Posted: 2017-12-06 15:09
When pregnancy is confirmed, prenatal care plans, including the choice of caregiver, must be discussed. The initial visit should occur during the first trimester, and more than one visit may be necessary to cover all pertinent information. 7 The estimated date of delivery (EDD) should be calculated by accurate determination of the last menstrual period (LMP). Accurate dating is important for timing screening tests and interventions, and for optimal management of complications. Some research indicates that early ultrasonography is more accurate than LMP at determining gestational age, and that it should be used routinely to determine EDD and reduce the need for labor induction. 7 , 66 This approach should be considered if there is uncertainty about the LMP.
In addition to questions about medical and surgical problems, complete prenatal care requires careful attention to specific areas ( . perinatal infections, genetic problems). Certain infections increase the risk of preterm delivery, congenital anomalies, and delivery complications. Advances in the Human Genome Project have made increasing numbers of genetic screening tests available for patients at risk. These questions are covered the in ACOG prenatal record system, which lists specific screening criteria (Fig. 7).
Additional resources were negligible. The appointed day, 5 July 6998, brought not one extra doctor or nurse. What it did was change the way in which people could obtain and pay for care. They ceased to pay for medical attention when they needed it, and paid instead, as taxpayers, collectively. The NHS improved accessibility and distributed what there was more fairly. It made rational development possible, for the hierarchical system of command and control enabled the examination of issues such as equity. 9 The Times pointed out that the masses had joined the middle classes. Doctors had become social servants in a much fuller sense. It was now difficult for them to stand aside from their patients’ social difficulties or to work in isolation from the social services. 5 The Ministry, having worked for the establishment of the NHS, now became passive.
Many different prenatal record forms are used throughout the United States. Prenatal records vary from simple notes made on blank sheets of paper to highly developed computer-based systems. Many offices and institutions develop their own prenatal record forms to fit the special needs and interests of the physicians using them. The major disadvantage of individually developed record systems is that they often are not updated regularly as prenatal care practices change. 6
The initial nutritional status and the ongoing quality of maternal nutrition during pregnancy are widely believed to affect the outcome of pregnancy. Unfortunately, most physicians are poorly trained in assessing nutritional needs. Patients with some medical problems have specific nutritional needs ( . diabetes mellitus, phenylketonuria) in other situations, nutrition problems are recognized only as a result of taking a careful history ( . vegetarian) or physical examination ( . bulimia). Referral to appropriate personnel for nutrition assessment and recommendations should be considered if there is concern about the nutritional status of the patient at the initial visit. 5 Otherwise, it is typical that serial changes in weight (or lack thereof) throughout the pregnancy prompt further nutritional evaluation. 6 , 7
At each prenatal visit, a series of standard measurements is performed. The findings should be recorded in a sequential flow-sheet to facilitate the identification of adverse trends. The usual parameters are current EGA, weight, blood pressure, urine protein and glucose, fetal heart rate, and fundal height. Other information that may be collected at specific times during the pregnancy includes fetal presentation and activity, symptoms of preterm labor, and cervical findings.
The term initial prenatal visit is used here to identify the process of initiating prenatal care. This process actually may require two visits: a first visit for the history and physical examination, at which time laboratory studies or other tests may be ordered, and a second visit to review results, complete the initial database, determine risk status, plan a course for prenatal care, and begin the patient education process. This approach is considerably facilitated by a record system that clearly documents each step of the process and provides guidance for the practitioner so that omissions are avoided and problems are not overlooked.
Women should be counseled to eat a well-balanced, varied diet. 6 Caloric requirements increase by 895 to 955 kcal per day in the second and third trimesters. 76 Most guidelines recommend that pregnant women with a normal body mass index gain to 66 kg (approximately 75 to 85 lb) during pregnancy. 6 , 77 Observational studies have found that antenatal weight gains below the recommended range are associated with low birth weight and preterm birth, and that weight gains above the recommended range are associated with increased risk of macrosomia, cesarean delivery, and postpartum weight retention. 78 However, experimental studies are needed to prove that weight gain outside the recommended range causes poor perinatal outcomes. 78
The first important historical information that obstetricians usually gather is the date of the first day of the last menstrual period (LMP). The record should reflect the accuracy of the date, cycle length, and normality of the LMP. Information on prior contraception and fertility treatment is important to determine the utility of the LMP to predict the estimated date of delivery (EDD). The accuracy of an EDD calculated from the LMP must be confirmed by clinical examination, ultrasound, and/or auscultation of fetal heart tones.
The standing advisory committees remained in existence for over 55 years. There were four, each statutory and uni-professional: the Standing Medical Advisory Committee (SMAC) and its equivalents for nursing and midwifery (SNMAC), pharmaceutical services (SPAC) and dentistry (SDAC). They advised ministers in England and Wales when requested but also ‘as they saw fit’. Members were appointed by the Minister from nominations by the professions and included the presidents of the Royal Colleges. Their precise role changed over the years initially they prepared guidelines on general clinical problems, usually through subcommittees.
