2019 Perinatal Care Guidelines
MHQP’s 2019 guidelines were developed by a collaborative group of Massachusetts healthcare organizations. These are recommendations for providing perinatal care to pregnant women 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.
Click here to access the PDF version of the Perinatal Care guidelines.
FIRST PRENATAL VISIT (6 TO 12 WEEKS)
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.
- Review last menstrual period and estimated delivery date.
- Ask about and record race, ethnicity, country of origin, primary language, marital/committed relationship status, education, and line of work.
- Discuss current and past health problems/treatments, past pregnancies and previous delivery experiences, medication allergies, surgical history, family history, genetic history, sexually transmitted infections, and gynecological conditions.
- Review current and past alcohol use, medication use (illicit, prescribed, over-the-counter, dietary/herbal supplements), cigarette and/or nicotine use (e.g. gum, patch, e-cigarettes), marijuana use, opioid use, and caffeine use.
- Discuss any history of past mental illness or postpartum depression, including any medication taken or treatments received.
- Discuss additional topics such as environmental exposures (smoke, seafood, chemicals, etc), exercise routine, hobbies, and household pets, along with dietary habits and/or restrictions.
- Ask women with a BMI ≥ 30 about snoring, excessive daytime sleepiness, orwitnessedapneas. If symptoms are present, refer patient for sleep evaluation.
MENTAL HEALTH RESOURCES
Massachusetts Child Psychiatry Access Project for Moms | EPDS
Discuss the patient’s 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 concerns that prevent you from keeping your health care appointments?
- Do you or does any member of your household go to bed hungry?
- Do you have family/friends who can provide help and support during your pregnancy and after your baby is born?
- How many times have you moved in the past 12 months?
- 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.)?
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?
Domestic Violence Programs
- Administer the EPDS or other validated screening tool to screen for maternal depression.
EPDS | PHQ-2/9 | PHQ-9
Massachusetts Child Psychiatry Access Project for Moms
Alcohol and Drug Use
- Do you currently drink or use any drugs?
- Did either of your parents have a problem 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 any drugs?
- In the past month, did you drink any beer, wine, or liquor, or use drugs?
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.
- The following tests should be completed:
- Hemoglobin electrophoresis (at-risk populations)
- Blood type and antibody screen
- Rubella (if immunity not previously documented)
- Hepatitis B surface antigen
- HIV (unless declined)
- Genetic testing, as discussed by provider and patient
- Urine culture (12 to 16 weeks or at the first prenatal visit)
- 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
- Note ACOG recommends testing for all women for chlamydia, and retest later in pregnancy for women <25 years or at high risk
- TB test for at-risk populations (may delay until 15 to 20 weeks)
- Offer 1 ultrasound, as indicated, between 10-12 weeks to establish due date and viability.
- Glucose tolerance screen for patients at high risk for gestational diabetes (BMI ≥ 30, known impaired glucose metabolism, or prior history of gestational diabetes).
- Discuss the benefits and risks of screening and diagnostic tests for genetic and structural abnormalities.
- Review risk factors that 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 Jewish, 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 discussions, decisions, and results; do not repeat screening for heritable conditions if individual has been screened previously.
- Recommend the use of low-dose aspirin (81 mg/dl) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia.
- Consider the use of low-dose aspirin (81 mg/d) in women with more than one moderate risk factor.
HIGH RISK FACTORS FOR PREECLAMPSIA
Previous preeclamptic pregnancy, chronic hypertension,chronic renal disease,multifetal pregnancy, type 1 or type 2 diabetes mellitus, autoimmune disease.
MODERATE RISK FACTORS FOR PREECLAMPSIA
First pregnancy, age >= 35, BMI >30, Mother or sister with hx preeclampsia, African American, low socioeconomic status, or personal hx LBW/SGA baby, previous adverse pregnancy outcome, >10 yr pregnancy interval.
- Review perinatal visit schedule and ask if there are any potential barriers to accessing care.
- Recommend breastfeeding as the best feeding method for most infants for the first 6 months of life.
- Discuss registering for childbirth, breastfeeding, and infant CPR classes.
