OFFICE OBSTETRICS CONTENTS Foreword xi William F. Rayburn Preface xiii Sharon T. Phelan Components and Timing of Prenatal Care 339 Sharon T. Phelan The primary objective for prenatal care has not changed in the past 100 years: to have the pregnancy end with a healthy baby and mother. By identifying risk factors for pregnancy complications or other maternal health concerns that need to be addressed, the provider hopes to optimize pregnancy outcome. By using a series of screening and diagnostic tests, as well as serially trending certain components of the physical examination, the provider monitors the ongoing ‘‘health’’ of the pregnancy. As the ability to screen and intervene has improved over the last century, the issues to be assessed have expanded to include not only medical aspects of care but also barriers to access, psychologic considerations, and patient education about general health, pregnancy, and childbirth. The Prenatal Medical Record: Purpose, Organization and the Debate of Print Versus Electronic 355 Sharon T. Phelan The obstetric prenatal record is one of the best, most organized medical record systems currently used in the United States. This has allowed a standardization of care and documentation that has benefited pregnant women over the past two decades. The transition to an electronic record must maintain these advances and, hopefully, strengthen them with the use of electronic prompts, seamless transfer of information, and universal accessibility to the records, regardless of the location of care. VOLUME 35 Æ NUMBER 3 Æ SEPTEMBER 2008 vii Nutrition During Pregnancy 369 Jean T. Cox and Sharon T. Phelan Nutritional concerns in pregnancy are gaining increasing impor- tance as problems with obesity, poor nutrition, and improper weight gain during pregnancy have been shown to result in morbidity for mother and infant during the pregnancy. More recent studies show that the impact of poor nutrition in pregnancy extends for decades to follow for the mother and the offspring. Clearly, prevention of problems is the best approach. This article discusses aspects of, and controversies concerning, prenatal weight gain and specific nutrients, and special patient groups who may benefit from intervention by a registered dietitian. Promoting Healthy Habits in Pregnancy 385 William F. Rayburn and Sharon T. Phelan Most women have an appreciation of what are generally considered healthy habits including more exercise; eating a healthy diet; avoiding cigarettes, alcohol, and drugs; using seatbelts; and being current on preventive care, such as good dental status. Being pregnant can be a strong motivator to change or modify behavioral choices. This is an optimal time for a provider to build on this potential motivator to effect change. Frequent follow-up visits allow re-enforcement of attempted change. This constant encour- agement and support helps to impress on the woman and her family the importance of change. Hyperemesis Gravidarum 401 T. Murphy Goodwin Hyperemesis gravidarum occurs in 0.3% to 2% of pregnant women, although populations with significantly higher rates have been reported. In clinical practice, hyperemesis gravidarum is identified by otherwise unexplained intractable vomiting and dehydration. This article discusses the causes, presentation, diagnosis, and management of hyperemesis gravidarum. Perinatal Depression 419 Emily C. Dossett Despite the fact that childbirth is often a time of joy for a family, the occurrence of perinatal depression is very common. It is essential for the depressed patient to be identified and treated during the pregnancy or postpartum because the failure to treat can have significant morbidity and even mortality for the woman and the child. Despite various concerns several antidepressant medications are generally safe and, after a careful risk/benefit analysis and informed consent, indicated for the severely depressed pregnant or lactating patient. viii CONTENTS Prenatal Diagnosis and Genetic Screening—Integration into Prenatal Care 435 Valerie J. Rappaport In the last 3 decades, perinatal medicine has made tremendous advances in scientific knowledge and in the successful application of this knowledge toward understanding the fetal aspects of pregnancy. Evaluation of the health of the fetus and screening for birth defects has become an important part of prenatal care. This article provides an overview of birth defects and the various screening methods for diagnosing birth defects before birth. It also discusses the role of preconception genetic screening. Recurrent Risk of Adverse Pregnancy Outcome 459 Lisa E. Moore It is an unfortunate fact that all pregnancies do not end with healthy babies and healthy mothers. Families who have experi- enced an adverse pregnancy outcome require accurate information about the risk of recurrence to plan future childbearing. This article examines the recurrence risk of four complications of pregnancy: gestational diabetes, preterm delivery, stillbirth, and preeclampsia. Combined, these four complications are responsible for