Вы находитесь на странице: 1из 7

Prenatal Care

First Prenatal Visit · EDC · Laboratory Tests · Subsequent Visits · Weight · Blood Pressure · Urine Protein/Glucose ·
Edema · Fundal Height · Fetal Heartbeat · Fetal Movement · Fetal Orientation

First Prenatal Visit


At the first prenatal visit, take a careful history, looking for factors that might increase the
risk for the pregnant woman.

Many providers use a questionnaire, filled out by the patient, as a starting point for this
evaluation. A sample Prenatal Registration and Obstetrical Questionnaire form can be used
for this purpose.

One important aspect of prenatal care is education of the pregnant woman about her
pregnancy, danger signs, things she should do and things she should not do.

Many providers find it useful to give the woman printed material covering these issues that
she can take with her. This allows her to read the material at a later time and to refer to it
whenever she has questions. A sample Prenatal Information form can be printed and used.

Early in pregnancy, often at the first prenatal visit, a complete physical exam is performed. At
that time, a Pap smear and cervical cultures are obtained. In many practices, an ultrasound
scan is done at or shortly after the first visit to:

 Confirm intrauterine pregnancy placement


 Confirm fetal viability
 Confirm the number of fetuses
 Provide a highly reliable estimate of gestational age

It is valuable to document your findings in a structured flow-sheet. Many offices and


hospitals have developed their own, but one is shown here:

Prenatal Flow Sheet

There are so many issues to cover during the first prenatal visit (history, physical, labs,
patient education, paperwork), that many physicians schedule two "first prenatal visits."


EDC
Based on the history, physical exam and ultrasound scan (if done), it is important to establish
a gestational age and estimated date of confinement (EDC, or "Due Date").

You may use the last menstrual period, if known, reliable, and the patient has a history of
regular periods. Add 280 days (40 0/7 weeks) to the LMP and this will give you her EDC.
This assumes that she ovulated on day #14 of her last menstrual cycle. To assist you in
making this calculation, I'm enclosing a LMP to EDC conversion chart here:

Gestational Age Calculator


You may take the LMP, add 7 days and subtract 3 months. This is a rough but usable
adaptation of the 280 day rule. It has the same limitations.

You may measure the fundal height (distance from the symphysis to the top of the uterus).
That distance in centimeters is roughly equal to the weeks gestation of the patient.

Estimates of gestational age and EDC are best done early in pregnancy when the patient's
memory is the best, and the variation is uterine size and fetal size is small.

Initial Lab Tests


Shortly after registration, initial
laboratory tests are ordered. Later in
pregnancy, other tests are usually
performed. Physician preference and
patient population guide some of the
choice of these tests, but commonly-
ordered tests include:

 Hemoglobin and hematocrit


(HGB/HCT)
 White blood cell count (WBC)
 Urinalysis (UA)
 Blood type and Rh
 Hepatitis B Screen
 Rubella Titer
 Atypical antibody screen
 Thyroid Stimulating Hormone (TSH)
 Serologic test for syphilis (RPR or VDRL)
 HIV
 Gonorrhea
 Chlamydia
 Pap
 Other lab tests as indicated by individual circumstances. For example, Sickle
screening for black patients, Tay-Sachs screening for Ashkenazi Jewish patients, and
thalassemia screening for patient's of Mediterranean extraction.

Pap Smear Video

Subsequent Lab Tests


 Serum AFP at 15-18 weeks
 Targeted (Level II) ultrasound scan for women at high risk at 16-20 weeks
 Hbg/Hct at about 28 weeks
 Glucose screening at about 28 weeks (50 g oral load with 1-hour glucose test)
 Antibody screen and Rhogam for Rh negative women at 28 weeks
 Vaginal/rectal culture for Group B Strep at about 36 weeks

Subsequent Visits

 every 4 weeks until 28 weeks' gestation


 every 2-3 weeks until 36 weeks' gestation
 every week from 36 weeks to delivery

At these visits, you will want to ask the patient about any interval changes. You'll also want to
know about any vaginal discharge or bleeding, fetal movements, and uterine contractions.

At each visit, perform a limited physical exam, consisting of weight, blood pressure, edema,
fundal height, fetal heart rate, and note the presence or absence of proteinuria and glucosuria.
At times, it may be important to determine fetal orientation.

Check weight
Typical weight gain is about a pound a
week. This means 30 to 40 pounds for
the entire pregnancy, although some
physicians feel the ideal weight gain
should be closer to 25 pounds.

Weight gain is usually slow during the


first 20 weeks. Then, there is usually
rapid weight gain from 20 to 32 weeks.
After that, weight gain generally slows
and there may be little, if any weight
gain during the last few weeks.

Too little weight gain (below 13


pounds) leads to concerns that the baby may not be getting enough nutrition.

Too much weight gain leads to concerns about soft tissue dystocia during labor and difficulty
with restoring normal weight after delivery.

If there is sudden weight gain (more than 2 pounds in a week or more than 6 pounds in a
month), this may be associated with the development of fluid retention due to pre-eclampsia
(toxemia of pregnancy).
Pregnancy Video

Blood Pressure
Measure the blood pressure at each prenatal visit. Significant cardiovascular changes occur
during pregnancy, including a 50% increase in blood volume, 50% increase in cardiac output,
significant reduction in peripheral resistance, and a mild, sustained tachycardia. While these
changes are taking place, I would make the following generalizations about blood pressure:

 Blood pressure in early pregnancy will usually reflect pre-pregnancy levels.


