Tài liệu Obstetrics and Gynecology Clinics of North America 35, 2008 docx

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

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

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

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

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

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

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

into Prenatal Care 435Valerie 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

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 473Lawrence 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

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

of the Clinics highlights areas where problems can occur, their warningsigns, and ways to prevent these problems.

Health and happiness in pregnancy are largely dependent on proper ance and vigilance by a competent obstetrician, with a team of nurses, nursemidwives, 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 broaderappreciation of the many problems that expectant mothers face, with theresult that individual questions are answered with increasing understandingand insight Meticulous attention to detaildalong with technologicaladvancesdhave added increasing demands to the schedules of doctorsand nurses

guid-More than ever before, prenatal care is a systematic way to providecomprehensive care and to screen for certain complications in an attempt

to anticipate or quickly intervene With the routine use of more screeningand diagnostic tests, the traditional schedule of visits and the content of eachvisit are continually being modified Use of electronic prenatal records tohandle data management is gaining momentum, but there are certain issues

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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 accurateinformation about healthcare maintenance and recurrence risks in order toplan future childbearing This issue cites multiple examples regarding howpregnancy is a time when many women are motivated to alter unhealthybehaviors, such as smoking, substance abuse, and poor nutritional intake,and to seek assistance with lifestyle changes For example, recent studiesshow that the impact of poor nutrition during pregnancy extends fordecades to follow for both the mother and the child Simple nausea duringpregnancy should be actively addressed with education, dietary modifica-tions, and certain medications, while more severe presentations require moreaggressive treatment, with the potential for hospitalization

Childbirth education is another key aspect to prenatal care and multiplemodels exist As a component of childbirth preparation, a birth plan can be

a means to improve patient-provider communications about a desired laborand the birth experience, as well as improved satisfaction with care Ofspecial importance is the obstetrician’s role in providing information to helpweigh the risks and benefits of an attempted vaginal birth or to plan on anoperative birth

Information in this issue represents the opinions of experts in obstetricsand related fields Portions of certain articles contain educational materialsfrom the American College of Obstetricians and Gynecologists Viewsexpressed 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, MBADepartment of Obstetrics and GynecologyUniversity of New Mexico School of Medicine

MSC10 5580

1 University of New MexicoAlbuquerque, NM 87131-0001

USAE-mail address:wrayburn@salud.unm.edu

obstetri-in earlier and more comprehensive prenatal care resulted obstetri-in a cost savobstetri-ings bydecreasing preterm births and delivery complications Over the past 20 years,

as technology and the Human Genome Project have impacted medical care,the scope of prenatal care has also changed

Originally, obstetrical care was directed at minimizing maternal andinfant death associated with delivery and the immediate postpartum period.Gradually, efforts to prevent the development of prenatal complications(eg, pre-eclampsia) and screening for other maternal problems (eg, diabetesand 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 involves coordinating the use of more technologyand screening or diagnostic testing The provider needs to be familiar withcost-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 inthe workplace, travel more, and participate in a variety of leisure activities.Women can enter pregnancy with unhealthy behaviors including obesity,smoking, and substance abuse This is a time in a woman’s life when sheshould be motivated to adopt healthier behaviors with guidance from herobstetrical provider Couples often want to have more say related to the

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35 (2008) xiii–xiv

birthing experience The use of childbirth education programs and birthplans can help a couple have reasonable expectations of the birth progress.Thus, the content and timing of prenatal visits have changed over thepast 20 years The obstetrical provider must stay current on these changes

to provide optimal care

Sharon T Phelan, MD, FACOGDepartment of Obstetrics and Gynecology

University of New MexicoMSC 10 5510, 1 University of New Mexico

Albuquerque, NM 87131

USAE-mail address: stphelan@salud.unm.edu

Components and Timing

of Prenatal Care Sharon T Phelan, MD, FACOGDepartment 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 forover 100 years William’s Obstetrics, first edition, from 1907 states ‘‘pregnancyshould be considered a normal processes but (the provider should) keep strictsupervision and be constantly on alert for the appearance of untoward symp-toms’’[1] The woman was to be encouraged to do outdoor exercise, eat anabundant, nourishing diet, and loosen clothing, including dispensing withher corset She was also to be given guidance on sexual intercourse, breastcare, and bowel health ‘‘Urine should be examined once a month for thefirst 7 months and at least twice a month.during the last 3 months lookingfor albumin and sugar or decreasing volume’’[1]

In the 1930s, the approach to care was designed to identify early the signsand symptoms of pre-eclampsia and was very similar to our current tradi-tional appointment schedule Much of the focus was to improve maternalmortality 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 ratehas decreased further to eight out of every 100,000 births [1], so now theemphasis has shifted more toward improving fetal outcome and preventingmaternal complications Through much of the 1940s and 1950s a great deal

of emphasis was placed on minimizing maternal weight gain It was thoughtthat this would decrease the incidence of hypertensive disorders The patientwas 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 toadd 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

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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 causedMedicaid 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 carehad worse outcomes In turn, if a patient receives ‘‘adequate’’ care, her risks

of a low birth-weight infant go down significantly [5], as well as pretermbirths [6] and neonatal deaths [7] Subsequent studies did challenge thesefindings, stating that women without prenatal care usually had majorpsycho-social or economic issues that increased their risk of obstetric com-plications [8–10] The six factors that most agree upon as having a directimpact on the quality of prenatal care are: amount of insurance, delay intelling others about the pregnancy, attitudes toward health professionals,month of gestation in which the pregnancy was suspected, perception ofthe 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 traditionallyjudged 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 variousobjective measurements and patient’s emotional adjustment to pregnancy,and (4) patient education This article reviews each of these issues whilethe following articles in this issue of Clinics will address most of thesecomponents 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 examinationnow is to identify significant maternal medical issues that require immediateintervention or education In fact, the ideal initial prenatal care visit occursbefore conception with a preconceptive visit A preconceptive visit allowsmodification of behavioral choices, medication, and optimizing medicalconcerns before conception Medications or illnesses that impact

a pregnancy typically have their greatest impact in the first 12 weeks ofthe pregnancy, often before the patient’s acknowledgment of the pregnancy.The damage will have already been done if behaviors or medications werenot modified before the conception Patients at increased risk for ectopicpregnancy should be seen earlier in the pregnancy to insure implantation

is in the uterus

In the uncomplicated pregnant patient the initial visit commonly can bedelayed until 10 to 12 weeks, after the major risk of spontaneous abortion.This visit consists of a comprehensive history, detailed examination, initialprenatal laboratory work, and introduction to patient educationalresources 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 physicalexamination Between the visits the patient has the appropriate lab workdone (Box 1) At the second session the history, laboratory results, andany pertinent physical findings are discussed and a prenatal care planestablished.