approx- imately 24% of maternal and neonatal morbidity and mortality. Prenatal Counseling Regarding Cesarean Delivery 473 Lawrence M. Leeman In 1970, the cesarean delivery rate in the United States was 5.5% and women receiving prenatal care only required the knowledge that cesarean delivery was an uncommon solution to dire obstetric emergencies. In 2008, when almost one in three women deliver by cesarean, counseling on cesarean delivery must be part of each woman’s prenatal care. The content of that discussion varies based on the woman’s obstetric history and the anticipated mode of delivery. Childbirth Education and Birth Plans 497 Joanne Motino Bailey, Patricia Crane, and Clark E. Nugent Childbirth education is considered a key component to prenatal care, although many women do not receive any formalized preparation. There are multiple models of childbirth education for both within health care settings, including Centering Preg- nancy, and external programs, such as Lamaze and Bradley. As a component of childbirth preparation, a birth plan can be a medium to improve patient-provider communication regarding a desired labor and birth experience and improve satisfaction with care. Index 511 CONTENTS ix Foreword William F. Rayburn, MD, MBA Consulting Editor This issue, with Dr. Sharon Phelan as Guest Editor, provides a timely update on topics of active interest in prenatal care. Pregnancy is a normal, natural process for most women, with a profound impact on those it touches. Although advances in prenatal care have improved the outcome for mothers and their babies, problems can still arise at any time. This issue of the Clinics highlights areas where problems can occur, their warning signs, and ways to prevent these problems. Health and happiness in pregnancy are largely dependent on proper guid- ance and vigilance by a competent obstetrician, with a team of nurses, nurse midwives, technicians, and allied health personnel. There are no better sub- stitutes for such care, based on the physician’s acquaintance with the expec- tant mother and her individual situation. Providers are developing a broader appreciation of the many problems that expectant mothers face, with the result that individual questions are answered with increasing understanding and insight. Meticulous attention to detaildalong with technological advancesdhave added increasing demands to the schedules of doctors and nurses. More than ever before, prenata l care is a systematic way to provide comprehensive care and to screen for certain complications in an attempt to anticipate or quickly intervene. With the routine use of more screening and diagnostic tests, the traditional schedule of visits and the content of each visit are continually being modified. Use of electronic prenatal records to handle data management is gaining momentum, but there are certain issues 0889-8545/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ogc.2008.07.002 obgyn.theclinics.com Obstet Gynecol Clin N Am 35 (2008) xi–xii and limitations that must be considered before completely adopting such a record system. Families who experience an adverse pregnancy outcome require accurate information about healthcare maintenance and recurrence risks in order to plan future childbearing. This issue cites multiple examples regarding how pregnancy is a tim e when many women are motivated to alter unhealthy behaviors, such as smoking, substance abuse, and poor nutritional intake, and to seek assistance with lifestyle changes. For example, recent studies show that the impact of poor nutrition during pregnancy extends for decades to follow for both the mother and the child. Simple nausea during pregnancy should be actively addressed with education, dietary modifica- tions, and certain medications, while more severe presentations requ ire more aggressive treatment, with the potential for hospitalization. Childbirth education is another key aspect to prenatal care and multiple models exist. As a component of childbirth preparation, a birth plan can be a means to improve patient-provider communications about a desired labor and the birth experience, as well as improved satisfaction with care. Of special importance is the obstetrician’s role in providing information to help weigh the risks and benefits of an attempted vaginal birth or to plan on an operative birth. Information in this issue represents the opinions of experts in obstetrics and related fields. Portions of certain articles contain educational materials from the American College of Obstetricians and Gynecologists. Views expressed here are not absolute, however, and should be considered as flex- ible guidelines based on medical advice and available local resources. William F. Rayburn, MD, MBA Department of Obstetrics and Gynecology University of New Mexico School of Medicine MSC10 5580 1 University of New Mexico Albuquerque, NM 87131-0001 USA E-mail address: wrayburn@salud.unm.edu xii FOREWORD Preface Sharon T. Phelan, MD, FACOG Guest Editor For years, prenatal care has been recognized as a component of obstetri- cal