- Counsel on proper nutrition, exercise (30 minutes of moderate activity per day), and weight management (review gestational weight-gain goal, based on patient’s BMI).
- Recommend the use of folic acid supplements.
- Discuss the use of iron supplements.
- Discuss foods to avoid or limit during pregnancy.
- Ask about oral health status. If last dental visit took place more than six months prior, or if any issues are identified, advise to schedule an appointment with a dentist.
- Discuss not using tobacco, alcohol, other drugs, and limiting exposure to second-hand smoke.
- Review the use of any medications or treatments (prescribed, over-the-counter, herbal/dietary supplements, alternative), and the need to discuss with a clinician before starting any regimen.
- Review risk factors for HIV and other sexually transmitted infections, and discuss HIV testing.
- Counsel to avoid activities with high risk of falling or abdominal trauma.
- Stress the continued use of seat belts during pregnancy.
- Counsel on environmental/occupational exposure, such as contact with cat feces, high temperatures (saunas/hot tubs, etc.), second-hand smoke.
- Review personal care and hygiene with attention to specific cultural/ethnic practices.
- Assess health literacy by asking “How confident are you filling out medical forms by yourself?”
- Suggest registering for Text4Baby, a free text-messaging service for pregnant women and new moms.
AT EACH SUBSEQUENT PRENATAL VISIT
- Record gestational age; assess well-being of mother and fetus; review presence of any pain, nausea, or depression; and ask patient about stress level/emotional well-being.
- Request urine sample for urine protein and glucose determination, as indicated.
- Perform physical exam, including blood pressure and weight.
- Listen for fetal heart tones, check and record uterine size, check fetal position, and perform cervical exam, as indicated.
- Beginning at 20 weeks (or when fetal movement is first noted), ask about fetal movements, contractions, bleeding, and leaking fluid.
13 – 35 WEEKS
- 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.
- Revisit results from genetic screenings (if performed), and discuss the benefits and risks of any recommended follow-up tests.
- Offer 1 ultrasound between 18-20 weeks to screen for fetal growth, placenta location and umbilical cord, as well as the baby’s general health and anatomy. Limit additional ultrasounds only as indicated for mothers considered high risk or who have a suspected fetal abnormality.
- Perform TB testing in at-risk populations (if not done previously) with follow-up, as indicated.
- HIV test in third trimester in women at high risk or not previously tested.
TB RISK FACTORS
Recently infected with TB bacteria, or having a medical condition that weakens the immune system.
24 – 28 WEEKS
- Perform antibody testing for Rh-negative patients, and administer Rh immune globulin as indicated.
- Screen for gestational diabetes.
- Screen for syphilis, chlamydia, gonorrhea, HIV, and other sexually transmitted infections (STIs) in at-risk populations.
STIs RISK FACTORS
Inconsistent use of condoms, new or multiple sex partners, history of and/or current STIs, history of alcohol or recreational drug use, partner who has other sexual partner(s), exchanging sex for money or drugs.
- Consider psychosocial assessment, if warranted.
- Screen for depression using EPDS at 24-28 weeks.
- Screen for physical and behavioral signs of intimate partner abuse.
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.
- Discuss postpartum contraception.
- Review travel restrictions during pregnancy, including avoiding travel to an area with active Zika virus transmission. The CDC provides steps you should take to try to protect yourself from getting Zika.
- Discuss umbilical cord blood banking.
Plans for Labor and Delivery
- Develop a plan for possible urgent/emergent medical needs (e.g., transportation to hospital, child care).
- Review 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.
- Discuss signs and symptoms of labor.
- Discuss birth plan (preferences and concerns about birthing, pain control, others to be present), and what to expect in the hospital, including length of stay.
- Review plans and methods of feeding baby, including the benefits of breastfeeding and the availability of a referral to lactation consultant, if necessary.
Keeping Baby Healthy and Safe
- Recommend Tdap vaccine to be administered to any person who has not been previously vaccinated and who will have close contact with baby aged ≤ 12 months.
- Discuss the need for a car seat for the baby.
- Review choosing a clinician for the baby, and consider scheduling a visit with baby’s clinician (if visit will be free or covered by insurance).
- Discuss circumcision, including preferences and what to expect.