Initial history (whether done before or after conception) should includethe issues listed in Box 1 One needs to conceptualize that this history isnot only assessing for maternal risks but also is a ‘‘fetal history,’’ assessingfor 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 sure for mother, father, and others in the home or workplace need to beelicited by the provider These issues could be as obvious as substance abuse

expo-or mexpo-ore subtle, such as a first year kindergarten teacher with exposure tomultiple viruses or a chemotherapy nurse at the local cancer center Certainethnic 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 asFragile X syndrome Exposures to some medications (certain antiseizuremedications or antihypertensives or anticoagulants) or high serum glucoselevels are potential teratogens and the patient or couple may benefit fromadditional counseling and fetal assessment earlier in the pregnancy Thesesituations are discussed further in the article by Rappaport elsewhere inthis issue

A detailed menstrual history will allow the provider to determine howreliable this data point is for gestational dating[22] To be used as a primarydating criteria, the woman should be certain of the date of onset of the lastmenses, 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 sound for establishing the due date or clinical examination

ultra-In addition to the medical history, a prior surgical history should also betaken The patient’s history may alert the provider to increased risk of cer-tain maternal problems or complications With the increasing obesityamong pregnant women, the risk of back problems or excessive weightgain with increased risk of macrosomia or gestational diabetes is increasing

A patient with prior gynecologic or obstetric history may be at increasedrisk for recurrent obstetric complications (see the articles by Moore and

Box 1 Components of the initial prenatal assessment

Detailed maternal review of systems

Occupation and potential concerns (briefly assess other

household members)

Socioeconomic, educational, and cultural concerns

Psychologic health and risks of depression

Safety issues in home, including domestic violence

Any religious beliefs that could impact care

Medical and surgical history of mother

Family medical history, including the father of the baby

Any issues since conception, such as exposures to infection

or other toxins

Behavioral issues of exercise, weight, smoking, alcohol,

or recreational drug use

Genetic screening of patient, partner, and relatives

Blood type, Rh, and antibody screen

Hematocrit or hemoglobin or complete blood count[20]

Syphilis screen

HIV screeninga

Rubella screen for immunity

Hepatitis B surface antigen screen

Chlamydia and gonorrhea screen

Consider Pap smear if due but not just as a routine

Urine for protein, glucose, and asymptomatic bacteriuria,

Leeman elsewhere in this issue) Other surgeries can impact care, such asprior splenectomy (need to be sure immunizations are current), cholecystec-tomy (can still has cholestasis), cardiac surgery (for subacute bacterial endo-carditis coverage and possible cardiac echo on fetus), and bariatric surgery(may have mechanical and psychologic difficulties with adequate nutrition)

to mention a few

Personal and family psychosocial issues can also have a major impact onpregnancy More studies are showing that severe stress in a pregnancy doeshave a negative impact For this reason, information regarding safety in thehome (see the article by Dossett in this issue), barriers to care (as discussedabove), educational or language barriers to following through with care, orpossible religious restrictions that may impact care (Muslims requiring a femaleattendant or Jehovah Witness refusing blood products) need to be elicited.This type of detailed history can be a time-consuming undertaking, sohaving a patient complete a personal history form or having a staff membertake the initial history may be a more efficient use of everyone’s time Theprovider can then review the information and modify care as indicated For-tunately, most women are relatively healthy as they enter a pregnancy.The initial physical examination also needs to be comprehensive, as theinitial obstetric examination is often the first physical examination the patienthas had in years By looking for signs of chronic illness (thyroid disease orhypertension) or poor behavioral choices (obesity or smoking) the providermay initiate early intervention Patients are often very willing and motivated

to change behaviors and be compliant with medical interventions during

a pregnancy This is an opportunity for intervention that should not be passed

up (See the article by Rayburn and Phelan in this issue)

There are core laboratory tests that all providers generally agree upon(seeBox 1) Other testing may be population-specific, such as early diabetes

Offer genetic screening and implement at gestationally

appropriate times, such as cystic fibrosis screening or firsttrimester genetic screening

Depending on population or medical history, may also get

additional testing, such as hemoglobin electrophoresis, thyroidscreen, early 1-hour 50-gm glucola challenge, purified proteinderivitive for tuberculosis, toxoplasmosis (if maternal

prevalence is >1.5 per 1,000)[25]and hepatitis A and C screen

screen or hemoglobulin electrophoresis screening for sickle cell or mia Public health departments in some states require additional testing,such as sexually transmitted infection screening in the third trimester ortuberculosis screening for all patients Depending on ethnicity, genetic his-tory, and gestational age, there are a number of genetic tests that should

thalasse-be offered at this visit or subsequent visits Because the decision to receiveadditional genetic testing can be difficult, with various psychologic ramifica-tions, written information regarding the availability of the testing, timing ofthe testing, and the implications of a positive test can be given to the patientideally before the need for a decision regarding testing

At the end of this initial assessment, a plan regarding prenatal carevisits, screening tests, and interventions should be made This plan shouldinclude how to monitor the pregnancy, based on the identification of anyrisk factors in the intake history, and physical, implementation of behav-ioral changes as needed, timing of routine assessments, and patienteducation

The patient is also usually very anxious to know her due date at this time.The average pregnancy is 280 days long[23] In the past, Naegle’s rule (LMP

þ 7 days  3 months þ 1 year ¼ EDC or expected date of confinement) wasthe typical way of calculating the EDC if the LMP was felt to be reliable.Currently, many providers use a gestational wheel to calculate not only

a current gestational age but the EDC This is generally fine, but a providerneeds to realize that these wheels have an error of plus or minus 3 to 4 days.There are now computer programs for hand held devices or incorporatedinto the ultrasound report programming that are more accurate and, hence,may be preferable to use to avoid patient confusion Patients will ‘‘bond’’ tothe first date given and do not understand the variation, especially if subse-quent dates mean that the patient has to be ‘‘pregnant longer.’’

Patient education is an essential part of prenatal care At the initial visit,general information regarding routine prenatal care schedule and promo-tion of good behavioral choices, including dental care, nutrition, wearing

a seat belt, continued exercise, avoiding substance exposure, and sexualactivity are some of the topics for the initial visit Referring a patient topurchase one of the patient-centered prenatal books is one approach.However, before recommending a specific title, you may want to reviewthe content to be sure it is fairly consistent with your practice style.Some practices develop their own educational material and provide it forpatients This can be a particularly good idea if the patient clientele hasunique needs, are non-English speaking (although many of the prenatalbooks are available in Spanish), or have specific cultural views that impact

on the education Finally, providing a patient with Web resources, such asthe American College of Obstetricians and Gynecologists (ACOG) is useful

If not given some direction patients may ‘‘surf’’ the Web and come acrosssites that are not scientifically based in their information and cause moreanxiety than needed

Subsequent prenatal visits

The remainder of the prenatal care visits need to be scheduled at intervalsthat allow serial monitoring for common complications, conduct specifictime-sensitive screening (ie, diabetes screening), administration of immuni-zations or Rhogam, or provide education Box 2 outlines data to trendand subsequent laboratory testing

Trending of fundal growth, maternal blood pressure, and weight [27]

often alert the provider to issues of abnormal fetal growth, poor nutrition,

or developing hypertensive concerns Typically the fundal height in ters equals estimated gestational weeks from 20 to 34 weeks This is altered

centime-in the situation of obesity but serial growth should still be approximately

a centimeter a week[25] A full bladder can alter measurements by 3 cm

[28] An oblique or transverse lie can result in smaller measurements thanexpected Excessive or inadequate fundal growth may be the first indication

of a potential fetal problem and will likely trigger an ultrasound assessment

of fetal growth and fluid volumes[29] Determination of fetal position in thelast month of pregnancy allows the potential to offer a version for an abnor-mal position at term or plan an operative delivery if indicated[30].Formalized maternal monitoring of fetal movement (fetal kick counts)can provide reassurance to the mother and the provider in the third trimes-ter regarding fetal well being The patient can be asked to count to a certainnumber of movements within a specified time interval If the fetus moves lessthan the requirement, the patient should have further fetal assessment Theoptimal number of movements or time interval or frequency of assessmentshas not been determined A commonly used criteria is 8 to 10 discrete move-ments within 2 hours every 1 to 2 days[24]

