Prenatal+care+checklist

=Prenatal Care Checklist= This prenatal care checklist was prepared by Ann Lockhart, last revised May 2014 (Bliss)

Preconception

 * Folate supplementation- 0.4-1mg/d (1-4mg/day if on seizure meds, twins, DM) 4mg per day if prior pregnancy with neural tube defect
 * No tobacco,ETOH,recreational drugs--use dates of cessation on problem list rather than "stopped one month ago" ?recommend vit C if smoking
 * Optimize medical problems-(DM, thyroid,anemia,etc) DM A1c goal __<__ 7
 * Review medications (avoid statins, ACE inhibitors, Depakote, etc)
 * Lab- HbA1c, rubella, RPR, HbsAg, HIV

First visit

 * H&P:**
 * Review healthy start intake-particularly narrative summaries
 * Review PNC labs
 * History addressing risk factors especially prior obstetric history (verify and correct Healthy Start info)
 * Clarify and correct medication list and problem list
 * Exam –include cervix/uterine size, breast exam (discuss breastfeeding)/ dating sono if possible
 * Obtain outside prior OB records-ie op notes
 * Assign gestational age/ EDC
 * LABS:**
 * Send GC, Chlamydia, PAP if needed
 * Send wet mount, KOH only if symptomatic or history of preterm delivery
 * Baselines labs if pregestational HTN, DM (creat/pro ratio, ALT,AST, creat,) -- can usually be deferred to next scheduled lab draw
 * HbA1c __>__ 6.5 dx GDM suspect DM2; 5.7-6.4 do 2 hour GTT or Dx GDM if history consistent (prior macrosomia or GDM2); < 5.7 consider GTT if still concerned for early GDM e.g. prior GDM2.
 * Hgb electrophoresis- MCV<70 or African, Asian, Mediterranean ethnicity
 * Quantiferon if prior pos untreated TST, out of US/Canada > 1 month in last 5 years, in jail, using street drugs or homeless in last 2 years
 * Rx:**
 * Prior spontaneous preterm birth- consider progesterone caproate (Makena) 250mg IM weekly starting at 16 wks till 36 wks Decreases risk by 1/3. Strongly recommend if < 34 weeks, conside/offer if 34-36 weeks
 * H/O cervical incompetence or suggestive loss 15-24 weeks- consider cerclage 12-14 wk gestation after sono--discuss with OB Attending
 * Consider perinatology/ high risk pregnancy consult complicated medical or obstetrical conditions
 * Flu vaccine
 * 1st trimester genetic testing/NT/CVS if appropriate
 * Ed:**
 * Toxin/teratogen avoidance-ETOH, smoking, drugs, OTC/Rx meds, hot tubs, fever, raw meats, cat litter boxes, soft cheese
 * Work, exercise, sexual activity, wgt gain, prenatal vits/folate/iron,
 * Domestic violence, seat belts
 * Pregnancy symptoms- nausea, constipation, leg cramps, back ache


 * 12-15 wk **
 * Consider genetic counseling ( AMA->35yr at delivery (33 yr for twin gestation), pregest DM, prior anomaly)
 * Consider level II sono- DM2 or HbA1c __>__ 6.5, AMA __>__ 35 at EDD
 * Colpo referral if abn pap with HGSIL or worse
 * Order anatomy ultrasound for 18-20 weeks
 * 15-20 wk **
 * Offer second trimester screen. Does not need to have done the NT or first trimester screen. Adds neural tube screening to earlier tests.
 * 18-22 wk **
 * ?shielded CXR if Quantiferon is positive ( 2nd trimester)
 * 20-22 wk **
 * Fetal echo- pregestational DM HbA1c __>__ 8 CHO referral to cardiology/ PA needed for CCHP
 * 24 wk **
 * PTL precautions/ diet-- increase protein, vegetables and water with increase in appetite--not just carbs
 * 1 hr GTT (24-28wk), repeat CBC; substitute HbA1c for GTT if already GDM or DM
 * Sign PPTL consent if desired (good for 6 months, needs 30 days before EDD)
 * 27-28wk **
 * Instruct in kick counts/Preeclampsia symptoms
 * Tdap 27-36 weeks to prevent neonatal pertussis (whooping cough--give **__every pregnancy__** even if received recently
 * Rhogam if Rh negative (type and screen will be drawn to r/o sensitization and Rhogam given before results)
 * Follow FH’s -consider follow up sono if lagging > 2cm
 * Consider ordering 32-34 week growth sono if fiboids or maternal BMI makes FH difficult
 * VBAC discussion--give handouts and consent to review
 * Order repeat limited sono if low lying placenta or previa earlier
 * 30 wk **
 * Sign PPTL consent if desired
 * Postpartum contraception options discussion if no PPTL (Nexplanon can be placed postpartum, IUD during repeat cesarean)
 * Review kick counts
 * 32 wks **
 * Consider need for antepartum testing (DM2, GDM2, IUGR, prior loss, etc)
 * Schedule elective repeat section if desired ( >39 wk EGA)
 * Discuss breastfeeding
 * If reports itching without rash order bile acids and begin antepartum testing pending results

**34 wks**

 * Repeat HIV, RPR, CBC, consider HbA1c if DM, GDM
 * Schedule elective repeat section if desired ( >39 wk EGA) ?tubal consent make sure consent done correctly, if desired
 * Order EFW to be done at 38-39 weeks if DM/GDM and any concern for macrosomia
 * 35-37 wks **
 * GBS culture (36-37 weeks best unless concern for early delivery)
 * Position check- consider version referral if non vertex-call L and D 55608 to schedule at 37 weeks
 * Labor precautions
 * ?State Disability available preg beyond 36 wks
 * Consider delivery plans elsewhere if significant fetal anomalies, placenta accreta, maternal cardiac condition, triplets ...
 * Induction at 37 weeks for cholestasis, gestational hypertension, preeclampsia without severe features
 * 38-40 wks **
 * Induction for OB indications e.g. prior demise, chronic HTN 38 weeks, GDMA2/DM2 39 weeks
 * 41 wks **
 * Start biweekly NST testing/ weekly AFI
 * Schedule induction TBD 41w0d to 41w6d
 * Postpartum **
 * CXR for + quantiferon if not done in 2nd tri- consider INH
 * Contraception discussion
 * 6 wk pap vs f/u colpo if initially done in pregnancy for abn pap
 * 6 wk 75gm GTT if GDM **or HbA1c at 2-3 months or use glucometer to monitor for FBS > 120**
 * Address breastfeeding issues, screen for depression