care; however, until the latter half of the twentieth century it has been relatively limited. In the 1970s and 1980s studies showed that an investment in earlier and more comprehensive prenatal care resulted in a cost savings by decreasing preterm births and delivery complications. Over the past 20 years, as technology and the Human Genome Project ha ve impacted medical care, the scope of prenatal care has also changed. Originally, obstetrical care was directed at minimizing maternal and infant death associated with delivery and the immediate postpartum period. Gradually, efforts to prevent the development of prenatal compli cations (eg, pre-eclampsia) and screening for other maternal problems (eg, diabetes and anemia) became more predominant. Now, more effort is directed to- ward the fetus: screening and potentially intervening for fetal pathology. This shift in focus of care involv es coordinating the use of more technology and screening or diagnostic testing. The provider needs to be familiar with cost-effective routine care, genetic and fetal screening tests, and must antic- ipate recurrence of prenatal problems, both medical and operative. Patient education becomes critical as pregnant women are more active in the workplace, travel more, and participate in a variety of leisu re activities. Women can enter pregnancy with unhealthy behaviors including obesity, smoking, and substance abuse. This is a time in a woman’s life when she should be motivated to adopt healthier behaviors with guidance from her obstetrical provider. Couples often want to have more say relat ed to the 0889-8545/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ogc.2008.07.001 obgyn.theclinics.com Obstet Gynecol Clin N Am 35 (2008) xiii–xiv birthing experience. The use of childbirth education program s and birth plans can help a couple ha ve reasonable expectations of the birth progress. Thus, the content and timing of prenatal visits have changed over the past 20 years. The obstetrical provider must stay current on these changes to provide optimal care. Sharon T. Phelan, MD, FACOG Department of Obstetrics and Gynecology University of New Mexico MSC 10 5510, 1 University of New Mexico Albuquerque, NM 87131 USA E-mail address: stphelan@salud.unm.edu xiv PREFACE Components and Timing of Prenatal Care Sharon T. Phelan, MD, FACOG Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, 1 University of New Mexico, MSC 10 5580, Albuquerque, NM 87131, USA History and public health implications of prenatal care The concept of prenatal care has been part of the obstetrician’s care for over 100 years. William’s Obstetrics, first edition, from 1907 states ‘‘pregnancy should be considered a normal processes but (the provider should) keep strict supervision and be constantly on alert for the appearance of untoward symp- toms’’ [1]. The woman was to be encouraged to do outdoor exercise, eat an abundant, nourishing diet, and loosen clothing, including dispensing with her corset. She was also to be given guidance on sexual intercourse, breast care, and bowel health. ‘‘Urine should be examined .once a month for the first 7 months and at least twice a month.during the last 3 months .looking for albumin and sugar . or decreasing volume’’ [1]. In the 1930s, the approach to care was designed to identify early the signs and symptoms of pre-eclampsia and was very similar to our current tradi- tional appointment schedule. Much of the focus was to improve maternal mortality rates, which did decrease by 14-fold in the first half of the twenti- eth century from 690 to 50 per 100,000 births. In the past 50 years the rate has decreased further to eight out of every 100,000 births [1], so now the emphasis ha s shifted more toward improving fetal outcome and preventing maternal complications. Through much of the 1940s and 1950s a great deal of emphasis was placed on minimizing maternal weight gain. It was thought that this would decrease the incidence of hypertensive disorders. The patient was instructed to gain only 20 pounds and might be given diuretics to assist in meeting this goal. The only real change in the past 50 years has been to add a number of screening and diagnostic tests and decrease the emphasis on minimizing weight gain, but not to modify the visit scheduling approach. The new tests were incorporated into the already established visit schedule. E-mail address: stphelan@salud.unm.edu 0889-8545/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ogc.2008.06.002 obgyn.theclinics.com Obstet Gynecol Clin N Am 35 (2008) 339–353 This ‘‘traditional’’ approach to visit scheduling is currently being challenged by the National Institutes of Health Expert Panel on Prenatal Care from 1989 [2], and other organizations, in favor of fewer but more focused visits. In the mid-1980s the public health arguments for prenatal care caused Medicaid coverage to extend to a large number of otherwise uninsured preg- nant women [3,4]. It was clear that women who did not receive prenatal care had worse outcomes. In turn, if a patient receives ‘‘adequate’’ care, her risks of a low