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Created: November 1996

Revised: 9/1007, 10/1998, 12/2000, 10/2002, 09/2004, 08/2006 Last Revision: August 2008

Prenatal and Postpartum Care Guidelines I. OVERVIEW

Health Plan of Nevada endorses the American College of Obstetricians and Gynecologists (ACOG) Guidelines for Perinatal Care.

PRENATAL VISIT DESCRIPTION

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First visit must be within the first trimester and after a missed menses. (or within 42 days of enrollment) Physical Obstetric Examination must include the following: o Auscultation for fetal tones or o Pelvic exam with obstetric observations or o Measurement of fundus height OR Evidence that a prenatal care procedure was performed, such as: o OB Panel (hematocrit, differential, WBC, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh (D) and ABO blood typing) or o TORCH antibody panel alone or a rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing or o Echography of a pregnant uterus OR Documentation of last menstrual period (LMP) or expected delivery date (EDD) in conjunction with either the following: o Prenatal risk assessment and counseling/education or o Complete OB history. Must be within 21 to 56 days post delivery or 14 days post delivery for C-Section. Postpartum visit must include one of the following: o Pelvic Exam or o Evaluation of weight, blood pressure, breast and abdomen or o Notation of "postpartum care". General guidelines for visits are as follows: o o o Every 4 weeks until the 28th week Every 2 weeks until the 36th week Once a week until delivery.

POSTPARTUM VISIT DESCRIPTION (Requirements based on NCQA criteria) ROUTINE PRENATAL VISITS

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Because of lack of data and differing patient risk profiles, scheduling of visits and the frequency of the individual preventive services listed herein are left to clinical discretions, except for those indicated at specific gestational ages.

II.

VISIT RECOMMENDATIONS LAB/DIAGNOSTIC TESTS · Blood pressure · Complete Blood Count (CBC) · ABO/Rh typing · Rh(D) and RBC antibody screen · VDRL/RPR · Hepatitis B surface antigen (HBsAg) · Urinalysis for bacteriuria, glucose and protein. · Gonorrhea culture/ Chlamydia culture · Pap smear if not within last 12 months. · Rubella antibodies titer · HIV testing for high risk patients (HR1) · Hemoglobin electrophoresis for high risk patients (African Americans) COUNSELING · Nutrition · Weight gain · Tobacco use Alcohol and other drug use · Safety belts · Risks of HIV infection · Genetic and ethnic disease · Exercise · Sexual activity · Amniocentesis education for high risk patients (Age 35 years & older)

VISIT First Prenatal Visit

ASSESSMENTS · Specific for women less than 18 years of age (When possible, · Specific for women "preconception greater than 35 years visit" is of age. recommended · Medical History and to evaluate the Physical including woman's family history. overall medical, · Genetic and Obstetric psychological history including and social prior C-section fitness prior to births. the pregnancy). · Nutritional Status · Tobacco/alcohol/drug use · Oral Health assessment · Risk factors for intrauterine growth retardation and low birth weight · Prior genital herpetic lesions · Medications · Physical and social environment. o Home o Work o Transportation access o Domestic Violence o Financial Resources · Height, Weight & BMI · Sexual Activity · Health Literacy · Cultural & religious beliefs

VISIT 16-18 Weeks

ASSESSMENTS · · · · · · Emotional/psychological health Physical abuse Fundal height Weeks gestation Fetal heart tones and position Height, weight & BMI

LAB/DIAGNOSTIC TESTS · · Blood Pressure Maternal Serum AlphaFetoprotein (MSAFP)*

COUNSELING

*Women with access to counseling and follow up services, skilled high resolution ultrasound and amniocenteses capabilities, and reliable, standardized laboratories · U/A Dipstick for Protein/Glucose Ultrasound U/A Dipstick for Protein/Glucose · · · · Nutrition Safety Belts Description and indication for upcoming tests. Breastfeeding

18-20 Weeks

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24-28 Weeks

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Fundal height Weeks gestation Fetal heart tones and position Height, weight & BMI Physical abuse Emotional/psychological health Fundal height Weeks gestation Fetal heart tones and position Height, weight & BMI Physical abuse Emotional/psychological health

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Hemoglobin/Hematocrit Oral glucose tolerance test (1 hour) · Rh(d) antibody (Rhogram) for Rh-negative women. · U/A Dipstick for Protein/Glucose

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Instruct patient to schedule a "Meet the Pediatrician" appointment Register for Prenatal classes Fetal Movement instructions at 28 weeks Signs of regular and premature labor Infant seats Smoke alarms

VISIT 35-37 Weeks

ASSESSMENTS · Fundal height · Weeks gestation · Fetal heart tones and position · Height, weight & BMI · Physical abuse · Emotional/psychological health

LAB/DIAGNOSTIC TESTS · Group B Strep cultures · Flu vaccine during flu season · Pelvic Exam · U/A Dipstick for Protein/Glucose

COUNSELING · Tobacco use for high risk women who continue to smoke during pregnancy · Alcohol and other drug use for high risk women with excessive alcohol consumption during pregnancy · Contraceptives · Schedule a 6 week post partum appointment

37-39 Weeks

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Fundal height Weeks gestation Fetal heart tones and position Height, weight & BMI Physical abuse Emotional/psychological health

· Pelvic Exam · U/A Dipstick for Protein/Glucose

HR1 ­ Women seeking treatment for sexually transmitted diseases; past or present intravenous (IV) drug users; women with a history of prostitution or multiple sexual partners; women whose past or present sexual partners were HIV-infected, bisexual, or drug users; women with longterm residence or birth in an area with high prevalence of HIV infection in women; or women with a history of transfusion between 1978 and 1985.

III. POSTPARTUM VISIT/CARE VISIT Six Weeks Or 14 days, if C-Section for surgical evaluation, and 6 weeks for regular postpartum assessment. ASSESSMENTS Assessment should include: · Pelvic exam · Weight, · Evaluation of breasts, abdomen · Post partum depression screening (Edinburgh Postnatal Depression Scale (EPDS) is an excellent tool for evaluation) · Family support · Domestic violence and child abuse. LAB/DIAGNOSTIC TESTS · Hemoglobin/Hematocrit to assess for anemia · Blood Pressure COUNSELING · Nutrition · Exercise · Family Planning · Breastfeeding · Contraceptives · Community resources

REFERENCE PERSONS: Carl Allen, MD, OB/GYN, Southwest Medical Associates Marguerite Brathwaite, MD F.A.C.O.G, Ob/Gyn Department Chief, Southwest Medical Associates REFERENCE: · American College of Obstetricians and Gynecologists Guidelines for Perinatal Care, 5th ed., Committee on Obstetrics, 2002. · Morbidity and Mortality Weekly Report (MMWR) Recommendation and Reports, August 16, 2002/vol. 51/no. RR-11. · Institute for Clinical Systems Improvement (ICSI), Eleventh Edition August 2007: Health Care Guideline: Routine Prenatal Care. · World Health Organization (WHO) Maternal and Newborn Health : Postpartum Care of the Mother and Newborn: a practical guide. http://www.who.int/reproductive-health /publications/msm_98_3/msm_98_3_11.html . · National Guideline Clearinghouse: Postnatal Care. Routine Postnatal Care of Women and their Babies (Royal College of General Practitioners, 2006). · National Guideline Clearinghouse: Michigan Quality Improvement Consortium, 2006, Routine Prenatal & Postnatal Care.

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