2014 Perinatal Care Recommendations

These recommendations represent a core set of clinical guidelines for average-risk patients from the general population. The guidelines should not supplant clinical judgment or the needs of individual patients. These guidelines are intended as quality-practice recommendations and are not intended as a description of benefits, conditions of payment, or any other legal requirements of any particular health plan or payer. Each health plan or payer makes its own determination of coverage and benefits. In the event that these practice recommendations are inconsistent with any applicable laws or regulations, such laws or regulations take precedence.

All clinical tools and handouts with the MHQP Perinatal Guidelines are provided as additional resources only and are meant to be used as examples. MHQP and the endorsing organizations of the Perinatal Guidelines have not tested the validity of these documents, and therefore do not formally endorse these clinical tools and handouts.

Click here to access the printer-friendly PDF of the perinatal guidelines.

First Prenatal Visit (Six to 12 weeks)

Note: If a patient's first visit is before the eighth week, make every effort to at least schedule a "mini-visit" for blood work before 12 weeks.

Initial History
  • Last menstrual period and establish estimated delivery date
  • Race, ethnicity, country of origin, primary language, marital/committed relationship status, education, line of work
  • Current and past health problems/treatments, past pregnancies and previous delivery experience, medication allergies, surgical history, family history, genetic history, sexually transmitted infections, gynecological conditions
  • Current or past emotional problems and treatments
  • Current and past alcohol use
  • Medication use (illicit, prescribed, over-the-counter, dietary/herbal supplements)
  • Cigarette and/or nicotine (e.g., gum, patch) use in past three months
  • Environmental exposures (smoke, seafood, etc.)
  • Exercise, hobbies, household pets
  • Dietary habits and/or restrictions
Psychosocial Assessment
Discuss the ability to care for a child and for herself by asking about the following topics. Consider a behavioral health referral or other follow-up if warranted.

Current Living Situation
  • Do you have any problems that prevent you from keeping your health care appointments?
  • How many times have you moved in the past 12 months?
  • Do you or does any member of your household go to bed hungry?
  • How do you rate your current stress level?
  • If you could change the timing of this pregnancy would you want it earlier, later, not at all, or no change?
  • Are there any barriers for you to be able to care for yourself and your baby (homelessness, financial concerns, etc.)?
  • Do you have family/friends that can provide help and support during your pregnancy and after your baby is born?

Safety and Well-Being

  • Have you ever been hurt or threatened by your partner, or anyone else (e.g., ex-partner, other family member)?
  • Do you ever feel afraid, controlled, or isolated by your partner or anyone else?

Depression

  • Over the past two weeks, have you felt sad, down, depressed, or hopeless?
  • Over the past two weeks, have you felt little interest or pleasure in doing things?

Alcohol and Drug Use

  • Did any of your parents have a problem with alcohol/drug use?
  • Do any of your friends have problems with alcohol/drug use?
  • Does your partner have a problem with alcohol/drug use?
  • Before you knew you were pregnant, did you drink any beer, wine, or liquor or use drugs?
  • In the past month, did you drink any beer, wine, or liquor or use drugs?

Depression and Substance Abuse Screening Tools and Resources

Physical Examination
Perform complete physical exam, including blood pressure, height, and weight with calculation of body mass index (BMI); and breast, heart and lung, abdominal, and pelvic examination.

Immunizations Laboratory Evaluation
  • Hemoglobin/hematocrit
  • Hemoglobin electrophoresis (at-risk populations)
  • Blood type and antibody screen
  • Rubella (if immunity not previously documented)
  • Syphilis
  • Hepatitis B surface antigen
  • HIV (unless declined)
  • Genetic testing, as discussed by provider and patient
  • Urine culture
  • Urine dipstick for protein and glucose determination as indicated
  • Pap smear for cervical cancer if due for screening
  • Test for chlamydia and gonorrhea as indicated
  • TB test for at-risk populations (May delay until 15 to 20 weeks)
Oral Health
  • Ask about oral health status, including oral health history and last dental visit.
  • Check mouth for problems (e.g., swollen or bleeding gums, dental decay, signs of infection).
  • Document oral health history and status in medical record.
  • If last dental visit took place more than 6 months ago or if any oral health problems identified, advise to schedule an appointment with dentist.