- Discuss need for insurance coverage for baby.
- Discuss safe sleep practices.
Post-Birth Health for Mom
- Counsel on postpartum depression, or “baby blues.”
- Review contraception after delivery.
- Discuss the possibility of perineal laceration and treatment.
36 – 42 WEEKS
- Group B streptococcus culture.
Preparing for Labor and Delivery
- Discuss awareness of fetal movements and calling clinician if patterns of movement change.
- Discuss signs and symptoms of labor and when to call clinician.
- Revisit childbirth plan.
- 39-40 weeks, discuss possibility of passing due date, and options in this situation.
- Discuss preparation for admission to hospital: transportation plans, child care, etc.
- Review anesthesia, pain-control issues, and options.
- Discuss benefits of breastfeeding for infant and mother and available supports (lactation consultants, community, etc.).
Post Due Date
- Assess fetal well-being.
- Counsel patient to be aware of fetal movements and to call clinician if patterns of movement change.
Keeping Baby Healthy and Safe
- Review discharge from hospital, need newborn car seat and clothing, home health services options, and notifying baby’s clinician of anticipated neonatal complications, if applicable.
- Discuss importance of safe sleep practices.
- Recommend scheduling first visit to baby’s clinician at 3-5 days.
- Discuss importance of learning infant CPR.
Post-Birth Health for Mom
- Discuss timing of and readiness for returning to work and/or other activities and related issues post-childbirth, including mental/physical health and disability.
- Counsel on signs and symptoms of postpartum depression, and the need to contact clinician.
- Review signs and symptoms of postpartum depression with partner, or other support person.
- Review the need of postpartum visits and vaccinations.
Initial Contact within 3 weeks of delivery. Comprehensive visit at 4-8 weeks, timing and frequency determined by individual patient and her particular needs. Note: Consider postpartum care as an ongoing process that is individualized and patient centered rather than a single visit.
- Counsel on bleeding, symptoms of infection (e.g., mastitis, endometritis), and resumption of menstruation.
- Confirm that patient has received rubella immunization (for non-immune mothers).
- Review the need for diabetic screening if patient was diagnosed with gestational diabetes mellitus (GDM) during pregnancy.
- Ask about bowel and urinary incontinence.
- Ask about medication use (including herbal and alternative medicines), allergies, etc. with attention to how this might affect breastfeeding mothers.
- Discuss chronic disease status in high-risk patients.
- Assess patient’s physical, social, and psychological well-being at every visit.
- Perform complete check of vital signs (height, weight, BMI, blood pressure).
- Assess uterine involution, and perineal and vaginal care as indicated.
- Consider performing breast exam, especially for those who are breastfeeding.
- Discuss breastfeeding and recommend lactation support if needed. 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.
- Discuss diet and exercise, including losing weight gained during pregnancy, plus additional weight loss if initial BMI >25.
- Counsel on continued use of prenatal vitamins or folic acid.
- Counsel women with preterm birth, gestational diabetes, preeclampsia, or hypertensive disorder of pregnancy that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.
- Counsel Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.
- Discuss resuming sexual activity, family planning, and contraception.
- Preconception counseling and risk factors for future pregnancies.
- Discuss reproductive planning and pregnancy spacing.
- Counsel that an interpregnancy interval of less than 6 months is associated with a higher incidence of low birth weight and preterm delivery.
- Ask about smoking, use of tobacco products, and exposure to secondhand smoke. Counsel to not resume use of tobacco products.
- Screen for domestic violence.
- Encourage infant well visits and immunizations.
- Provide emotional support and counseling in the setting of pregnancy or neonatal loss. While there is no clear evidence to support any specific counseling approach, it is generally agreed that physician, family and social supports are all needed.
- Refer patient and family to organizations that can help connect to support groups and other resources.
- Reassure patient that early pregnancy loss is not usually indicative of future fertility problems or repeat pregnancy loss.
- Encourage patient involvement in decision making around spontaneous abortion management.
- With spontaneous abortion, newer data suggest that it is reasonable to counsel a couple that may try to get pregnant as soon as they feel ready.
- Assist with understanding cause of late pregnancy loss or neonatal death if possible.