Finally, key educational points should be raised at the relevant andappropriate times during the pregnancy For example, the patient needs toknow the signs of preterm labor from 26 to 34 weeks in contrast to 34 weeks

on, where an understanding of the role of fetal movements in assessing fetalwell being becomes more relevant along with labor precautions and poten-tial symptoms of developing pre-eclampsia Many practices either conducttheir own childbirth education classes that cover this material and morespecifics about the labor process, or refer patients to such childbirth classes(see the article by Bailey, Crane and Nugent elsewhere in this issue).For approximately 50 years, these ongoing visits have been every 4 weeksuntil 28 weeks estimated gestational age (EGA), then every 2 to 3 weeks un-til 36 weeks into the pregnancy, and then weekly until delivery This is thepattern of care still listed by ACOG in the Guidelines for Perinatal Care

[31] This tradition is being actively challenged on many fronts.The National Institutes of Health Expert Panel on Prenatal Care 1989, rec-ommends less frequent visits for the uncomplicated nulliparous or parouspatient[2] This type of scheduling is being advocated by many Europeanprofessional societies In fact, even more restricted prenatal care was

Box 2 Subsequent visits: data to trend and interval lab testingHistory

Symptoms of potential preterm contractions: bleeding, increasedvaginal discharge, excessive pelvic pressure

Symptoms of pre-eclampsia or potential hypertension

Fetal movement:

Onset in second trimester around 18 to 20 weeks,

Fetal kick counts (FKC) in the third trimester (>8–10 FKC every

2 hours or similar threshold)[24]

Safety at home

Risky maternal behaviors: update success with smoking

cessation, abstinence from drugs, improved diet, and so forth.Physical examination

Weight and interval weight gain

Blood pressure

Fundal height in centimeters

Fetal heart tones and rate

Fetal presentation from 36 weeks and on

Optional issues are cervical examination during the last fewweeks of pregnancy with potentially sweeping membranes topromote labor

Laboratory testing

Diabetes screen, either by:

50-gm 1-hour glucose challenge test: early if high risk fordiabetes and again at 24 to 28 weeks of gestation (mostsensitive)[25,26]or

Risk factors (age <25, not a member high risk ethnic group,body mass index <25, no history of glucose intolerance, nodiabetes in a first degree relative, no history of obstetriccomplication associated with diabetes mellitus, such asmacrosomia[25]

Repeat hematocrit or hemoglobin around 26 to 30 weeks[20,25]

Rhogam workup and administration around 26 to 30 weeksGonorrhoea, chlamydia, and syphilis screening depending onpopulation

Group B Streptococcus (GBS) screening at 35 to 37 weeks[25]

Urine for protein and glucosedof questionable value[25]

recommended by the United Kingdom National Instutute for ClinicalExcellence in 2003[32] This panel recommended abandoning the early pel-vic examination, pelvimetry, regular weighing unless it will change manage-ment, no GBS cultures, no urine dips each visit, and other items Althoughmany of their recommendations are unlikely to be accepted by the providers

or patients in the United States, they also recommend the number of tal visits be greatly decreased[32] This approach advocates for fewer totalvisits that are strategically scheduled to allow testing, intervention at keytimes in the pregnancy, and ideally more time for patient education [33]

prena-As more pregnant women are in the work force each prenatal visit canmean missing half a day of work, this can place a hardship on the patientand employer For women not employed outside the home, there are stillmany demands, responsibilities, and barriers to making it to frequentappointments, such as transportation or childcare [34] The patient alsoappreciates fewer visits with more accomplished at each visit regardingongoing assessment, testing, and education Tables 1 and 2 compare thetraditional and a suggested modification for both a nulliparous and multip-arous patient[33,35]

This modified approach is appropriate for the uncomplicated patient

It still provides closer surveillance of the first time mother in the third mester to assess for complications of pre-eclampsia or fetal growth con-cerns The nulliparous patient commonly needs more reassurance andeducation regarding the common end-of-pregnancy complaints, labor signs,and labor process, and thereby finds benefit with the more frequent visits thelast month of the pregnancy [36] The reduction of total number prenatalvisits does not result in an increase in the use of other medical services orunscheduled visits[37]

tri-Testing done in pregnancy is reflective of the pressures on health caredelivery, including increasing technology, patient expectations, third partypayers, and concerns of medical liability[38] Extensive testing has become

a community standard However, laboratory testing commonly done duringpregnancy is under review for its evidence-based cost-effective contribution

to prenatal outcomes

One such test is the urine assessment for glucose, protein, and nitrite ateach visit These were initiated to screen for gestational diabetes, pre-eclampsia, and asymptomatic urinary tract infections Because most patientsare screened for gestational diabetes by risk factors or the 1-hour 50-gmglucose challenge [25], the finding of glucosuria rarely adds any accurateinformation Most positive tests are false-positives because of a large glu-cose intake before visit and are not indicative of diabetes If the initial urineanalysis is negative it is unlikely that the patient will develop significantrenal disease during the pregnancy, except for hypertensive-related pathol-ogy The blood pressure is the best screen for new onset renal disease orthe development of pregnancy-related hypertensive disorder[25] If hyper-tension develops, then an assessment of proteinuria with protein/creatinine

ratio or a timed urine collection for protein is more accurate[39] After theinitial screen for asymptomatic bacteruria at the initial visit, patients onlyneed to be screened for urinary tract infections if they are symptomatic or

in a high-risk group, such as preterm labor, twins, gestational diabetes,

Table 1

Comparing traditional and modified scheduling of prenatal care visits for nulliparous women

Nulliparous

Traditional prenatal care Modified prenatal care

Visit time Testing Visit time Testing

NOB ideally

8–10 weeks prior

Routine NOB labs, offer first trimester screening

NOB at 10–12 wks

Routine NOB labs, offer first trimester screening

if to be done

at 20 wks

18 wks MMS, order

dating/anatomy ultrasound if

to be done at

20 wks

20 wks Ultrasound

for anatomy and visit

28 wks Diabetes screen

and Rhogam workup and administration

28 wks Diabetes screen,

Rhogam workup and administration

36 wks GBS screening,

discuss contraceptive choice, fetal position

known renal disease, or sickle cell disease/trait[25,40–43] Fewer than 2% ofpatients without bacteriuria at the initial screen will develop a symptomaticurinary tract infection.

Ultrasounds have become a standard of care, despite studies showing thatthe routine use of ultrasounds do not significantly improve obstetric outcome

An ultrasound in the first trimester is optimal for dating but an ultrasoundscan in mid-second trimester is best for anatomy It is possible to have a singlescan around 20 weeks and confirm dating while getting a good anatomic sur-vey Unless the patient opts for terminating the pregnancy in the case of lethal

or potentially lethal anomalies, there is little cost benefit to society for patients

to have a ‘‘routine’’ ultrasound screening If there is no particular reason for

an earlier scan (ie, rule out an ectopic pregnancy or first trimester screening),the first scan can be delayed to the second trimester[25,35,44] Having said

Table 2

Comparing traditional and modified scheduling of prenatal care visits for parous women

Parous

Traditional prenatal care Modified prenatal care

Visit time Testing Visit time Testing

NOB Ideally prior

to 8–10

weeks

Routine NOB labs, offer first trimester screening

At 10–12 wks Routine NOB labs,

offer first trimester screening.

16 wks MMS, order

dating/anatomy ultrasound if

discuss contraception if considering PPTL

28 Diabetes screen,

Rhogam workup and administration; discuss contraception

39 wks May sweep membranes 39 wks May sweep membranes

41 wks Consider induction 41 wks Consider induction

Total number

of visits

Abbreviation: PPTL, postpartum tubal ligation.

