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The Initial OB Visit


Happy hump day! Today we’re continuing the series on prenatal care. If you missed the first post on preconception care – catch up here! Did you guys like pink/blush tones of the tool? My favorite color is green, so that’s where I naturally trend when thinking of color schemes. But I always try to think about what things look like in black and white as well.

If you missed it….

The point of this series is two-fold:

  1. Provide education from the evidence on the components each prenatal visit.
  2. Offer a tool to guide the mama/family and provider through all the recommended components of the visit while offering a vehicle for the woman to take home that reviews everything covered at the visit and a list of additional resources for education and information.

Let’s dive into the first prenatal visit!

I love the first obstetric visit (also known as the “new OB” or “IOB”). I like setting up the initial foundation of pregnancy care for a woman and her family. I love the education. I love talking about the expected progression of care through pregnancy and the postpartum visit. I love the excitement of the family.

But oh my goodness, there is a lot of opportunity on how to improve the care at this first visit on the front lines. In my experience, the failure points of this visit are usually that a good history wasn’t taken by the provider, the right questions weren’t asked (by the provider or the patient), the patient didn’t know what to ask and the time wasn’t taken to provide important education.

The visit has so much potential to set a tone for the pregnancy but is also a great opportunity to plant some really important goals for the pregnancy (appropriate weight gain, regular exercise, working and pregnancy, common discomfort management).

For practicing providers, I’ve never seen this information put together in a summary form but this would have be AMAZING to have had in midwifery school. If you have something to add that would benefit others, please send it my way!

Where do prenatal care guidelines come from?

As always, let’s start at the beginning. Who wrote the current guidelines for perinatal care? The main American guideline I found for routine prenatal care comes from a joint publication from the American College of Obstetricians & Gynecologists and the American Academy of Pediatricians appropriately titled: Guidelines for Perinatal Care. The guideline is easily accessible online but is a lengthy 700 pages (the last 150 pages are a series of Appendices).

My favorite thing about the guideline is the Antepartum Record (see below) located in an Appendix at the end of the document. This form is familiar to most individuals practicing in obstetric care in some form or fashion.

Source

The only other prenatal care guideline I was able to locate was the VA/DoD Practice Guideline for the Management of Pregnancy. This was also the only guideline listed on the ECRI website search as well!

After searching online, I also pulled some good old textbooks off the shelf. Varney’s Midwifery (5th ed.) does a really nice review of the initial prenatal visit – the history, physical and review of systems are all presented nicely. Williams Obstetrics (23rd ed.) also offers details for the visit but the components are presented in a piecework fashion throughout the text versus all in a single place.

Regardless of which guideline you reference, I recommend looking at a few different sources. Each source seems to offer something another source doesn’t mention.

What is the initial obstetric visit?

The initial obstetric visit, or the first obstetric visit, is often the visit that most women are equally most nervous and most excited about.

I like to think of the initial visit as a “A-Z” of all your health history and a “head to toe” physical. Both your history and your physical exam offer valuable information that help a provider to put a plan into place to give you and your babe the best prenatal care possible.

Another definition I liked was this one: antepartum care is a comprehensive program of “coordinated medical care [and] continuous psychosocial support” that begins in pregnancy and continues through the postpartum and interpregnancy period (American Academy of Pediatrics [AAP], & American College of Obstetricians and Gynecologists [ACOG], 2017).

The initial visit for your pregnancy sets a foundation for the rest of your pregnancy care to stand on!

A lot of information that is completed in preconception care is also included in the initial visit – mainly because so few women present for preconception care and half of pregnancies are unplanned. But evidence differs on what is indicated for care before you are pregnant and after you are pregnant. This makes sense but is often glossed over in counseling.

Recommended laboratory testing or screening

This is a review of the labs completed at the initial visit and why they are tested during pregnancy. The Centers for Disease Control and Prevention recommend screening all pregnant women for human immunodeficiency virus (HIV), hepatitis B, syphilis, and chlamydia and gonorrhea infection(s) during the initial prenatal visit (AAP & ACOP, 2017). Generally, the majority of labs are completed prior to your appointment and the pap smear, STD screening(s) and vaginitis screening(s) are all completed during the physical exam as indicated.

Prior to the visit

Blood type

This lab is completed for informational purposes only. A woman’s blood type is only used as information in case a blood transfusion is indicated or if there is a risk of blood type incompatibility with the woman’s newborn after birth (AAP & ACOG, 2017).

