Prenatal Care

configuration, amnionic fluid volume adequacy,and cervical
consistency, effacement, and dilatation
PRENATAL CARE
SUBSEQUENT PRENATAL VISITS
Subsequent prenatal visits have been traditionally scheduledat :

4-week intervals until 28 weeks
every 2 weeks until 36 weeks, and
weekly thereafter.
Women with complicated pregnancies often require return visits at 1- to
2-week intervals.
The panel recommended, among other things, early and continuing risk
assessment that is patient specific. It also endorsed flexibility in clinical
visit spacing; health promotion and education, including preconceptional
care;
medical
and
psychosocial
interventions;
standardized
documentation; and expanded prenatal care objectivesto include
family health up to 1 year after birth.
Prenatal Surveillance
At each return visit, the well-being of mother and fetus are assessed
Fetal :
Fetal heart rate,
growth,
amnionic fluid volume,
and activity are evaluated.
Maternal :
Maternal blood pressure and
weight and
their extent of change are assessed.
Symptoms to be sought, such as :
o headache,
o altered vision,
o abdominal pain,
o nausea and vomiting,
o bleeding,
o vaginal fluid leakage,
o and dysuria
Uterine examination measures size from the symphysis to
thefundus.
In late pregnancy, vaginal examination often providesvaluable
information that includes confirmation of the presentingpart and
its station, clinical estimation of pelvic capacityand its general
Fundal Height
Between 20 and 34 weeks :the height of the uterine
fundusmeasured in centimeters correlates closely with
gestational agein weeks used to monitor fetal growth and
amnionicfluid volume.
o It is measured as the distance along the abdominalwall
from the top of the symphysis pubis to the top of
thefundus.
o Importantly, the bladder must be emptied before
fundalmeasurement.
at 17 to 20 weeks : fundal height was 3 cm higher with afull
bladder. Obesity or the presence of uterine masses such
asleiomyomata may also limit fundal height accuracy.
using fundal height alone, fetal-growth restriction may
beundiagnosed in up to a third of cases
Fetal Heart Sounds
Instruments incorporating Doppler ultrasound are often used to
easily detect fetal heart action, andin the absence of maternal
obesity, heart sounds are almost always detectable by 10 weeks
with such instruments .
The fetal heart rate ranges from 110 to 160 beats per minute and
is typically heard as a double sound.
Using a standard nonamplified stethoscope, the fetal heartmay
be audible as early as 16 weeks in some women. Herbertand
coworkers (1987) reported that the fetal heart was audible by 20
weeks in 80 percent of women, and by 22 weeks, heart sounds
were heard in all.
Because the fetus moves freely in amnionic fluid, the site on the
maternal abdomen where fetal heart sounds can be heard best
will vary.
Sonography
Sonographyprovides invaluable information regarding fetal
anatomy, growth, and well-being.
The American College of Obstetricians and Gynecologists (2011b)
has concludedthat sonography should be performed only when
there is a valid medical indication under the lowest possible
ultrasound exposure setting a physician is not obligated to
perform sonography without a specific indication in a low-risk
patient, but that if she requestssonographic screening, it is

reasonable to honor her request.
Subsequent Laboratory Tests

If initial results were normal, most tests need not be repeated.
Fetal aneuploidy screening : performed at 11 to 14 weeksand/or

at 15 to 20 weeks, depending on the protocol selected
Serum screening for neuraltubedefects is offered at 15 to 20
weeks
Hematocrit
or
hemoglobin
determination,
along
with
syphilisserology if it is prevalent in the population, should be
repeatedat 28 to 32 weeks.
For women atincreased risk for HIV acquisition during pregnancy,
repeattesting is recommended in the third trimester, preferably
before 36 weeks gestation.
Similarly, women who engage inbehaviors that place them at
high risk for hepatitis B infectionshould be retested at the time of
hospitalization for delivery
Women who areD (Rh) negative and are unsensitized should
have an antibodyscreening test repeated at 28 to 29 weeks, with
administrationof anti-D immune globulin if they remain
unsensitized
Group B Streptococcal Infection
The Centers for Disease Control and Prevention (2010b)
recommendthat vaginal and rectal group B streptococcal
(GBS)cultures be obtained in all women between 35 and 37
weeksgestation, and the American College of Obstetricians
andGynecologists (2013g) has endorsed this recommendation.
o Intrapartum antimicrobial prophylaxis is given for those
whosecultures are positive.
o Women with GBS bacteriuria or a previousinfant with
invasive
disease
are
given
empirical
intrapartumprophylais.
Gestational Diabetes
All pregnant women should be screened for gestationaldiabetes
mellitus, whether by history, clinical factors, orroutine laboratory
testing.
o Although laboratory testingbetween 24 and 28 weeks
gestation is the most sensitiveapproach, there may be
pregnant women at low risk whoare less likely to benefit
from testing
Selected Genetic Screening
Selected screening for certain genetic abnormalities shouldbe
offered to those at increased risk based on family history,ethnic
or racial background, or age (American College ofObstetricians

and Gynecologists, 2009c, 2011c, 2013h).
Some examples include testing for
o Tay-Sachs diseasefor persons of Eastern European Jewish
or French Canadianancestry;
o -thalassemia for those of Mediterranean, SoutheastAsian,
Indian, Pakistani, or African ancestry;
o -thalassemia forindividuals of Southeast Asian or African
ancestry;
o
o
sickle-cellanemia for people of African, Mediterranean,

Middle Eastern,Caribbean, Latin American, or Indian
descent; and
trisomy 21for those with advanced maternal age.
Reference : William Obstetrics 24th Edition

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configuration, amnionic fluid volume adequacy,and cervical

consistency, effacement, and dilatation

Subsequent prenatal visits have been traditionally scheduledat :

patient, but that if she requestssonographic screening, it is

Subsequent Laboratory Tests

Fetal aneuploidy screening : performed at 11 to 14 weeksand/or

or racial background, or age (American College ofObstetricians

sickle-cellanemia for people of African, Mediterranean,

Reference : William Obstetrics 24th Edition

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