptic
abbreviations, incomplete data, and inability to readily trend any data,
such as blood pressure or fundal growth. Today the record serves multiple
roles, and for that reason must be more structured.
Clinical care
Clinical care is the primary reason for the current obstetric record. It
serves as a prompter for the provider to solicit a complete history for risk
assessment, record a baseline physical and subsequent data in a format
that allows it to be monitored for worrisome trends. The scope and
timing of laboratory testing can be hard to manage. A good prenatal
form can prompt ordering tests and reviewing the results in a timely fashion.
Interventions and patient education can be readily documented. Thi s is the
primary focus of this article.

Communication
A good prenatal record is the major way of communication with other
providers, both within the practice and at the hospital when they must
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doi:10.1016/j.ogc.2008.06.001 obgyn.theclinics.com
Obstet Gynecol Clin N Am
35 (2008) 355–368
assume care of the patient. A systematic way to record information allows
a new provider to readily identify problems and concerns for a patient.
Commonly, the prenatal form and flow sheet are sent to the labor and
delivery unit around 34 to 36 weeks, so it is available when the patient pres-
ents in labor. A good record system that addresses effectively the provision
of good clinical care will automatically accomplish the task of facilitating
communication between providers.
Billing and reimbursement
A well-designed prenatal record makes it easy for the provider to system-
atically record the information from a visit to allow appropriate billing. The
use of grids and lists with checks and comment sections helps to prompt the
provider to not forget to note key components of the care. Accurate and
complete documentation of patient complications and of services provided
is essential for full reimbursement, especially if the care provided is out-
side the scope of the global fee. By providing appropriate prompts for
recording the results of commonly asked questions, such as preterm labor
symptoms, the record allows not only for better care but also for more
clarity in billing documentation.
Quality indicators
There are certain quality indicators in the provision of prenatal care.
A good record prompts the performance and completion of these qua lity
indicators. In turn, compliance with these indicators can be readily moni-

tored. So a record system that reminds the provider to ask about genetic
background, prior obstetric complications, or to do a screening test,
improves the provider meeting and documenting quality indicators, which
in turn provides better clinical care.
Medical liability
By having a record that encourages complete documentation of a compre-
hensive prenatal care, more support is available regarding the quality of care
provided and potential risk fact ors or behaviors that the patient contributed
to the pregnancy outcome. The record should show that risk factors and
complications were properly identified and that the pregnancy was managed
in an appropriate fashion [1].
To be useful, a prenatal record must be systematic, well organized for
easy retrieval of information, and sufficientl y detailed. The quality of the
record depends on accurate recording of the data. The record must be sim-
ple but complete, directive but flexible, legible and able to display the nec-
essary information readily. The ability to record care in a simple fashion
helps with compliance and conformity of documentation. The incorpora tion
of risk assessment tools allows triaging of the patient regarding the most
356 PHELAN
appropriate care provider: certified nurse midwife, physician, or maternal
fetal medicine specialist [2]. The use of check boxes and flow-charts aid in
tracking trends and more complete documentation. In fact, the obstetric
prenatal record is probably the best developed charting system available
in medical practice.
If one reflects on the prenatal medical record form as if it was a blueprint
for building a home, then one can see how the data from the initial visit is
like laying the foundation. The risk assessment and baseline laboratory is
like the framing of the structure. The remainder of the visits gradually
‘‘frame in the walls’’ and add dimension and character to the house, while
referring to the original blueprint for the basic form.

The components of a prenatal record include all the initial demographics,
family, and personal medical and genetic histo ry, complete physical exami-
nation and laboratory testing, and provides room for additional records and
serial examinations to be recorded in a fashion to allow trending. Finally,
screening tools for behavioral assessments and educational documentation
have become a must. Boxes 1–10 list the key portions of the prenatal med-
ical record [3].
Many areas may benefit by a description of the care given or the issues
assessed. For example, a listing on the record for the symptoms queried
when deciding if there is possible preterm labor, allows one to simply check
no or, if yes, note the symptoms present. For the physical examination,
define what is covered when an item is checked within normal limits and
have room to expand when there is an abnormality or additional assessment
was done. Supplemental visits need to allow documentation in a format that
allows ready trending of data points, especially fundal size, blood pressure,
and weight. The template should be comprehensive enough to allow com-
prehensive documentation with minimal effort for routine care, but flexible
to have room for additional notations and progress notes.
Box 1. Demographic information
Location of prenatal care: name of clinic or practice
Birth date
Patient’s level of education
Contact information: address, phone numbers, emergency
contacts
Partner or husband’s name
Occupation
Language of preference
Religious preference, especially those that might impact the
scope of care that is acceptable, such as Jehovah’s Witness
or Muslim

357THE PRENATAL MEDICAL RECORD