Rh (Rhesus) type

This is a screening to see if your red blood cells contain a certain protein on their surface. If this protein is present, you are Rh “positive.” If this protein is absent, you are Rh “negative.” When women are Rh negative and their babies are Rh positive this can cause Rh incompatibility. Additional information on the Rh factor if available here.

Antibody screen

An antibody screen is completed at the beginning of every pregnancy to assess for an immune response in the mother that could be harmful to the fetus or neonate. Antibodies can be created by the immune system after maternal bleeding or can occur after a woman has received a blood transfusion (ACOG, 2018).

Complete blood count (CBC)

A CBC screens mainly for anemia in pregnant women. The test also offers information on platelet levels and characteristics of the red blood cells (this is helpful to determine which type of anemia you may have) (AAP & ACOG, 2017).

Hepatitis B surface antigen (HbsAg)

A hepatitis B screening is completed during pregnancy to assess a woman’s immunity to the virus. Specific to the infant, pediatricians need to plan for proper post-birth interventions if a mother is hepatitis B positive. Infants born to mothers that are positive for hepatitis B should be given the hepatitis B vaccine and one dose of hepatitis b immune globulin (HBIG). Infants born to mothers that are hepatitis B positive should be treated or the infant has a 90% chance of developing chronic hepatitis B. If these interventions are administered correctly, the infant has a 90% chance of protection from the hepatitis B infection (AAP & ACOG, 2017; Hepatitis B Foundation, 2021). More information about the hepatitis B virus and pregnancy can be found:

Human immunodeficiency virus (HIV)

A HIV screening is completed to assess if a woman is positive or negative for the HIV infection. HIV screening laws can vary from state to state. As of 2021, only Nebraska and New York have laws that differ from CDC recommendations. Women should be counseled that they are being tested for HIV, including the option to decline the test. Any opt-out of screening should be documented (AAP & ACOG, 2017). Women that are HIV positive will need additional multidisciplinary care during their pregnancy (AAP & ACOG, 2017). Women who are HIV positive can pass HIV to their babies. The transmission of the virus can occur across the placenta, during labor and birth, or through breastfeeding (ACOG, 2017b). More information about HIV and pregnancy is available here.

Syphilis screening

Syphilis screening is performed in pregnancy to assess for syphilis infection. A syphilis infection can be extremely harmful to a fetus during pregnancy. Untreated syphilis can result in stillbirth or congenital syphilis. Congenital syphilis can cause bone damage, severe anemia, enlarged liver and spleen, jaundice, blindness, deafness, meningitis or skin rashes (CDC, 2020c). The number of syphilis cases in both women and infants born with congenital syphilis has increased every year since 2013 (CDC, 2020c). False positives for syphilis screening are common and infection after the first prenatal screening is always possible (AAP & ACOG, 2017). Some states require all women to be screened at time of delivery. As of 2021, Alabama, Arizona, North Carolina, and Texas all screen at time of birth (CDC, 2020b). More information on state by state screening is here (CDC, 2020b). Additionally, screening should also be repeated for any exposure to an infected partner or for any woman who gives birth to a stillborn (ACOG & AAP, 2017).

Rubella screening

Rubella screening is recommended in pregnancy to determine if a woman has immunity to the rubella virus. Rubella vaccination started in 1969. Less than 10 people are reported to have rubella in the United States annually and all rubella infections since 2012 were from exposure to the virus while individuals were living or traveling outside the United States. Although rubella is rare in the United States, it is still endemic in other parts of the world (CDC, 2020a).

Rubella infection in pregnancy can cause miscarriage, fetal death or congenital rubella syndrome. If rubella infection occurs during the first 12 weeks of gestation or between 13-16 weeks of gestation, risk of congenital defect in the fetus is 85% and 50%, respectively (AAP & ACOG, 2017).

Screening is recommended unless there is:

Varicella screening

Varicella screening is recommend for all pregnant women. Women should be questioned about either a history of varicella infection or the varicella vaccination. If both are unknown, varicella immunity can be tested via blood work. Neonatal infection of varicella is associated with a high death rate is a woman develops the disease 5 days before birth or 2 days after birth. Women who do not have varicella immunity should obtain the varicella vaccine after pregnancy and prevent pregnancy for 1 month after the dose is received (AAP & ACOG, 2017).

Urinalysis

The screening assess renal function by examining abnormal levels of protein, however, in an absence of any risk factors, the test has not shown any benefits (AAP & ACOG, 2017). The test can also screen for dehydration and ketones – both of which are an easy way to screen for the severity of nausea or vomiting in the first trimester.