Data from Refs [2,31–35]

that, from an evidence based view, patients expect one or two ultrasoundsduring the pregnancy and see it as a bonding experience and an opportunity

to get their first ‘‘baby’’ pictures Some independent commercial endeavorshave started to provide this type of nonmedical ultrasound, complete with

a picture album ACOG actively discourages this type of ultrasound, statingthe concern that it provides a false sense of reassurance and often little reliablemedical information

Patient education

Patient educational issues are discussed in more depth in a subsequentarticles in this issue of the Clinics, but basic issues should be addressed early

in care and re-enforced as indicated There are safety issues, such as the use

of seat belts, minimal use of hot tubs (less than 10 minutes) or saunas (lessthan 15 minutes)[21]; use of medications, immunizations[45,46], avoidance

of substances, and domestic violence; comfort issues (back pain, symphysealpain[47], varicose veins, hemorrhoids, heartburn, dental care[48]and roundligament); and activity issues revolving around work and leisure that need to

be discussed early during care Toward the end of the pregnancy, issues ofbreast feeding, family planning desires [49], circumcision, umbilical cordblood banking, circumcision, and childcare need to be raised Womenwho report receiving sufficient health behavior advice as part of their prena-tal care are at lower risk of delivering a low birth-weight infant[50].Back pain is a common complaint during pregnancy, As the lordosisincreases in the second and third trimester, so does the occurrence of backpain The presence of obesity or a history of back problems increases theincidence The patient needs to be taught better back mechanics and liftingtechniques Although most times the patient can be reassured, if there areneurologic deficits found on examination, a referral to a neurosurgeonmay be indicated [38] Otherwise, conservative measures of heat, goodbody mechanics, pain medication, and potentially a muscle relaxant willprovide some relief

Leisure time physical activity is associated with a reduced risk of term delivery [51] (see the article by Rayburn and Phelan in this issue).There continues to be discussion regarding the role of work and poor ob-stetric outcomes Some data support that very physical activity jobs mayincrease the risk of poor outcomes, and yet very physical exercise is as-sociated with a better outcome The provider needs to know what type

pre-of work-related activities and exposures that the patient has and counselaccordingly

Heartburn and indigestion are common complaints, especially in the firsttrimester and again in the third trimester During the first trimester, much ofthe indigestion is associate with the common nausea and vomiting of preg-nancy (see the article by Goodwin in this issue) The complaints in thethird trimester are commonly because of the pressure of the enlarging uterus

in combination with the muscular relaxation of the intestinal tract Theseconcerns can often be handled with dietary changes and antacids, but onecan use proton pump inhibitors if necessary.

[3] Baldwin LM, Larson EH, Connell FA, et al The effect of expanding Medicaid prenatal services on birth outcome Am J Public Health 1998;88:1623–9.

[4] Huntington J, Connell FA Sounding board: for every dollar spentdthe cost-saving ment for prenatal care N Engl J Med 1994;331:1303–7.

argu-[5] Poland ML, Ager JW, Olson KL, et al Quality of prenatal care; selected social, behavioral, and biomedical factors, and birth weight Obstet Gynecol 1990;75:607–12.

[6] Vintzileos AM, Ananth CV, Smulian JC, et al The impact of prenatal care in the United States on preterm birth in the presence and absence of antenatal high-risk conditions.

Am J Obstet Gynecol 2002;187:1254–7.

[7] Vintzileos AM, Ananth CV, Smulian JC, et al The impact of prenatal care on postneonatal deaths in the presence and absence of antenatal high-risk conditions Am J Obstet Gynecol 2002;187:1258–62.

[8] Fink A, Yano EM, Goya D Prenatal programs: what the literature reveals Obstet Gynecol 1992;80:867–72.

[9] Fiscella K Does prenatal care improve birth outcomes? A critical review Obstet Gynecol 1995;85:468–79.

[10] Alexander GR, Cornely DA Prenatal care utilization: its measurement and relationship to pregnancy outcome Am J Prev Med 1987;3:243–53.

[11] Braveman P, Marchi K, Egerter S, et al Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors Obstet Gynecol 2000;95:874–80 [12] Gazmaragiran JA, Arrington TL, Bailey CM, et al Prenatal care for low-income women enrolled in managed-care organization Obstet Gynecol 1999;94:177–84.

[13] Hellerstedt WL, Pirie PL, Lando HA, et al Difference in preconceptional and prenatal behaviors in women with intended and unintended pregnancies Am J Public Health 1998; 88:663–6.

[14] Blankson ML, Goldenberg RL, Keith B Noncomplaince of high-risk pregnant women in keeping appointments at an obstetric complication clinic South Med J 1994;87:634–8 [15] Kost K, Landry DJ, Darroch JE Predicting maternal behaviors during pregnancy: does intention status matter? Fam Plann Perspect 1998;30:79–88.

[16] Hellerstedt WL, Pirie PL, Lando HA, et al Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies Am J Public Health 1998; 88:663–6.

[17] Augustyn M, Maiman LA Psychological and sociological barriers to prenatal care Women’s Health Issues 1994;4:20–8.

[18] Misra DP, Guyer B Benefits and limitations of prenatal care from counting visits to ing content JAMA 1998;279:1661–2.

measur-[19] Kogan MD, Martin JA, Alexander GR, et al The changing pattern of prenatal care utilization

in the United States, 1981–1995, using different prenatal care indices JAMA 1998;279:1623–8 [20] Meng Z, Goldenberg RL, Cliver SP, et al The relationship between maternal hematocrit and pregnancy outcome Obstet Gynecol 1991;77:190.

[21] Lockwood CJ, Lemons JA, editors Guidelines for perinatal care 6th edition Washington, DC: American Academy of Pediatrics and American College of Obstetricians and Gynecol- ogist; 2007.

[22] Nguyen TH, Larsen T, Engholm G, et al Increased adverse pregnancy outcomes with able last menstruation Obstet Gynecol 2000;95:867–73.

unreli-[23] Mittendorf R, Williams MA, Berkey CS, et al The length of uncomplicated human tion Obstet Gynecol 1990;75:929–32.

gesta-[24] ACOG Practice Bulletin Number 9 Antepartum fetal surveillance Washington, DC: ican College of Obstetricians and Gynecologists; 1999.

Amer-[25] Wildschut HIJ, Weiner CP, Peters TJ When to screen in obstetrics and gynecology 2nd edition Philadelphia: Saunders Elsevier; 2006.

[26] Yogev Y, Langer O, Xenakis EM, et al Glucose screening in Mexican-American women Obstet Gynecol 2004;103:1241–5.

[27] Hickey CA, Cliver SP, Goldenberg RL Prenatal weight gain, term birth weight and fetal growth retardation among high-risk multiparous Black and White women Obstet Gynecol 1993;81:529–35.

[28] Mongelli M, Gardosi J Symphysis-fundus height and pregnancy characteristics in sound-dated pregnancies Obstet Gynecol 1999;94:591–4.

ultra-[29] Jelks A, Cifentes R, Ross MG Clinician bias in fundal height measurement Obstet Gynecol 2007;110:892–9.

[30] Witkops CT, Zhang J, Sun W, et al Natural history of fetal position during pregnancy and risk of nonvertex delivery Obstet Gynecol 2008;111:875–80.

[31] Scope of service for uncomplicated obstetric care Appendix G In: Lockwood CL, Lemons JA, editors Guidelines for perinatal care 6th edition Washington, DC: American Academy of Pediatrics and The American College of Obstetricians and Gynecologists; 2007 [32] Antenatal care: routine care for the healthy pregnant woman Clinical Guideline October

2003 RCOG Press, 27 Sussex Pl Regent’s Park, London NW1 4RG.

[33] Binstock MA, Wolde-Tsadik G Alternative prenatal care: impact of reduced visit frequency, focused visits and continuity of care J Reprod Med 1995;40:507–12.

