2013 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)

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
  • 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
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.

Immunizations
  • Immunizations status (e.g. Tetanus, Varicella, Hepatitis A, Hepatitis B)
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)
  • 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)
  • 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/friends who can provide help and support during your pregnancy and after your baby is born?

Safety and Well-Being

Depression*

Alcohol and Drug Use*

* Consider behavioral health referral if indicated

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 (e.g. cystic fibrosis, hemoglobinopathies, fetal aneuploidy, congenital heart disease).
  • Review risk factors which may influence the likelihood of genetic abnormalities (e.g. maternal age, family history, race/ethnicity, fetal anomalies)
  • Document all testing discussion, decisions, and results; do not repeat screening for heritable conditions if individual has been screened previously
General 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)
  • Exercise: 30 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 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
  • 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)
  • Recommend flu vaccine women who will be pregnant during flu season, regardless of stage of pregnancy

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 27 weeks

Immunizations
  • Administer Tdap vaccine during each pregnancy between 27 and 36 weeks
Laboratory and Additional Testing

(10 to 24 weeks)

  • Offer fetal survey ultrasound as indicated for fetal age, growth, and/or anatomy
  • Perform TB testing in at-risk populations (if not done previously) with follow-up as indicated
  • Revisit results from genetic screenings (if performed), and discuss the benefits and risks of any recommended follow-up tests
Counseling/Education
  • Discuss childbirth options. Counsel on risk of early elective pre-term delivery
  • Discuss benefits of breastfeeding
  • Encourage registration for childbirth, breastfeeding, infant CPR classes
  • Discuss signs and symptoms of preterm labor
  • Develop plan for possible urgent/emergent medical needs (e.g. transportation to hospital, child care, etc.)
  • Discuss 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, HIV, and other sexually transmitted infections in at-risk populations
  • Screen for gestational diabetes (24-28 weeks)
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
  • Recommend Tdap vaccine to be administered to any person having close contact with baby aged 12 months and who has not been previously vaccinated
  • Plans and methods of feeding baby. Emphasize benefits of breastfeeding; referral to lactation consultant as necessary
  • Getting a car seat for the baby
  • Safe sleep arrangements for the baby
  • Circumcision: preferences, what to expect
  • Travel restrictions
  • Perineal laceration
  • Family planning after delivery
  • Other suggested topics
    • Discuss choosing a clinician for the baby, and scheduling a visit with baby’s clinician if visit will be covered by insurance
    • Umbilical cord blood banking

Repeat full psychosocial assessment at least once more before delivery

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
  • 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
  • Discharge from hospital: newborn car seat and clothing, home health services 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
  • Postpartum visits and vaccinations
  • Importance of visits to baby’s clinician
  • Infant CPR
Post Due Date(40 to 42 weeks)

Assess condition of patient and baby

  • 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(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 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

  • 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)
  • 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

 

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