Urine culture

A urine culture is collected to see if a woman has an asymptomatic urinary tract infection at the beginning of pregnancy. 25% of women with urinary tract infections will have no symptoms but untreated, the infection can lead to other complications during pregnancy. Urine cultures that result with group beta streptococcus (GBS) bacteria should be documented in the chart and the woman should be advised of the recommended management during labor and delivery (AAP & ACOG, 2017).

During the visit

Cervical cancer screening (pap smear)

Routine cervical cancer screening is recommended at 21 years of age. The screening, commonly known as a pap smear, looks for abnormal cells that could lead to cancer. A pap smear can be completed during pregnancy. Most cases of cervical cancer are caused by the human papillomavirus (HPV). HPV is common. There are vaccines to prevent HPV but the vaccines are not recommended in pregnancy. Women may receive them postpartum and while they are breastfeeding (AAP & ACOG, 2017).

Chlamydia/gonorrhea screening

Pregnant women should be screened for chlamydia and gonorrhea infection. Many women with chlamydia infections do not have any symptoms but reported symptoms include: abnormal vaginal discharge, bleeding after sex or itching/burning with urination. Untreated chlamydia is associated with preterm labor, premature rupture of membranes and low birth weight. Newborns exposed to chlamydia can suffer from eye and lung infection (AAP & ACOG, 2017; CDC, 2016).

Untreated gonorrhea infection during pregnancy is associated with miscarriage, preterm birth, low birth weight, premature rupture of membranes and chorioamnionitis. Gonorrhea can cause eye infections in infants (CDC, 2016).

Vaginitis screening

Women with symptoms of yeast, bacterial or trichomonas infection should be screened and assessed as appropriate at the initial visit (King et al., 2015).

Additional labs as indicated

Early glucola screen or hemoglobin A1C

There are a number of risk factors that predispose a woman to have pregestational or gestational diabetes. Recommendations for early glucola testing are below:

Hemoglobin electrophoresis

This test is recommended for women of African, Asian or Mediterranean descent. The test screens for thalassemia or sickle cell disease and often identifies woman who are carriers of these diseases (AAP & ACOG, 2017). A person generally needs this test only once in their lifetime.

Tuberculin (TB) test (PPD)

Women at high risk for tuberculosis infection should be screened in early pregnancy with a TB test. A blood test is also available. Risk factors for infection include: known HIV infection, close contact with a suspected or confirmed TB case, homelessness, birth in or immigration from a country with increased TB activity or prevalence, healthcare or long term care facility workers and certain chronic medical conditions (AAP & ACOG, 2017).

Thyroid testing (TSH – thyroid stimulating hormone)

Universal thyroid testing is not recommended in pregnancy unless clinically indicated (King et al., 2015)

The History

I had a very wise midwife tell me in graduate school – the history will tell you 90% of what you need to know. The physical exam makes up the other 10% of the assessment and if you did a good history, the exam supports what you already suspect! I have found this to be very true in practice.

These questions should be inherent in a good history taking but I find it’s helpful a women to review the questions before a visit. It also allows for women to ask family members about any childhood conditions they may have had but can’t remember details about, or a member in the family tree that had an aggressive cancer they can’t remember the name of.

Here are the recommended components of the initial obstetric history:

History of the pregnancy

Review medical history

Review family history

Review genetic history/complete genetic screening

Review surgical history

Review gynecologic/sexual history

Review obstetric history

Review nutritional history

Review allergies to medications, latex, foods or allergens

Review current medications and supplements (herbal/homeopathic/nutritional)

Complete a social assessment

Review current or history of alternative therapies (chiropractor, acupuncture, physical therapy)

Other

Inevitably, there is a part of the patient’s history that doesn’t fit into one of these assessments. A simple question at the end of the history such as “Is there anything else in your history that was not covered?” usually uncovers any unturned stones.

The Physical Exam & The Ultrasound

Physical Exam

The physical exam always starts with vital signs (temperature, blood pressure, heart rate, weight, height, and body mass index). Oxygen saturation and respiration rate assessment varies from practice to practice.

The exam then moves to a series of body systems, usually done in a similar order as listed, with a review of the components that can be completed (i.e. what the provider is assessing in each system!):

Routine breast examination also varies depending on the provider, the practice and a woman’s history or risk factors. This is because a number of organizations disagree on recommended screening for clinical breast exam. ACOG summarizes the differences nicely in this practice bulletin, but recommendations as of 2021 are listed below for a low risk woman (ACOG, 2017a):

Source

Lastly, it is reasonable to mention the assessment of clinical pelvimetry. Clinical pelvimetry is completed during the gynecologic portion of the physical exam but is an uncommon practice as the years pass (pelvimetry can also be completed during a cervical exam during the final week so gestation or during labor). Pelvimetry is the measurement of the pelvis in an effort to gain more information about the general architecture of each woman’s pelvic structures. Pelvic structure used to be assessed by x-ray to determine if a woman was a good candidate for a vaginal delivery. X-rays are no longer used, but diseases that used to cause concern for pelvic abnormalities are also uncommon (scurvy, rickets, polio) (King et al., 2015). No evidence supports that clinical pelvimetry is necessary and that regardless of pelvimetry findings, woman should be encouraged to attempt birth vaginally unless otherwise contraindicated.