birth-weight infant go down significan tly [5], as well as preterm births [6] and neonatal deaths [7]. Subsequent studies did challenge these findings, stating that women without prenatal care usually had major psycho-social or economic issues that increased their risk of obstetric com- plications [8–10]. The six factors that most agree upon as having a direct impact on the quality of prenatal care are: amount of insurance, delay in telling others about the pregnancy, attitudes toward health professionals, month of gestation in which the pregnancy was suspected, perception of the importance of prenatal care, and initial attitude toward the pregnancy [5]. Other studies show that whether the pregnancy was intended or not (in addition to how important a woman felt prenatal care was) could pre- vent even insured women from getting early and adequate care [11–17]. It should be noted that ‘‘adequate’’ prenatal care has been traditionally judged on onset of care and number of visits, not the content of the care [18,19]. Prenatal care can be organized into four general components: (1) the initial intake history and physical examination, (2) periodic screening or diagnostic testing, (3) serial examinations watching trends of various objective measurements and patient’s emotional adjustment to pregnancy, and (4) patient education. This article reviews each of these issues while the following articles in this issue of Clinics will address most of these components in greater detail. Initial history and examination In the past a great deal of emphasis was placed on the early examination, primarily for dating the pregnancy. With ultrasounds being routinely done to assist in pregnancy dating, the primary reason for the early examination now is to identify significant maternal medical issues that require immediate intervention or education. In fact, the ideal initial prenatal care visit occurs before conception with a preconceptive visit. A preconceptive visit allows modification of behavioral choices, medication, and optimizing medical concerns before conception. Medications or illnesses that impact a pregnancy typically have their greatest impact in the first 12 weeks of the pregnancy, often before the patient’s acknowledgment of the pregnancy. The damage will have already been done if behaviors or medications were not modified before the conception. Patients at increased risk for ectopic pregnancy should be seen earlier in the pregnancy to insure implantation is in the uterus. 340 PHELAN In the uncomplicated pregnant patient the initial visit commonly can be delayed until 10 to 12 weeks, after the major risk of spontaneous abortion. This visit consists of a comprehensive history, de tailed examination, initial prenatal laboratory work, and introduction to patient educational resources. This visit is designed to assess health of the mother and (by proxy) the fetus, date the pregnancy, and initiate a plan for individu- alized care. Many providers divide this into two sessions, with the first be- ing the history followed a few days or a week later with the physical examination. Between the visits the patient has the appropriate lab work done (Box 1). At the second session the history, laboratory results, and any pertinent physical findings are discussed and a prenatal care plan established. Initial history (whether done before or after conception) should include the issues listed in Box 1. One needs to conceptualize that this history is not only assessing for maternal risks but also is a ‘‘fetal histo ry,’’ assessing for fetal risks of genetic or environmental concerns. To do this effectively a detailed personal, family, and partner medical and genetic history must be obtained. Poor maternal behavioral choices or potential teratogen expo- sure for mother, father, and others in the home or workplace need to be elicited by the provider. These issues could be as obvious as substance abuse or more subtle, such as a first year kindergarten teacher with exposure to multiple viruses or a chemotherapy nurse at the local cancer center. Certain ethnic groups should be offered additional screening for genetic concerns, such as Tay-Sachs or sickle cell anemia. Detailed personal and family repro- ductive history may also raise concern of other genetic disorders, such as Fragile X syndrome. Exposures to some medications (certain antiseizure medications or antihypertensives or anticoagulants) or high serum glucose levels are potential teratogens and the patient or couple may benefit from additional counseling and fetal assessment earlier in the pregnancy. These situations are discussed further in the article by Rappaport elsewhere in this issue. A detailed menstrual history will allow the provider to determine how reliable this data point is for gestational dating [22]. To be used as a primary dating criteria, the woman should be certain of the date of onset of the last menses, it should have been normal in flow, not be associated with hor- monal contraceptive use, and she should have regular 28 to 30 day cycles. If these criteria are not met, the provider should consider using an ultra- sound for establishing the due date or clinical examination. In addition to the medical history, a prior surgical history should also be taken. The patient’s history may alert the provider to increased risk of cer- tain maternal problems or complications. With the increasing obesity among pregnant women, the risk of back problems or excessive weight gain with increased risk of macrosomia or gestational diabetes is increasing. A patient with prior gynecologic or obstetric history may be at increased risk for recurrent obstetric complications (see the articles by Moore and 341COMPONENTS AND TIMING OF PRENATAL CARE [...]