Routine Obstetric Visit

Aka: Routine Obstetric Visit, Routine Obstetric Exam, Prenatal Visit, Prenatal Care, Antepartum Visit, Antenatal Care, Antepartum Care

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II. Preparation: Prior to Pregnancy

  1. See Preconception Counseling

III. Protocol: Schedule of Clinic Visits

  1. Confirmation of intrauterine pregnancy
  2. First Obstetric Visit at 8 weeks gestation
  3. Routine Obstetric Visit (typically 10-12 visits per pregnancy)
    1. Prenatal Visit every 4 weeks to 28 weeks gestation
    2. Prenatal Visit every 2 weeks to 36 weeks gestation
    3. Prenatal Visit every 1 week until delivery
  4. Consider replacing some in-person Routine Obstetric Visits with Telemedicine visits
    1. Rogers (2023) Am Fam Physician 107(2): 187-90 [PubMed]

IV. Symptoms

  1. Pregnancy Induced Hypertension history (after 20 weeks)
    1. Headache
    2. Vision change
    3. Swelling of hands or face
    4. Epigastric Pain
  2. Fetal well being history
    1. Fetal movement ("quickening" at 16-18 weeks)
    2. Fetal Kick Counts (after 36 weeks)
      1. No longer recommended
      2. Results in increased patient anxiety, additional triage visits without improvement in fetal outcomes
  3. Infection history
    1. Dysuria or urgency
    2. Increased or other change in Vaginal Discharge
  4. Vaginal Bleeding history
    1. See First Trimester Bleeding
    2. See Second Trimester Bleeding
    3. See Third Trimester Bleeding

V. Exam

  1. Blood Pressure
  2. Weight
    1. See Weight Gain in Pregnancy
    2. Obtain patient height at first visit to calculate Body Mass Index
    3. Weight gain >2.3 kg (5 lb) per week is consistent with edema
  3. Fetal Heart Activity by doptone (after 10-12 weeks)
  4. Fundal height (after 20 weeks)
  5. Abdominal palpation for Fetal Presentation (Leopold maneuvers) starting at 36 weeks
  6. Edema
    1. Face and hand edema (more suggestive of Preeclampsia)
    2. Lower Extremity Edema (more than 1+ Pitting Edema after 12 hours of bed rest)
      1. Non-specific as present in >80% of pregnancies

VI. Labs: At each visit

  1. Urinalysis for Urine Glucose and Urine Protein
    1. Some guidelines have discontinued routine Urinalysis
    2. Proteinuria has poor Test Sensitivity for detecting early Preeclampsia
    3. Trace Glycosuria has poor Test Specificity for Gestational Diabetes

VII. Labs: At Specific times after initial Prenatal Labs

  1. See Prenatal Labs for other lab testing
  2. Urine Culture at 12 weeks
  3. Aneuploidy and Neural Tube Defect Screening
    1. Requires education starting in first trimester
    2. First trimester screening (Nuchal Translucency, Free bHCG, PAPPA) at 9-11 weeks
    3. Second trimester screening (AFP, uE3, HCG, Inhibin) at 15-19 weeks
    4. Amniocentesis for abnormal screening or women over age 35 years
  4. Blood Type and Rh
    1. Indicated for maternal blood type Rh Negative
    2. Performed prior to RhoGAM administration at 28 weeks
  5. Glucose Challenge Test (GCT)
    1. Performed by 26 to 28 weeks
    2. Perform with initial Prenatal Labs if indicated
      1. See Glucose Challenge Test for indications
  6. Hemoglobin or Hematocrit
    1. Perform at 26-28 weeks
    2. Not necessary to repeat later in low risk pregnancy
      1. No Anemia at 26-28 weeks (physiologic nadir)
      2. Uncomplicated pregnancy
        1. No Hemoglobinopathy
        2. No Pregnancy Induced Hypertension
        3. Single gestation pregnancy
      3. Sherard (2001) Obstet Gynecol 98:1038-40 [PubMed]
    3. Treat Iron Deficiency Anemia
      1. Iron Deficiency Anemia increases risk of IUGR, Preterm Labor and Postpartum Depression
      2. Recheck Hemoglobin 4-6 weeks after starting Iron Replacement
        1. Consider evaluation for malabsorption, blood loss, Thalassemia or other comorbidity if refractory Anemia
  7. Group B Streptococcus routine screening
    1. Culture vagina and Rectum at 36 weeks
  8. Sexually Transmitted Disease screening
    1. Universal screening at First Obstetric Visit
    2. Labs repeated at 28 weeks if at exposure risk
    3. See Prenatal Labs for protocol
  9. Genital Herpes
    1. See Genital Herpes in Pregnancy
    2. Acyclovir 400 mg orally three times daily (or Valacyclovir 250 mg orally twice daily) from 36 weeks until delivery
    3. Indicated in all pregnant women with Genital Herpes history

VIII. Prevention: Vaccinations

  1. See Vaccination in Pregnancy
  2. Influenza Vaccine to all pregnant women (after first trimester)
  3. Hepatitis B Vaccine if non-immune and at risk of exposure
  4. Give Tdap at 27-36 weeks gestation in each pregnancy, regardless of interval (Pertussis protection)
    1. Allows time for maternal Pertussis antibodies to transfer to the baby (passive Immunity)
  5. Rh Immune Globulin (RhoGAM) 300 mcg for Rh Negative, non-sensitized women
    1. Given at 28 weeks
    2. Given within 72 hours of delivery of an Rh Positive infant
    3. Given at times of risk of fetal-maternal transfusion (e.g. Amniocentesis, Abdominal Trauma, Vaginal Bleeding, Miscarriage)

IX. Management: Education

  1. See First Trimester Education
  2. See Second Trimester Education
  3. See Third Trimester Education
  4. See Nutrition in Pregnancy

X. References

  1. Zolotor (2014) Am Fam Physician 89(3): 199-208 [PubMed]

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