For more information please visit www.mchoralhealth.org

Genetic Counseling, Screening, and Testing
  • Discuss the benefits and risks of screening and diagnostic tests for genetic and structural abnormalities.
  • Review risk factors which may influence the likelihood of genetic abnormalities (e.g., maternal age, family history).
  • Discuss testing as appropriate for patient's ethnicity and family history (e.g., Tay-Sachs for Ashkenazi Jewsih, Cajun or French Canadian descent; Canavan's disease and familial dysautonomia for Ashkenazi Jewish descent; hemoglobin electrophoresis for Asian, African, Caribbean or Mediterranean descent).
  • Discuss testing for cystic fibrosis with discussion of sensitivity of the test in different populations.
  • Offer information on aneuploidy screening.
  • Document all testing discussion, decisions, and results; do not repeat screening for heritable conditions if individual has been screened previously.
General Counseling/Discussion
  • Review perinatal visit schedule.
  • Discuss not using tobacco, alcohol, other drugs, and limiting exposure to second-hand smoke
  • Asking clinician before using any medications or treatments (prescribed, over-the-counter, herbal/dietary supplements, alternative)
  • Discuss the use of folic acid and iron supplements.
  • Proper nutrition, exercise, weight management (review goal gestational weight gain, based on patient’s BMI)
  • Thirty minutes of moderate exercise per day. Counsel to avoid activities with high risk of falling or abdominal trauma.
  • Continued use of seat belts during pregnancy
  • Benefits of breastfeeding for infant and mother
  • Risk factors for HIV and other sexually transmitted infections; HIV testing
  • Foods to avoid or limit
  • Environmental/occupational exposure, such as contact with cat feces, high temperatures (saunas/hot tubs, etc.), second-hand smoke
  • Personal care and hygiene with attention to specific cultural/ ethnic practices
  • Registering for childbirth, breastfeeding, and infant CPR education classes
  • Health literacy: How confident are you filling out medical forms by yourself?
At Each Subsequent Prenatal Visit
  • Record gestational age.
  • Assess well-being of mother and fetus.
  • Request urine sample for urine protein and glucose determination as appropriate.
  • Perform physical exam, including blood pressure, weight, and cervical exam as indicated by clinical history.
  • Listen for fetal heart tones (as indicated).
  • Check and record uterine size.
  • Check fetal position (as indicated).

Ask About

  • Any pain
  • Any nausea
  • Stress level, depression, physical and emotional well-being
  • Beginning at 20 weeks (or when fetal movement is first noted): fetal movements, contractions, bleeding, leaking fluid

13 to 35 weeks

Immunizations
  • Administer Tdap vaccine during each pregnancy between 27 and 36 weeks
  • Recommend flu vaccine to women who will be pregnant during flu season, regardless of stage of pregnancy.
Laboratory and Additional Testing
  • Revisit results from genetic screenings (if performed), and discuss the benefits and risks of any recommended follow-up tests.
  • Perform TB testing in at-risk populations (if not done previously) with follow-up as indicated.
18-20 Weeks
  • Offer fetal survey ultrasound as indicated for fetal age, growth, and/or anatomy.
24-28 Weeks
  • Hemoglobin/hematocrit
  • Antibody testing for Rh-negative patients
    • Administer Rh immune globulin as indicated
  • Syphilis, chlamydia, gonorrhea, HIV, and other sexually transmitted infections in at-risk populations
  • Screen for gestational diabetes.
Counseling/Education
  • Repeat full psychosocial assessment at least once more before delivery.
Getting Ready for Baby
  • Discuss childbirth options. Counsel on risk of early elective pre-term delivery.
  • Encourage registration for childbirth, breastfeeding, and infant CPR classes.
  • Travel restrictions
  • Umbilical cord blood banking
Plans for Labor and Delivery
  • Develop plan for possible urgent/emergent medical needs (e.g., transportation to hospital, child care).
  • Signs and symptoms of preterm labor, preeclampsia (nausea, vomiting, visual changes, headaches, epigastric pain, or malaise), preterm premature rupture of membrane, and other potential danger signs that require patient to call clinician immediately.
  • Signs and symptoms of labor
  • Birth planning (preferences and concerns about birthing, pain control, others to be present)
  • What to expect in the hospital, including length of stay
  • Plans and methods of feeding baby: benefits of breastfeeding, referral to lactation consultant as necessary
Keeping Baby Healthy and Safe
  • Discuss need for insurance coverage for baby.
  • Recommend Tdap vaccine to be administered to any person having close contact with baby aged <12 months and who has not been previously vaccinated.
  • Getting a car seat for the baby
  • Safe sleep arrangements for the baby
  • Circumcision: preferences, what to expect
  • Choosing a clinician for the baby, and scheduling a visit with baby's clinician if visit will be covered by insurance
Post-Birth Health for Mom
  • Perineal laceration
  • Family planning after delivery

