2009/10 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.

First Prenatal Visit (Six to 12 weeks)

Initial History
  • Document 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
  • 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
  • Varicella antibody status (consider testing if indicated)
  • Check tetanus status; provide booster or refer as needed
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 examinations.

Laboratory Evaluation
  • Hemoglobin/hematocrit
  • Hemoglobin electrophoresis (at-risk populations)
  • Blood type and antibody screen
  • Rubella (if immunity not previously documented)
  • Syphilis (RPR)
  • Hepatitis B surface antigen
  • HIV (unless declined)
  • Urine culture
  • Urine dipstick for protein and glucose determination as indicated
  • Pap smear with reflex HPV testing (if not normal within previous three months)
  • Test for Chlamydia and gonorrhea as indicated
  • TB test for at-risk populations (May delay until 15 to 20 weeks)
Genetic screening (offer population-based screening as indicated; offer CF and Down Syndrome screening to all; document but do not repeat screening for hereditable conditions if individual has been screened previously)

Review perinatal visit schedule Psychosocial Assessment

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 or friends who can provide help and  support during your pregnancy and after your baby is born?

Safety and Well-Being:

Health Literacy
  • How confident are you filling out medical forms by yourself?
Depression * Alcohol and Drug Use *
* Consider behavioral-health referral if indicated
Counseling/Discussion
  • Not using tobacco, alcohol, other drugs
  • Asking clinician before using any medications or treatments (prescribed, over-the-counter, herbal/dietary supplements, alternative)
  • Folic acid and iron
  • Proper nutrition, exercise, weight management (review goal gestational weight gain, based on patient’s BMI)
  • Safe physical activities, using seat belts
  • Benefits of breastfeeding for infant and mother
  • Risk factors for HIV and other sexually transmitted infections; HIV testing
  • Genetic counseling and potential need for testing those at risk (based on genetic risks/diseases as appropriate to age, family history, and race/ethnicity)
  • Foods to avoid or limit
  • Environmental/occupational exposures, such as contact with cat feces and 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
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, cervical exam as indicated
    by clinical history
  • Listen for fetal heart tones (as indicated)
  • Check and record uterine size
  • Check fetal position (as indicated)
  • Flu vaccine — Recommend for women who will be pregnant during flu season
Ask About
  • Any pain
  • Any nausea
  • Exposure to second-hand smoke
  • 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 27 weeks


Laboratory and Additional Testing (10 to 24 weeks)
  • Offer multiple-marker screen (blood test) for spinal-cord abnormalities and
    Down Syndrome
  • Offer fetal-survey ultrasound as indicated for fetal age, growth, and/or anatomy
  • Recommend genetic screening as indicated
  • Perform TB testing in at-risk populations (if not done previously) with follow-up
    as indicated
  • Screening for gestational diabetes (24 to 28 weeks)
Education

Discuss childbirth options, benefits of breastfeeding. Encourage registration for childbirth, breastfeeding, infant CPR classes

Repeat full psychosocial assessment

Counseling/Discussion
  • Signs and symptoms of preterm labor
  • Develop plan for possible urgent/emergent medical needs (transportation to hospital, child care, etc.)
Other suggested topic:
  • investigating insurance-coverage options for baby

28 to 35 weeks


Laboratory Evaluation
  • Hemoglobin/hematocrit
  • Antibody testing for Rh-negative patients (administer Rh immune globulin
    as indicated)
  • Syphilis, Chlamydia, gonorrhea, other sexually transmitted infections in
    at-risk populations  
  • Re-test HIV (unless declined)
Repeat full psychosocial assessment at least once more before delivery

Counseling/Discussion
  • Birth planning (preferences and concerns about birthing, pain control, others
    to be present)
  • 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
  • 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
  • Getting a car seat for the baby
  • Circumcision: preferences, what to expect
  • Travel restrictions
  • Episiotomy
  • Sexuality
  • Family planning after delivery
  • Other suggested topic:
    • Choosing a clinician for the baby and scheduling a prenatal visit, if desired. Be aware of insurance-coverage issues

36 to 40 weeks


Laboratory Evaluation (35 to 37 weeks)

Group B streptococcus culture

Counseling/Discussion
  • Awareness of fetal movements and calling clinician if less movement than usual
  • Revisit delivery options based on any previous birthing experience
  • Signs and symptoms of labor and when to call clinician
  • 39-40 weeks: possibility of passing due date, and options in this situation
  • Review of preparation for admission to hospital:
    transportation plans, child care, etc.
  • Anesthesia, pain-control issues, and options
  • Returning to work and/or other activities and related issues, including
    mental/physical health and disability
  • Benefits of breastfeeding for infant and mother and available supports (lactation consultants, community, etc.)
  • Signs and symptoms of postpartum depression; the need to contact clinician
  • Notifying baby’s clinician for anticipated neonatal
    complications, if applicable
  • Other suggested topics
    • Importance of visits to baby's clinician
    • Importance and timing of postpartum visit
    • Postpartum vaccinations
    • Infant CPR

Post Due Date (40 to 42 weeks)

  • Cervical exam
  • Assessment of fetal well-being
  • Counsel patient to be aware of fetal movements and to call clinician if less
    movement than usual
  • Discuss what will happen if patient does not go into labor (i.e., induction)

Postpartum Visit (4 to 6 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 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
  • Episiotomy repair and healing as indicated, uterine involution, and breast exam
  • Pap smear if needed
Repeat Full Psychosocial Assessment Counseling/Discussion
  • Ask how long patient plans to breastfeed. 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)
  • Resuming sexual activity
  • Family planning and birth control
  • Preconception counseling and risk factors for future pregnancies
  • Plans to address other health issues identified during pregnancy. Link patient
    with PCP as needed
  • Importance of visits to baby’s clinician

PRINTABLE FORMATS OF THESE RECOMMENDATIONS

 

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