[34] McDuffie RS, Beck A, Bischoff K, et al Effect of frequency of prenatal care visits on tal outcome among low-risk women JAMA 1996;275:847–51.

perina-[35] Budenholzer BR Efficient prenatal care: fewer visits, fewer sonograms Eff Clin Pract 1999;2: 145–8.

[36] Sikorski J, Wilson J, Clements S, et al A randomized controlled trial comparing two ules of antenatal visits: the antenatal care project BMJ 1996;312:546–53.

sched-[37] McDuffie RS, Bischoff KJ, Beck A, et al Does reducing the number of prenatal office visits for low-risk women result in increased use of other medical services? Obstet Gynecol 1997;90: 68–70.

[38] Gabbe SG, Niebyl JR, Simpson JL Obstetrics: normal and problem pregnancies 4th edition Philadelphia: Churchill Livingstone; 2002.

[39] Waugh JJ, Clark TJ, Khan KS, et al Accuracy of urinalysis dipstick techniques in predicting significant proteinuria in pregnancy Obstet Gynecol 2004;103:769–77.

[40] Murray N, Homer CS, Davis GK, et al The clinical utility of routine urinalysis in pregnancy:

a prospective study Med J Aust 2002;177:477–80.

[41] Rhode MA, Shapiro H, Jones OW Indicated vs routine prenatal urine chemical reagent strip testing J Reprod Med 2007;52:214–9.

[42] Bachman JW, Heise RH, Nassems JM, et al A study of various tests to detect asymptomatic urinary tract infections in an obstetric population JAMA 1993;270:1971–4.

[43] Sheffield JS, Cunningham FG Urinary tract infection in women Obstet Gynecol 2005;106: 1085–92.

[44] Committee on Practice Bulletins d OB Ultrasonography in Pregnancy Practice bulletind clinical management guideline for obstetricians and gynecologists #58 Washington DC: American College of Obstetricians and Gynecologists 2004.

[45] Committee on Obstetric Practice Committee opinion #282 immunization during pregnancy Washington DC: American College of Obstetricians and Gynecologist 2003.

[46] Ingardia CJ, Kelley L, Steinfeld JD, et al Hepatitis B vaccination in pregnancy: factors encing efficacy Obstet Gynecol 1999;93:983–6.

influ-[47] Snow RE, Neubert AG Peripartum pubic symphysis separation: a case series and review of the literature Obstet Gynecol Surv 1997;57:438–43.

[48] Boggess KA Maternal oral health in pregnancy Obstet Gynecol 2008;111:976–86 [49] Klerman LV, Phelan ST, Poole VL, et al Family planning: an essential component of pre- natal care J Am Med Womens Assoc 1995;50:147–51.

[50] Kogan MD, Alexander GR, Kotelchuck M, et al Relation of the content of prenatal care to the risk of low birth weight JAMA 1994;271:1340–5.

[51] Hegaard HK, Hedegaard M, Damm P, et al Leisure time physical activity is associated with

a reduced risk of preterm delivery Am J Obstet Gynecol 2008;198:180, e1–5.

The Prenatal Medical Record: Purpose, Organization and the Debate of Print

Versus Electronic Sharon T Phelan, MD, FACOGUniversity 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 the prenatal record

The primary objective of the prenatal record is to have a standardizedway to systematically record the large amount of information that needs

to be obtained during a pregnancy In the late 1800s and early 1900s, textbooks recommended simple note cards for the obstetric provider to keeptrack of their patients Even in the 1980s information from each prenatalvisit was often recorded in a series of progress notes with crypticabbreviations, incomplete data, and inability to readily trend any data,such as blood pressure or fundal growth Today the record serves multipleroles, and for that reason must be more structured

Clinical care

Clinical care is the primary reason for the current obstetric record Itserves as a prompter for the provider to solicit a complete history for riskassessment, record a baseline physical and subsequent data in a formatthat allows it to be monitored for worrisome trends The scope andtiming of laboratory testing can be hard to manage A good prenatalform can prompt ordering tests and reviewing the results in a timely fashion.Interventions and patient education can be readily documented This is theprimary focus of this article

Communication

A good prenatal record is the major way of communication with otherproviders, both within the practice and at the hospital when they must

E-mail address: stphelan@salud.unm.edu

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35 (2008) 355–368

assume care of the patient A systematic way to record information allows

a new provider to readily identify problems and concerns for a patient.Commonly, the prenatal form and flow sheet are sent to the labor anddelivery unit around 34 to 36 weeks, so it is available when the patient pres-ents in labor A good record system that addresses effectively the provision

of good clinical care will automatically accomplish the task of facilitatingcommunication between providers

Billing and reimbursement

A well-designed prenatal record makes it easy for the provider to atically record the information from a visit to allow appropriate billing Theuse of grids and lists with checks and comment sections helps to prompt theprovider to not forget to note key components of the care Accurate andcomplete documentation of patient complications and of services provided

system-is essential for full reimbursement, especially if the care provided system-is side the scope of the global fee By providing appropriate prompts forrecording the results of commonly asked questions, such as preterm laborsymptoms, the record allows not only for better care but also for moreclarity in billing documentation

out-Quality indicators

There are certain quality indicators in the provision of prenatal care

A good record prompts the performance and completion of these qualityindicators In turn, compliance with these indicators can be readily moni-tored So a record system that reminds the provider to ask about geneticbackground, prior obstetric complications, or to do a screening test,improves the provider meeting and documenting quality indicators, which

in turn provides better clinical care

Medical liability

By having a record that encourages complete documentation of a hensive prenatal care, more support is available regarding the quality of careprovided and potential risk factors or behaviors that the patient contributed

compre-to the pregnancy outcome The record should show that risk faccompre-tors andcomplications were properly identified and that the pregnancy was managed

in an appropriate fashion[1]

To be useful, a prenatal record must be systematic, well organized foreasy retrieval of information, and sufficiently detailed The quality of therecord depends on accurate recording of the data The record must be sim-ple but complete, directive but flexible, legible and able to display the nec-essary information readily The ability to record care in a simple fashionhelps with compliance and conformity of documentation The incorporation

of risk assessment tools allows triaging of the patient regarding the most

appropriate care provider: certified nurse midwife, physician, or maternalfetal medicine specialist[2] The use of check boxes and flow-charts aid intracking trends and more complete documentation In fact, the obstetricprenatal record is probably the best developed charting system available

in medical practice

If one reflects on the prenatal medical record form as if it was a blueprintfor building a home, then one can see how the data from the initial visit islike laying the foundation The risk assessment and baseline laboratory islike the framing of the structure The remainder of the visits gradually

‘‘frame in the walls’’ and add dimension and character to the house, whilereferring 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 exami-nation and laboratory testing, and provides room for additional records andserial examinations to be recorded in a fashion to allow trending Finally,screening tools for behavioral assessments and educational documentationhave become a must.Boxes 1–10list the key portions of the prenatal med-ical record[3]