36 to 42 weeks

Laboratory Evaluation (35 to 37 weeks)
  • Group B streptococcus culture
Counseling/Discussion

Preparing for Labor and Delivery
  • Awareness of fetal movements and calling clinician if less movement than usual
  • Signs and symptoms of labor and when to call clinician
  • Revisit childbirth plan
  • 39-40 weeks: possibility of passing due date, and options in this situation
  • Preparation for admission to hospital: transportation plans, child care, etc.
  • Anesthesia, pain-control issues, and options
  • Benefits of breastfeeding for infant and mother and available supports (lactation consultants, community, etc.)
Post Due Date
  • Assessment of fetal well-being
  • Counsel patient to be aware of fetal movements and to call clinician if less movement than usual
Keeping Baby Healthy and Safe
  • Discharge from hospital: newborn car seat and clothing, home health services options
  • Notifying baby’s clinician for anticipated neonatal complications, if applicable
  • Importance of visits to baby’s clinician
  • Infant CPR
Post-Birth Health for Mom
  • Signs and symptoms of postpartum depression; the need to contact clinician
  • Postpartum visits and vaccinations
  • Returning to work and/or other activities and related issues, including mental/physical health and disability
Postpartum Visit (Four to six weeks after delivery)

Note: Full postpartum visit is still needed by patients who visit early for a brief check

Interval History
  • Bleeding, symptoms of infection (e.g., mastitis, endometritis), resumption of menstruation
  • Diabetic screening if gestational diabetes mellitus (GDM) diagnosed
  • Chronic disease status in high-risk patients
  • Bowel and urinary incontinence
  • Medication use (including herbal and alternative medicines), allergies, etc.
  • Confirmation of rubella immunization (for non-immune mothers)
Physical Examination
  • Full check of vital signs (height, weight, BMI, blood pressure)
  • Perineal and vaginal care as indicated, uterine involution
  • Consider breast exam, especially for those who are breastfeeding
Repeat Full Psychosocial Assessment
  • Screen for postpartum depression and adaptation to new baby
Counseling/Discussion
  • Ask how breastfeeding is going. Emphasize ACOG/AAP/AAFP recommendation of exclusive breastfeeding for at least six months. Discuss related issues, such as returning to work while breastfeeding, safe medications for breastfeeding, etc.
  • Promoting health (e.g., diet, exercise, preventive health measures; losing weight gained during pregnancy, plus additional weight loss if initial BMI >25)
  • Counsel on specific risk factors developed during pregnancy (e.g., diabetes or high blood pressure). Refer patient back to her PCP as needed.
  • Counsel on continued use of prenatal vitamins or folic acid.
  • Resuming sexual activity
  • Family planning and birth control
  • Preconception counseling and risk factors for future pregnancies
  • Ask about smoking, use of tobacco products, and exposure to second-hand smoke. Counsel to not resume use of tobacco products.
  • Importance of visits to baby’s clinician

 

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