# Prenatal Care --- **Prenatal care** is special care for [[pregnancy|pregnant]] people for both their health and the health of their baby. ![[prenatal and newborn screening.png]] goals - Assess the health status of pregnant client and fetus - Determine the gestational age of the fetus & monitor fetal development - Identify people at risk for complications and minimize that risk whenever possible - Provide appropriate education and counseling - Promote physical and psychosocial wellness - Help the client prepare for childbirth How to diagnose pregnancy - Presumptive signs: could be pregnant Amenorrhea, breast changes, nausea/vomiting, urinary frequency, quickening  - Possible signs: likely to be pregnant Positive [[human chorionic gonadotropin]], enlargement of abdomen, vaginal/cervical/uterine changes, sustained increase in basal body temperature - Positive signs: definitely pregnant Examiner hears fetal heartbeat with Doppler or fetoscope, examiner palpates fetal parts, fetus visible on ultrasound At every prenatal visit Assess fetal well-being, size, and position Fetal heart rate after 10 weeks (before then, it's still in the pelvis) Fundal height after 20 weeks Leopold’s maneuvers to identify fetal position after 28 weeks (identifying fetal parts, like head or butt or back) Blood Pressure Weight Presence of danger signs? Discomforts? Psychosocial status Normal fetal heart rate: 110-160 beats per minute (and regularly irregular. their neuro systems are underdeveloped so it doesn't stay stead. auscultate for a full minute) At the first one: Gather Information to Assess Strengths and Risks Vitals History Medical, Surgical, OB/GYN Family Psychosocial Physical exam Heart, lungs, breasts, thyroid Abdomen, uterus Pelvic if indicated Laboratory tests Blood type & Rh CBC Rubella titer Varicella titer HbSAg (Hepatitis) Hepatitis C RPR (syphilis) HIV Urine culture Pap (if due & > 21yo) CT/GC Genetic screening if desired LABS TO KNOW (know 11) Hemoglobin •First trimester: at least 11.0 •Second trimester: at least 10.5 •Third trimester: at least 11.0 •Less is anemia Platelets •150-450,000/microL ## Maternal Blood Volume The body knows it's going to loose a lot of blood. The blood volume increases: plasma increases 30-50% by end of pregnancy RBC production also increases. pseudoanemia of pg: plasma increase exeeds production of RBCs, creating a dilutional anemia on hematocrit. ![[maternal blood volume.png]] **How can you distinguish between pathological and physiological anemia of pregnancy? Blood volume increases to decrease blood viscosity, facilitating placental eprfusion and lowering cardiac work Also provides some reserve against normal blood loss of pregnancy Pseudoanemia of pg  peaks between 30-34 weeks of pregnancy  Anaemia in pregnancy is a HB conc.of less than 11 gm/dl  Most common cause iron deficient anemia   •Enhancers of absorption like proteins, ascorbic acid,gastric acidity, alcohol, low iron stores •Inhibitors of iron absorption like : Ca, tea, coffee A population-based, case-control study using data from the Swedish Medical Birth Register found that women with a hemoglobin concentration of 14.6 g/dL or higher at the first prenatal visit were at increased risk of stillbirth (odds ratio (OR) 1.8), antepartum stillbirth without malformations (OR 2.0), and preterm and small for gestational age nonmalformed stillbirth (OR 2.7 and 4.2, respectively)  Blood clots: progesterone and relaxin is released and that means we have trouble with venous return. so we also get edma Hypercoag of pregnancy protectice with hemostasis at delivery, but risk of DVT  Blood clots are serious concerns and even more so while you are pregnant. A blood clot during pregnancy has additional risks or concerns because of your developing baby. The good news is blood clots during pregnancy are rare and there is little need for concern. However,  a condition known as deep-vein thrombosis (DVT), which happens when blood clots form in the legs and pelvic region,  can occur and is linked with a number of serious health concerns.  