Many areas may benefit by a description of the care given or the issuesassessed For example, a listing on the record for the symptoms queriedwhen deciding if there is possible preterm labor, allows one to simply check

no or, if yes, note the symptoms present For the physical examination,define what is covered when an item is checked within normal limits andhave room to expand when there is an abnormality or additional assessmentwas done Supplemental visits need to allow documentation in a format thatallows ready trending of data points, especially fundal size, blood pressure,and weight The template should be comprehensive enough to allow com-prehensive documentation with minimal effort for routine care, but flexible

to have room for additional notations and progress notes

Box 1 Demographic information

Location of prenatal care: name of clinic or practice

Birth date

Patient’s level of education

Contact information: address, phone numbers, emergency

Finally, there needs to be a dedicated area on the record for a problem orconcern list that allows an ongoing current listing of obstetric issues Forexample, at the initial visit there may be a fundal height-dating discrepancythat would be on the problem list This would likely be resolved by an ultra-sound and the problem could be ‘‘retired,’’ with a notation that dating is es-tablished by ultrasound or by the last menstrual period (LMP), which wasconfirmed by an ultrasound done at what gestational age The problem listshould include important issues for antenatal care (ie, repeat chlamydiascreening at 36 weeks) or intrapartum care (needs antibiotics in labor because

of a GBS plus urinary tract infection) This helps to avoid any ‘‘dropped balls’’when a partner is covering for you during the patient’s prenatal course.Some institutions may require more details regarding educational activi-ties, including who was taught (just patient or patient and family members),method used, any identified barriers to learning, outcome of education, andany referrals made based on educational activities If such documentation isrequired, a dedicated ‘‘page’’ to education in a grid template may help withdocumentation of compliance (Fig 1)

Box 3 Menstrual history

First day of last normal menstrual period and certainty of the dateLast use of hormonal contraception or cessation of breast

feeding

Frequency of menses

Menarche

Box 4 Medical history of patient, her family, and the father

of the pregnancy

Neurologic/Epilepsy

Thyroid disorder

Cardiovascular or hypertensive diseases

Pulmonary problems, asthma, tuberculosis

Kidney diseases

Autoimmune disorders

Clotting/thrombophilia disorders

Psychiatric disorders including postpartum depression

Liver disease, hepatitis

Recent infectious disease or exposure

Box 5 Genetic or teratology screening and counseling

Mother’s and father of baby’s ethnic and racial backgroundFamily history of congenital anomalies, such as neural tubedefects and congenital heart defects

Maternal and paternal ages

Genetic disorders, such as Down’s, Tay-sachs, thalassemia,sickle cell, canavan disease, familial dysautonomia, cysticfibrosis, Huntington chorea

Mental retardation, autism or Fragile X

Maternal metabolic disorders: Type 1 diabetes, phenylketonuriaHistory of recurrent miscarriages or stillbirth or neonatal demise.Exposure to medications or drugs since conception

and Gynecologists should be used as a standard for all other charting tems[4] Prenatal records have traditionally been available only in print ver-sions Because of the cost and unique issues within a practice or areas, someinstitutions or groups have developed their own version of a prenatal record.Although this approach can address the local specific needs or preferences of

sys-a group, there is sys-a significsys-ant downside to prsys-actice- sys-and institution-specificforms These typically are not reviewed and revised on a regular basis andwill become dated or less effective in trending or monitoring quality indica-tors and new testing recommendations To help avoid this problem with be-coming outdated, the form should have printed on it the last date ofrevision This will prompt review of the charting templates every 2 to 3 years

at a minimum Another significant limitation to a print version of the natal record is that only one person at a time can use a paper chart Giventhe large number of roles a prenatal record addresses (billing, quality assur-ance, and so forth) the chart may not be available for clinical care when

pre-a ppre-atient comes to be seen

Box 6 Screening tools for behavioral issues

Smoking during pregnancy and exposure to second-hand smokeAlcohol use during pregnancy

Use of illicit drugs during pregnancy

Intimate violence

Prenatal and postpartum depression

Box 7 Initial physical examination (for the uncomplicated

pregnancy with more comprehensive examination as indicated

by patient history)

Vital signs, including blood pressure, height, and weight;

calculated body mass index

General HEENT (head, eye, ear, nose, and throat) and neurologicexamination

Box 8 Laboratory and ultrasound testing

Hepatitis B surface antibody

HIV counseling and testing

Optional baseline labs as indicated by history, community

prevalence or state regulation

Screening for diabetes

Tuberculin skin testing

Chlamydia and gonorrhea screening

Pap smear

Hemoglobin electrophoresis

Assessment before 22 weeks

Genetic screening as indicated: Tay-sachs, cystic fibrosis,

and others

First trimester screening

Multiple marker screening

Group B Streptococcus (GBS) screen

Sexually transmitted disease screen as indicated by prior testing

With paper records, there needs to be a system to have the informationavailable at the hospital when the patient presents in labor or with otherconcerns When to send a copy of the record to labor and delivery is chal-lenging If one waits until the last testing (typically the GBS screen), it is notavailable until 36 to 38 weeks, resulting in an increasing risk of not havingrecords available when the patient presents If the records are sent sooner,late trimester information, such as blood pressure, weight, and late testing

is not available Many groups with paper charts send a copy of the pleted new obstetric assessment once initial laboratory data is in, andthen a copy of the antenatal care flowchart around 34 to 36 weeks Othergroups have the patient carry a ‘‘shadow’’ chart, with instructions thatshe brings it to labor and delivery

com-Electronic medical records

There is an increasing push for conversion to electronic medical records

at a national level across all specialties There are a number of advantages tothis transition, including legibility, prompts for testing, ability to graphtrends (Fig 2), have ‘‘pop-up’’ windows for additional documentation forabnormalities (Fig 3), and the ability for multiple individuals to have access

to the same record at the same time Many electronic records are Webaccessible This allows access from home for documentation when fieldingpatient queries while on call, or from the hospital when the patient presentswith complaints to the labor and delivery unit, irrespective of gestational age

or time of day In a fully integrated computerized perinatal medical recordsystem, the information from prenatal care is pulled into the intrapartumforms, providing a fairly seamless flow of information This latter situation

is currently really only available in larger groups, such as HMOs, academicinstitutions, or some government institutions

Box 9 Documentation of ongoing care: documentation at eachsubsequent visit

Gestational age and fundal height

Blood pressure

Weight

Fetal heart tones

Pain scale (JACHO requirement)

Preterm labor signs and symptoms

Cervical examination if done

Fetal presentation during last couple of months

Provider at this visit

When is next visit and any prompters for testing or follow-up

Box 10 Patient education

Initial visit

First trimester danger signs

Nutritional guidelines, avoidance of certain foods (mercury incertain fish) and optimal weight gain

Vitamin and iron supplements

Motor vehicle safety stressing proper seat belt use

Activities, exercise, and work management

Use of cigarettes, alcohol, illicit drugs, medications

Sexual activities

Dental care

Vaccinations during pregnancy: influenza, hepatitis B if testsnegative, and possibly HPV vaccine if appropriate candidate.Laboratory and screening tests

Counseling regarding genetic screening options

Routine schedule of visits and testing

Occurrence of intimate violence during pregnancy

Antepartum education from 20 to 28 weeks

Childbirth education classes

Hospital preregistration

Rhogam information if appropriate

Management of normal discomforts of an advancing pregnancyTravel precautions

Warning signs in the third trimester, including preterm laborsymptoms

Contraceptive plans, with signature of federal tubal ligationconsent if appropriate

Education 32 to 36 weeks

Fetal kick/movement counts

Labor precautions

Managing normal discomforts of advanced pregnancy

Newborn issues of feeding choice, car seat, and pediatricianchoice

Circumcision desires

Postpartum adjustments and stress management

Postpartum follow-up

Fig 1 A comprehensive template for documentation of patient education if the system requires more in-depth assessment of adult learning objectives.

Fig 2 The ability to graph certain data allows demonstration of developing complications Demonstrated is the late term development of polyhydramnios from duodenal atresia Graph represents weeks gestation and fundal height (in centimeters).

The features to consider when looking at whether on not to convert to anelectronic record system include:

Accessiblity from locations other than the office (ie, hospital, home): inother words, is the record available 24/7 365 days of the year no matterwhere you are?