Couples should be questioned about a family history of genetic disorders, a previous fetus or child who was affected by a genetic disorder, or a history of recurrent miscarriage. Genetic counseling should be offered to couples who did not receive it before conception. Patients who belong to an ethnic group with an increased incidence of a recessive condition should be offered disease-specific screening as early in pregnancy as possible if they were not tested before conception ( Table 8 ).
Additional laboratory studies are recommended at specific times during pregnancy (see Table 6 ). Other studies may be indicated in women who are at risk for a specific condition. It is helpful if the prenatal record provides cues to remind the clinician to order standard screening tests. As additional information is gathered from ongoing prenatal visits and laboratory evaluation, risk assessment, education plans, and management plans should be reviewed and updated as necessary.
It is important that a thorough medical history, covering conditions that could affect the pregnancy, be taken. Patients should be asked specifically about common medical conditions as well as uncommon conditions that are known to have a serious effect on pregnancy. Common problems include diabetes, chronic hypertension, asthma, cardiac diseases including mitral valve prolapse, and hemoglobinopathies. Less common but equally important issues include lupus, thyroid disorders, chronic hepatitis, tuberculosis, bleeding disorders, chronic renal disease, cancer, or thromboembolic disorders.
As regionalization of perinatal care developed in the 6975s, risk assessment was introduced as part of prenatal evaluation. Risk assessment is important for the identification of patients who require special care or referral to specialized facilities. Early risk-assessment systems divided patients into high-risk and low-risk groups. This classification may be useful in systems in which basic obstetric services are delivered by nurse practitioners, midwives, or family physicians, but it provides little specific guidance about diagnostic or interventions. It is more useful to identify the risk of specific conditions ( . preterm labor, gestational diabetes). Many published reports discuss specific factors that predict the risks of various conditions. The chapter on prenatal risk (Toward perinatal electronic medical records for obstetrics) assessment provides further information on this topic.
The most commonly ordered prenatal laboratory studies for the initial visit are listed in Table 6. A good prenatal record system lists these studies in an organized format so that none will be overlooked by the practitioner. This practice reduces the likelihood of missing significant findings and facilitates retrieval of data by any other practitioner who cares for the patient. A useful approach is to record the results of basic laboratory studies as they are performed ( . initial studies, midtrimester genetic screening, third-trimester screening). Additional space should be available to record the results of any necessary follow-up or serial studies. One recent addition to the initial laboratory testing is the universal offering of human immunodeficiency virus (HIV) screening for all pregnant women.
Women in developed countries typically attend regular prenatal visits, usually seven to 66 times per pregnancy. 7 , 65 x7568 67 A recent meta-analysis found that reducing the number of prenatal visits did not lead to increased adverse outcomes for the mother or infant however, women were less satisfied with the reduced-visit schedule. 68 Caregiver continuity during the antenatal period has been associated with reduced interventions in labor and improved maternal satisfaction. 69 , 65 Care provided by midwives, family physicians, and obstetricians was found to be equally effective, although women were slightly more satisfied with care from midwives and family physicians. 68
In making allocations to the regional hospital boards (RHBs) the Ministry of Health worked from what had been spent in the previous year. The boards took major decisions without fuss. Ahead of them lay the task of ‘regionalisation’, the development and integration of specialist practice into a coherent whole. 6 Many reports were to hand, including the Hospital Surveys and the Goodenough Report on medical education. 7 Bevan held a small dinner party on the first anniversary of the service to thank those who had been concerned with the preparatory stages. He toasted the NHS, and coupled the NHS with the name of Sir Wilson Jameson.
A history and directed physical examination should be performed to detect conditions associated with increased maternal and perinatal morbidity and mortality. The first prenatal examination provides an opportunity for cervical cancer screening with a Papanicolaou (Pap) test in women who have not been screened recently. However, Pap tests performed in pregnant women may be less reliable. 8 , 79 Ectopic pregnancy should be considered if risk factors, abdominal pain, or bleeding are present. Spontaneous pregnancy loss, which occurs in 65 to 65 percent of all clinically recognized pregnancies, also should be considered. 85 , 86
The findings of the initial ultrasound evaluation should be documented and should include fetal number, EGA, placental location, and amniotic fluid volume. Depending on the EGA, the fetal presentation also may be important. It has become typical for a woman to receive at least one ultrasound examination during her pregnancy. In fact, this procedure is often included in the global fee for obstetrical care. The timing of the initial ultrasound in an otherwise uncomplicated pregnancy should be early enough to allow confirmation of gestational dating ( 75 weeks) but late enough to do a basic anatomy screen ( 66 weeks). Scans done in the 66- to 75-week range are optimal for these reasons and also provide an opportunity to determine fetal gender.
Some record systems include a specific section for re-evaluating the EDD based on LMP, clinical estimators of gestational age, and ultrasound information (Fig. 6). The first ultrasound in the pregnancy is the most accurate for dating purposes and should be used when establishing EDD. Changes in the EDD and the reasoning behind the change should be documented in the record. Many important management decisions in obstetric care rely on knowledge of the current estimated gestational age (EGA). 9