The good news is there are ways to both prevent DVT and to treat it after it occurs. Also, blood clots affect only 1 or 2 pregnant women out of every 1,000, so there is no need for alarm, unless you feel you may be at risk. Research has shown a number of possible causes of DVT, and it is important to note whether you fall into any of these categories. Women are most likely to experience a blood clot in their first three months of pregnancy or in the first six weeks after giving birth. If you believe you may be at risk for DVT, be sure to talk to your healthcare provider. You could be at risk if:  You or a close relative have experienced  DVT before You smoke or are exposed to secondhand smoke frequently You are over 35 years old You are overweight You [travel long distances](http://americanpregnancy.org/pregnancy-health/traveling-during-pregnancy/) while pregnant You are expecting [multiples](http://americanpregnancy.org/multiples/complications/) You are sedentary for long periods of time You have a c-section ## Vital signs in pregnancy Pulse •30-50% increase in blood volume over the pregnancy •Pulse increases by 10-15 beats per minute •Occasional palpitations are normal Blood pressure •Physiologic 2nd trimester decrease occurs with hemodilution •Returns to normal 3rd trimester •Greater than 140/90 meets diagnostic criteria for gestational hypertension* this doesn't seem that high, but remember there's a higher blood volume but also lower arterial tone *Even though 130-139/80-89  is new diagnostic criteria for Stage 1 hypertension in non-pregnant adults [[preterm birth]] ## Blood Type Incompatibility •Proteins on the surface of red blood cells are called antigens. •There are many antigen types. The most important in pregnancy is the Rh antigen. •When blood lacks the Rh antigen, it is called Rh-negative. If it has the antigen, it is called Rh-positive. •When a pregnant person is Rh-negative and the other parent is Rh-positive, the fetus can inherit the Rh factor, making the fetus Rh-positive, too. •When the fetus’s blood has the Rh factor and the pregnant person’s blood does not, the pregnant person can develop an immune response to the Rh antigen. •Antibodies can cross the placenta and attack the fetus’ blood causing RBC break down (this usually happens in a subsequent pregnancy). •A fetus affected by Rh incompatibility becomes anemic – this is called called hemolytic disease of the fetus and newborn (HDFN), and puts the baby at risk of severe (pathologic) jaundice [[hemolytic disease of the newborn]] ![[HDFN.png]] Preventing Rh Sensitization Sensitization can occur via: A miscarriage or abortion Ectopic pregnancy Chorionic villus sampling A blood transfusion trauma, like a MVA How to prevent sensitization: Know both parents’ Rh types Screen all pregnant patients for antibodies to see if they have been sensitized If not, then provide RhoGAM during 28th week of pregnancy to prevent sensitization for the rest of the pregnancy (12 weeks) Give another dose at delivery if baby found to have Rh+ blood Give Rh-neg patients RhoGAM after any miscarriage/abortion or ectopic pregnancy ## Medical Conditions and Medications •Thorough medical history to identify chronic conditions, current prescriptions, and OTC medication use Asthma, chronic hypertension, diabetes, thyroid, mental health diagnoses •Discuss benefits and risks of continuing medications with provider •Discuss ways to monitor and reduce risks from any chronic conditions Well-managed chronic conditions (including psychiatric conditions) reduce pregnancy risks ## Psychosocial Wellness We catch a lot of things during this time, because actually a lot of the time pregnancy is the only time a person seeks healthcare. •Universal depression, substance use, and intimate partner violence (IPV) screening •Assess family and community support •Are referrals needed? Mental health/behavioral health Social work, legal aid, IPV resources WIC Community pregnancy support programs Employment, rental assistance ## Genetic Screening •Multiple tests available to screen fetus for genetic diseases •Parents can also be tested with carrier screenings for autosomal recessive disorders False positive rates are high. and there theses are invasive, so there are sequela involved we can do [[chorionic villus sampling]] or [[amniocentesis]] but the tests and screening make money, and the risks go up for these kinds of tests, and the negative outcomes go up. ## Early Gestational Diabetes Screening Early gestational diabetes screening is indicated if a pregnant person has risk factors, including •Family history of gestational diabetes or Type II diabetes •Personal history of gestational diabetes •BMI >30 Screening via: •<13 weeks: Hemoglobin A1c •≥ 13 weeks: 1-hour 50g oral glucose tolerance test [[gestational diabetes]] ## Prenatal Care Models T radiitional • Provided by physicians (OB}GYN, FP) or midwives (CNMs. I-MS) on traditional schedule: Monthiy until 28 weeks Every 2 weeks until 36 weeks Weekly from 26 weeks until birth Key visits 18-20 weeks •Anatomy