Do laboratory results automatically populate into the system or do theyneed to be specifically entered (an opportunity for error)?

How is point-of-care entry done: on a PC, tablet, handheld, by physician,

RN, or clerical staff?

Is there a patient portal, where she can have access to do initial history orrequest a refill or download educational materials, via the Web?Does the software package have a billing component?

Is it a comprehensive ob-gyn care system with templates for other cologic care, or is it just for obstetric care?

gyne-Will the data from a pregnancy pull forward to populate the appropriatefields in a subsequent pregnancy, so one does not have to re-enter allthe family, medical, obstetric, and surgical history again? Ideally, itjust needs to be verified and potentially updated

Fig 3 Example of an electronic medical record system that allows documentation of normal examination findings (with a definition of normal), or area not assessed or, in this case, further documentation indicated for a cardiovascular examination.

What are the start up costs, service contracts, support, warranty, andupgrades?

Does it directly interface with hospital systems, such that office tion populates hospital records, and hospital records can in turn pop-ulate the practice records? This is nice for patients with numerous visits

informa-to the hospital before delivery or for postpartum care

What type of printouts are generated? If a patient transfers out of thepractice, can it readily print out the complete prenatal record for thepatient to take to her next provider?

Can you import photos to the patient’s chart, such as ultrasound photos,picture of the patient, newborn, or colposcopy?

How easily can the screen views be modified to reflect the practice style ofthe provider?

Can it handle phone messages, place an order for laboratory testing, orsend a prescription to a pharmacy? In other words, how does it handlethe mechanics of a busy clinical practice?

Does it support or is it compatible with the newer voice recognition ware programs for dictation?

soft-These are just a few considerations with the obstetric documentation with

an electronic record Have statements such as ‘‘preterm labor symptoms’’ or

‘‘pre-eclampsia symptoms’’ with a listing of the query of specific symptoms

If one clicks ‘‘no,’’ a patient does not have the constellation of concerns,then the provider has affirmed that those four to five questions were asked

If the provider clicks yes, another screen or pop-up box allows tion of further information about the symptoms (Fig 4) Have a similar sys-tem with the initial comprehensive physical examination Under each organsystem, list what portions of an examination were done if the notation iswithin normal limits Have each organ or discrete component of the exam-ination with three choices: not done (this would be the default checked box),

documenta-Fig 4 A prompt for preterm labor signs and symptoms, with list of complaints following.

A ‘‘no response’’ means that the following possible complaints were all negative.

within normal limits, or need to document When the latter is clicked, a ment box or a supplemental check-sheet opens, readily allowing further de-tails Having each section default to ‘‘not done’’ rather than ‘‘within normallimits,’’ forces the active documentation of the components done, which is

com-a more powerful demonstrcom-ation of ccom-are for both billing com-and licom-ability(seeFig 3)

The ability to automatically calculate gestational age at a given visit andpopulate that box on the supplemental visit flow sheet is nice However, thisneeds to be calculated off the final determination of estimated date of con-finement made by the provider after considering the LMP, physical exami-nation, and potentially the ultrasound Once this is established, the programshould not recalculate it based on the latest ultrasound or clinicalexamination

Once a practice decides to implement an electronic record, do NOTunderestimate the time for training at all levels Older providers and staffmay be very intimidated by the computers; in addition, some programsare not intuitively obvious in how they work and become frustrating touse Too many ‘‘bells and whistles’’ can make a program too complicatedand it may run slower on some systems Have the vendor or the institutional

IT person in the clinic for a number of days to work one-on-one with staff,and then have them return to the clinic setting periodically for assistance.Make sure you have a ‘‘hot line’’ to IT and ideally, at least one member

of the practice who is knowledgeable and understands the system wellenough to serve as a champion of the program in the office Do not expect

an electronic record to save the practitioner time In most cases, it is at besttime-neutral It will primarily save time and frustration because of fewer lostcharts, more legible records, and smoother communication with other keygroups (hospital, billing, partners, and other departments)

Another problem at this time with electronic medical records is that there

is not a universally accepted program language that all electronic recordsuse This is like the competition between Beta and VHS systems, with video-taping or cassette versus 8-track with recording At the time of that compe-tition, if one made the wrong decision, the entire library of tapes becameobsolete This could be extremely problematic with medical records, espe-cially when the statute of limitations can be up to 20 years or more Besure that the vendor is prepared to help you keep current with nationaldevelopments

The hardware demands can be extensive, depending on the practice working with a high-speed but secure system is critical A computer in eachconsultation and provider office is minimal, with a computer terminal ineach examination room ideal or the ability to use a tablet or hand-heldunit for data entry and collection The room saved, regarding old papercharts, will be used by the server and backup drives Security with both localbackups daily and remote backup daily or weekly is necessary in case

Net-of a physical disaster at the office site For example, the Veteran’s

Administration lost none of the New Orleans patient records, despite ricane Katrina, because the records were backed up at a remote location.The more features in the software, the greater the demands on the com-puters being used, and hence the greater the risk of network problems orsystem difficulties In other words, know what you want, how you plan touse the electronic record, and what the hospital can and will support, andmake the decision from those perspectives Listen to all the features andsee if they can be added later (once the practice has a better understanding

Hur-of what they want and after other groups may have debugged the sHur-oftware).One only has to think of some of the ‘‘latest and greatest’’ software plat-forms that have been pushed and then flopped to realize that being on thecutting edge of computers is not always the best place to find oneself

In summary, the obstetric prenatal record is one of the best most nized medical record systems currently used in the United States This hasallowed a standardization of care and documentation that has benefitedpregnant women over the past two decades The transition to an electronicrecord must maintain these advances and, hopefully, strengthen them withthe use of electronic prompts, seamless transfer of information, and univer-sal accessibility to the records, regardless of the location of care

Washing-Nutrition During Pregnancy

Jean T Cox, MS, RD, LN * ,

Sharon T Phelan, MD, FACOGDepartment of Obstetrics & Gynecology, University of New Mexico,

MSC 10 5510, 1 University of New Mexico, Albuquerque, NM 87131, USA

Nutritional issues in pregnancy have gained greater importance in routineprenatal care as obesity issues, low birth weight (LBW) concerns, and neuraltube defect (NTD) prevention strategies have moved into the forefront ofprevention measures A discussion of nutritional considerations in preg-nancy can be organized as weight gain, specific nutrients, and special patientgroups relative to dietary concerns

Prenatal weight gain issues

Pregnancy weight gain goals were set by the Institute of Medicine (IOM)

in 1990[1] The goal at the time was to optimize pregnancy outcome (ie, term delivery of a healthy baby weighing 3 to 4 kg) An attempt was made tobalance the needs of mother and baby, but ‘‘at that time, there was insuffi-cient data available to conclude whether the higher gestational weight gainswould result in increased maternal body weight or influence the risk ofbecoming overweight’’[2]

full-Weight gain goals are based on the mother’s prepregnant body massindex (BMI) and are summarized in Table 1 Prepregnant weight is heractual weight just before this pregnancy or at the first prenatal visit, if it

is early If care is late and no reliable estimate of prior weight exists, oneshould assume she has gained appropriately and go from there Under-weight women overestimate their prepregnant weight, but overweightwomen underreport their weight, especially if they have less than a highschool education[1,3] The discrepancy is worse as the degree of overweightincreases[3] Height also needs to be measured, not asked People tend to

* Corresponding author.

E-mail address: jcox@salud.unm.edu (J.T Cox).

0889-8545/08/$ - see front matter Ó 2008 Elsevier Inc All rights reserved.

35 (2008) 369–383

overestimate height, especially if they have little formal education [1]or ifthey are short or overweight[3].