... risk of preterm delivery Am J Obstet Gynecol 2008; 198:180, e1–5 Obstet Gynecol Clin N Am 35 (2008) 355–368 The Prenatal Medical Record: Purpose, Organization and the Debate of Print Versus Electronic Sharon T Phelan, MD, FACOG University of New Mexico School of Medicine, Department of Obstetrics and Gynecology, 1 University of New Mexico, MSC 10 5580, Albuquerque, NM 87131, USA Objective and purpose of. .. electronic record, and what the hospital can and will support, and make the decision from those perspectives Listen to all the features and see if they can be added later (once the practice has a better understanding of what they want and after other groups may have debugged the software) One only has to think of some of the ‘‘latest and greatest’’ software platforms that have been pushed and then flopped... Williams and Willkins; 2003 p 1–9 [3] Phelan ST The prenatal record and the initial prenatal visit In: Sciarra J, editor Chapter 17 Obstetrics and gynecology, vol 2 Philadelphia: Lippincott Williams and Willkins; 2003 p 1–8 [4] Guidelines for Perinatal Care In: Lockwood CL, Lemons JA, editors 6th edition Washington, DC: American Academy of Pediatrics and The American College of Obstetricians and Gynecologists;... toxoplasmosis (if maternal prevalence is >1.5 per 1,000) [25] and hepatitis A and C screen a Recommended by the American College of Obstetricians and Gynecologists that this is done routinely [21] Data from Lockwood CJ, Lemons JA editors Guidelines for perinatal care 6th edition American Academy of Pediatrics and American College of Obstetricians and Gynecologists; Washington, DC: 2007 p 87–111 Leeman elsewhere... practice can purchase The one created by the American College of Obstetricians Box 3 Menstrual history First day of last normal menstrual period and certainty of the date Last use of hormonal contraception or cessation of breast feeding Frequency of menses Menarche THE PRENATAL MEDICAL RECORD 359 Box 4 Medical history of patient, her family, and the father of the pregnancy Neurologic/Epilepsy Thyroid... with the use of electronic prompts, seamless transfer of information, and universal accessibility to the records, regardless of the location of care References [1] Peoples-Sheps MD, Kalsbeek WD, Siegel E, et al Prenatal records: a national suvery of content Am J Obstet Gynecol 1991;164:514–21 [2] Hauth JC Prenatal care documentation and triage In: Sciarra J, editor Chapter 16 Obstetrics and gynecology, ... associate with the common nausea and vomiting of pregnancy (see the article by Goodwin in this issue) The complaints in the third trimester are commonly because of the pressure of the enlarging uterus COMPONENTS AND TIMING OF PRENATAL CARE 351 in combination with the muscular relaxation of the intestinal tract These concerns can often be handled with dietary changes and antacids, but one can use proton... retrieval of information, and sufficiently detailed The quality of the record depends on accurate recording of the data The record must be simple but complete, directive but flexible, legible and able to display the necessary information readily The ability to record care in a simple fashion helps with compliance and conformity of documentation The incorporation of risk assessment tools allows triaging of the... assessment and baseline laboratory is like the framing of the structure The remainder of the visits gradually ‘‘frame in the walls’’ and add dimension and character to the house, while referring to the original blueprint for the basic form The components of a prenatal record include all the initial demographics, family, and personal medical and genetic history, complete physical examination and laboratory... Components of the initial prenatal assessment History Gynecologic and menstrual history, with emphasis on last menstrual period (LMP) timing Obstetric history with any complications noted because of risk of recurrence Detailed maternal review of systems Occupation and potential concerns (briefly assess other household members) Socioeconomic, educational, and cultural concerns Psychologic health and risks of . PREFACE Components and Timing of Prenatal Care Sharon T. Phelan, MD, FACOG Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, 1. edition. American Academy of Pediatrics and American College of Obstetricians and Gynecologists; Washington, DC: 2007. p. 87–111. 343 COMPONENTS AND TIMING OF