Ultrasound

The ultrasound confirms whether the pregnancy is viable, confirms the gestational age and screens for signs of a normal intrauterine pregnancy while also looking for any risk factors (twins, subchorionic hemorrhage, uterine fibroids, ovarian cysts) (AAP & ACOG, 2017). Currently, there is no evidence that ultrasound in pregnancy is harmful but that does not rule out the possibility of harms identified in the future (ACOG, 2020). ACOG (2017) offers a nice FAQ for woman about ultrasounds during pregnancy.

The Education

This is the BULK of the visit! There are so many questions that women have and so many resources out there. Education is generally received better in groupings and is organized as such below. For patients that do not speak English, please strive to utilize and provide education with a translator.

Review of visit: laboratory results, pertinent history, physical exam and ultrasound

Review genetic screening options during pregnancy

General housekeeping

Review of other important patient education

Handout options for further pregnancy education

Other helpful websites for further education

The Follow Up

Whew, we made it through all that information…but where do you go from here? The follow up information is just as important as the rest of the visit!

Here’s a list to review with a woman and her family before leaving the clinic!


That’s a wrap for the initial visit! There is a lot of content and most women only see a fraction of the education presented. Maternity care can do better. I think slip ups happen in a few places. One, some clinics utilize a nurse to review intake forms. This is a great way to utilize a clinic nurse, but even the best intake form needs to be reviewed by a provider review and clarifying questions asked as indicated. Two, if a patient transfers care during their pregnancy, all of these components are important to review at the new place of care. It’s amazing how often things are overlooked. And three, the raw truth is that prenatal education takes time. But it’s one of the most important ways to spend your time with women.

I leave you with this last thought: Although it seems like a tidal wave of information, if every woman’s initial prenatal visit included these components, would that help improve maternal and neonatal mortality?

Happy hump day!

Jamie

Tune in next week for the initial visit tool!


References

American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care (8th ed.). DOI 10.1002/14651858.CD003519.pub3

American College of Obstetricians & Gynecologists. (2017a). Breast cancer risk assessment and screening in average-risk women. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/07/breast-cancer-risk-assessment-and-screening-in-average-risk-women

American College of Obstetricians & Gynecologists. (2017b). HIV and pregnancy. https://www.acog.org/womens-health/faqs/hiv-and-pregnancy

American College of Obstetricians & Gynecologists. (2018). Management of alloimmunization during pregnancy. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/03/management-of-alloimmunization-during-pregnancy

American College of Obstetricians & Gynecologists. (2020). Frequently asked questions: Ultrasound exams. https://www.acog.org/womens-health/faqs/ultrasound-exams#:~:text=How%20many%20ultrasound%20exams%20will,the%20first%20trimester%20of%20pregnancy.

Centers for Disease Control & Prevention. (2016). Sexually transmitted diseases. https://www.cdc.gov/std/pregnancy/stdfact-pregnancy-detailed.htm#:~:text=Untreated%20chlamydial%20infection%20has%20been,membranes%2C%20and%20low%20birth%20weight.&text=The%20newborn%20may%20also%20become,develop%20eye%20and%20lung%20infections.

Centers for Disease Control & Prevention. (2020a). Rubella (German measles, three-day measles). https://www.cdc.gov/rubella/about/in-the-us.html

Centers for Disease Control & Prevention. (2020b). Sexually transmitted diseases: State statutory and regulatory language regarding prenatal syphilis screenings in the United States. https://www.cdc.gov/std/treatment/syphilis-screenings.htm#

Centers for Disease Control & Prevention. (2020c). Syphilis. https://www.cdc.gov/nchhstp/pregnancy/effects/syphilis.html

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J.C., Rouse, D.J., & Spong, C.Y. (2010). Williams obstetrics (23rd edition.). New York: McGraw-Hill Education.

Hepatitis B Foundation. (2021). Pregnancy and hepatitis B. https://www.hepb.org/treatment-and-management/pregnancy-and-hbv/

King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning.

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