ultrasound 28 weeks •“Third trimester labs”: CBC, RPR, diabetes screening •If Rh negative: repeat antibody screen, give Rhogam •Offer Tdap vaccination 36 weeks: •Birth plan •Group B strep test GBS is a normal flora of the perineum, but if you have a really high amount that is a risk of vertical transmision to the baby. It's a low risk, only about 1% of people with a high amount of GBS will pass it to baby, but that baby will almost certainly get sick and die. So we give prophylactic IV antibiotics to reduce that risk. • Group model of care, clients with similar due dates participate together • Combines essentials of risk assessment. and support and bundles prenatal services into a cohesive model of care ## Health Promotion Nutrition Vitamins and Minerals Prenatal vitamin with folic acid recommended for all Macronutrient and caloric needs increase in pregnancy First trimester: 1800 kcal/day Second trimester: 2200 kcal/day Third trimester: 2400 kcal/day 2nd trimester: one additional serving of protein/day 3rd trimester: 1.5 additional servings/day We want to avoid certain foods: - uncooked meats (e.g. sushi) - you can eat deli meat but you have to heat it though - prepackaged salads - shark meat fiber and good hydration help with constipation #### Anemia Management AFAB people already are at risk for [[anemia]] but now you have a dilutional effect of the increased plasma. •Most pregnant patients with anemia will be prescribed an oral iron supplement •Iron is best absorbed from the diet – diet teaching is important even if supplements are ordered •Patients with severe anemia may be offered an IV iron infusion if you're anemic you don't have proper perfusion to the fetus. ## Health Promotion: Exercise Improves fitness and mood, relieves stress, and improves rest Lowers pregnancy risks including gestational diabetes, cesarean birth, and fetal macrosomia 20 to 30 minutes of moderate activity at least three times per week Even small increases in activity can be beneficial Pregnant people can continue any prior exercise regimen, but may need to decrease intensity/duration Sedentary people should should begin with low-intensity workouts in pregnancy you may not have the same physical reserves as you're used to so listen to the body And balance, especially in the third trimester, is affected. and physical trauma to the abdomen is risky so. ## Health Promotion: Health Weight Gain No matter anyone's [[body mass index|BMI]], you should be gaining weight. Weight gain goals correspond to pre-pregnancy BMI Starting pregnancy under- or overweight, gaining too much or too little weight can increase pregnancy risks •Severely underweight: increases risk of preterm labor and low birth weight (LBW) •Inadequate weight gain: increases risk of intrauterine growth restriction (IUGR) •Obesity in pregnancy is associated with increased risks of gestational diabetes, hypertensive disorders of pregnancy, cesarean section, and postpartum hemorrhage [[trauma informed care]]: Weight, BMI, and weight gain in pregnancy are sensitive topics Counseling should be sensitive to potential trauma histories 🡪 Experiencing fat stigma in healthcare and society 🡪 Potential history of eating disorders Honor patient requests 🡪 Some with ED history may find being weighed triggering ## Stress Pregnancy can exacerbate preexisting stress Ongoing stress can trigger physical reactions (rapid heart rate, elevated BP, muscle tension, weakened immune system) and contribute to illnesses and psychologic symptoms Stress management strategies include role playing, relaxation techniques, biofeedback, meditation, imagery, yoga, diet, exercise, and adequate sleep Social support is key! Concept Connections: Health Equity Stress, including the stress of experiencing racism, is associated with poor pregnancy outcomes, including preterm birth Programs that offer culturally congruent social support to pregnant women consistently show improved outcomes, especially decreases in preterm birth ## Vaccinations Won't give live vaccines, but can give attenuated ones. •Can prevent severe illness and complications in pregnancy •Newborns benefit from passive immunity •“Cocooning” concept – vaccinate family members •Vaccines Indicated in Pregnancy Annual flu vaccine (preservative-free) at any GA Tdap with each pregnancy at 27-36 weeks (really giving it for the pertussus, we want to give passive immunity to the baby for whooping cough) COVID vaccine at any GA (endorsed by ACOG, SMFM) •Vaccines to defer until postpartum: Live vaccines: MMR, varicella Gardasil series ___