 During the 2nd trimester, maternal blood pressures usually fall below prepregnancy
levels.
 During the 3rd trimester, blood pressure usually goes back up to the pre-pregnancy
level.
 Any sustained BP of 140/90 or greater is considered significant and may indicate the
development of pre-eclampsia.

Fundal Height
Use a tape measure to record the size
of the uterus. The fundal height,
measured in cm, should be
approximately equal to the weeks
gestation, from mid-pregnancy until
near term (MacDonald's Rule).
Measurements falling within 1-3 cm of
the expected value are considered
normal. Fundal heights 4 cm different
than expected are considered abnormal
and suggest the need for further
investigation.

If the measurements are too small,


consider:

 Your estimate of gestational age may be incorrect


 There may be very little amniotic fluid (oligohydramnios).
 The baby may be small for gestational age (or growth retarded)
 The baby may be normal, but simply constitutionally small.

If the measurements are too big, consider:

 Your estimate of gestational age may be incorrect


 There may be too much amniotic fluid (polyhydramnios)
 The baby may be large for gestational age (as is seen in gestational diabetes)
 The baby may be normal, but constitutionally large.
Listen for the heartbeat
The normal rate is generally considered to be between 120 and 160 beats per minute.

 The rates are typically higher (140-160) in early pregnancy, and lower (120-140)
toward the end of pregnancy.
 Past term, some normal fetal heart rates fall to 110 BPM.
 There is no correlation between heart rate and the gender of the fetus.

Use a coupling agent (eg, Ultrasound jel, surgical lubricant, or even water) to make a good
acoustical connection between the transducer and the skin.

Doppler fetal heartbeat detectors are moderately directional, so unless you happen to aim it
directly at the fetal heart initially, you will need to move it or angle it to find the heartbeat.

Confirm a normal rate, and listen for any abnormalities in the rhythm of the fetal heart beat.

Check for edema


Swelling of the feet, ankles and hands is common during pregnancy. If mild, and in the
absence of hypertension, the patient can be reassured that:

 This is a normal occurrence


 While unpleasant, it is not dangerous
 It will resolve spontaneously after the baby is born.
 It may take weeks for the edema to resolve after delivery.
Edema of the ankle and foot, with marks from the
elastic of the patient's socks indenting the skin.

Facial edema, severe pedal edema, or any sudden increase in edema can be a sign of
developing pre-eclampsia, so the BP should be checked. Usually, rapid accumulation of
extracellular fluid is accompanied by a significant weight gain in a very short time.

It is not necessary to treat simple edema, in the absence of pre-eclampsia. However, some
patients are so uncomfortable or their edema is so substantial that you may feel compelled to
treat the patient. One effective treatment for edema is bed rest for 2-3 days, while drinking
plenty of plain water and avoiding excessive salt. This technique:

 Mobilizes the extracellular salt and fluids


 Increases urine output
 Will lead to a loss of several pounds through urination.

Check urine protein and glucose


A urine dipstick test for protein is generally negative or trace during pregnancy. If 1+ (30 mg/dl) or
more, it is considered significant.

Negative Trace 1+ 2+ 3+ 4+
Category
Protein Protein Protein Protein Protein Protein
Dipstick
<15 mg/dL 15-29 mg/dL 30 mg/dL 100 mg/dl 300 mg/dl >2000 mg/dL
Results
Equivalent
1000-2999
24-hour <150 mg 150-299 mg 300-999 mg 3-20 g >20 g
mg
Protein

For glucose, urine normally shows negative or trace. If persistently 1/4 (250 gm/dl) or more,
it is considered significant.

Ask about fetal activity


Although fetal movement can be documented by ultrasound as early as 7-8 weeks of
pregnancy, fetal movement is not usually felt by the mother until the 16th week (for women
who have delivered a baby) to the 20th week (for women pregnant for the first time).
Once they positively identify fetal movement, most women will acknowledge that they have
been feeling the baby move for a week or two, but didn't realize that the sensation (fluttery
movements) was from the baby.

Movements generally increase in strength and frequency through pregnancy, particularly at


night, when the woman is at rest. At the end of pregnancy (36 weeks and beyond), there is
normally a slow change in movements, with fewer violent kicks and more rolling and
stretching fetal movements. A sudden decrease in fetal movement is a danger sign that needs
to be reported and investigated immediately.

"Kick counts" are sometimes recommended to patients as a means of quantifying fetal


movement. One common way of doing a kick count is to ask the woman to count each
distinct fetal movement, starting from the time she awakens in the morning. When she
reaches 10 movements or kicks, she is done counting for the day. If she gets to 12 noon and
hasn't reached a count of 10 movements, she reports this to her provider and further testing is
done.

Fetal Orientation
The presentation (head first, breech
first, transverse lie) and position
(anterior, posterior, transverse) can be
determined in several ways:

 An ultrasound scan will


confirm the presentation and
position any time it is needed.
 An x-ray of the abdomen can
provide nearly as much
information as the ultrasound
scan, but exposes both the
mother and fetus to radiation
and thus is rarely used.
 Clinical examination of the abdomen (Leopold's Maneuvers) can provide very reliable
information, although the more experienced the examiner, the more reliable the
information. Patient habitus also makes this exam easier or more difficult.

Read more about Leopold's Maneuvers

Вам также может понравиться