Both LBW and very low birth weight (VLBW) rates are higher forwomen whose prepregnant weight is outside the normal category [4], andthey are made worse if gestational weight gain is inadequate Prepregnantunderweight is associated with a higher risk for preterm delivery and for

a small for gestational age (SGA) baby [5] Prepregnant obesity providesparticular concerns[6–8] Obesity rates in the United States are rising and

it is estimated that one third of adult women are now obese, with rateshigher among non-Hispanic black women and Mexican American women.The prevalence of women in the United States weighing at least 250 pounds

at entry to prenatal care rose from 2% in 1980 to more than 10% in 1999and those at least 300 pounds rose to more than 4%[9]

Polycystic Ovary Syndrome prevalence and miscarriage rates are higheramong obese women [6,7,9] Fetal anomalies occur more often, evencontrolling for diabetes, and NTD rates are double those of babies ofnormal-weight mothers, independent of folic acid supplementation [6,10].Macrosomia and SGA babies are common among obese women[10] Risksincrease[6,7,9]during pregnancy (higher rates of gestational diabetes, gesta-tional hypertension, and deep vein thrombosis, and more difficulty withmonitoring fetal growth), delivery (higher rates of cesareans, complications,stillbirths), and post partum (hemorrhage, wound infections, depression,lactation dysfunction), and their use of health care is higher, especially forthose who have a BMI of at least 35[11] Even appropriate for gestationalage (AGA) infants of obese mothers are at increased risk for obesity as chil-dren, independent of maternal weight gain[12]

Prepregnant weight predicts the likely gestational weight gain Weightgain within the IOM recommendations is associated with the best outcomesfor the mother and baby [5] However, only 30% to 40% of pregnantwomen stay within the recommended ranges Although overweight women

Table 1

Institute of Medicine prenatal weight gain goals

Body mass index Total weight gain (lb) Total weight gain (kg)

Data from Institute of Medicine, Subcommittee on Nutritional Status and Weight Gain During Pregnancy Nutrition during pregnancy: part I, weight gain, part II, nutrient supple- ments Food and nutrition Board, Institute of Medicine, National Academy of Sciences, National Academy Press, Washington, DC, 1990.

tend to gain more than the recommendations, underweight women tend togain less than the guidelines, consistent with their targeted weight gains[13].Insufficient weight gain is associated with an increased risk for delivering

a growth-restricted baby[1], with higher rates of perinatal morbidity andmortality[14] The effect of insufficient weight gain on birth weight is stron-gest in underweight women [15] and it may be less, or not, important inoverweight or obese women However, the mother would need to concen-trate on high-nutrient but low-calorie foods to protect fetal growth anddevelopment

Excessive weight gain is also of concern High weight gain is associatedwith macrosomia and large for gestational age (LGA) babies[5,6,8], withhigher risk for cesarean delivery Other complications include higher riskfor assisted ventilation, neonatal infections, hypoglycemia, respiratory dis-tress, neonatal intensive care unit admission, and longer hospital stays

[14] Excessive weight gain during pregnancy, independent of prepregnantweight, has been shown to be associated with a higher chance of failing toinitiate breastfeeding successfully and also a higher risk for early termina-tion of breastfeeding[16] For obese women, the effects of high prepregnantweight and excessive weight gain in pregnancy were additive

Considerable research has been done recently regarding the long-termconsequences of fetal nutrition Under- and overnutrition during gestationmay be problematic regarding health risks, even if birth weight is appropri-ate[17], and epigenetic mechanisms are now being investigated[18] Much

of the work has concentrated on the development of the ‘‘thrifty type,’’ (ie, an infant deprived in utero and then exposed to nutritional abun-dance is more vulnerable to obesity)[15,17] Babies born LBW, with higherbody weight later, have a higher risk for developing metabolic syndrome,type 2 diabetes, and cardiovascular disease [8,19] Early malnutrition inutero appears to enhance fetal fat deposition, whereas late restriction mayaffect fetal leptin sensitivity [20] LGA babies have an increased risk forchildhood obesity [6], which also may lead to higher rates of metabolicsyndrome as adults, including obesity, insulin resistance, diabetes, and hy-pertension [7,10] This area of research is active and prospective studiesare now being done[21,22] It may be that birth weight alone as an outcomemeasure may underestimate the effect of maternal nutrition on the baby’slong-term health[19]

pheno-Inappropriate weight gain may also cause long-term consequences for themother because excess weight gain increases the risk for postpartum weightretention, leading to higher rates of obesity[2] The IOM says mothers tend

to retain 1 kg for each delivery[1] However, gestational weight gains haveincreased from an average of 10 kg (22 pounds) in the 1960s to 15 kg(33 pounds) in the late 1980s[2]and obesity rates in the United States areincreasing[6–9,23]

The mother is most likely to keep extra postpartum weight if she gainstoo much during pregnancy [2,7] Those women who are most likely to

gain extra and also keep it later include overweight and obese women,minorities, those who have high gains before 20 weeks [24], and thosewith a short interconceptual period [2] Lactation has potential to helpwith postpartum weight loss, but most mothers in the United States donot breastfeed long enough or intensely enough for it to be a major factor.For some researchers, the issue is not the gestational weight gain, but theamount lost soon after delivery that predicts long-term risk Two studieshave shown increased long-term risk for obesity-related illnesses if themother had not lost the excess weight gain within a year of delivery

[8,23] Weight loss may vary by ethnicity [25] In a study of low-incomewomen, all lost weight from birth to 6 weeks, but the white women contin-ued to lose (6 weeks to 12 months), whereas the African American womenplateaued and Mexican American women gained slightly

The IOM guidelines may need to be modified One concern has been that,

by raising the upper limits of weight gain, we may cause more LGA babies,more cesarean sections, and more obese mothers[5] A study[26]has foundthat adequate weight gain in pregnancy, not just excessive weight gain, in-creased the chances that the child would be overweight at age 3, independent

of parental BMI, maternal glucose tolerance, and breastfeeding duration.The IOM report had encouraged African American women to gain weight

at the top of the recommendations to overcome the higher risk for LBW ever, these women have been shown to retain more postpartum weight thanwhite women, even when gaining within the recommendations[5], and excessweight retention is worse if mothers gain more than the recommended levels.The 1990 guidelines [1] acknowledged that weight gain and birth out-comes were least correlated for the obese mothers, suggesting individualizedweight gain targets and encouraging sufficient essential nutrients New birthcertificate data [27]finds that if obese mothers (class I, II, and III) gainedless than 15 pounds, the rates of pre-eclampsia, cesarean deliveries, andLGA babies all decreased, but the rates of SGA babies increased Theyobserved minimum risk when class I mothers gained 10 to 25 pounds, class

How-II mothers gained 0 to 9 pounds, and class How-III mothers lost 0 to 9 pounds

In addition, the BMI cut points are defined differently for pregnancy come[1]and cardiovascular risk[6] Because of all of the controversy, theAgency for Healthcare Research and Quality (AHRQ) and the IOM arere-examining the issue of prenatal weight gain Results for the AHRQ’sproject, ‘‘Adverse Maternal and Child Health Outcomes Associated withMaternal Weight Gain,’’ are expected in mid-2008 (http://www.ahrq.gov/clinic/tp/admattp.htm) and the IOM results are expected mid-2009 The pri-mary goal of the 1990 recommendations was to prevent LBW [28] Nowmore issues can be examined, including refining the recommendations forolder women and mothers with multiples, and looking at outcomes otherthan just birth weight, including obesity We must remember, though,that BMI levels and weight gain are screening tools for appropriate nutritionand not necessarily predictive of health outcomes