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INTRODUCTION

Many family physicians assist pregnant women and deliver their infants as a routine part of their practice. In 2012, 15% of surveyed family physicians delivered babies and averaged 20 deliveries per year. In rural areas, 17% of family physicians delivered babies. Many more family physicians provide prenatal care without assisting in the delivery. Practicing maternity care provides an opportunity to establish relationships with an entire family, developing lifelong continuity of care. It is also a time for initiating preventive care and adopting a healthier lifestyle by making better dietary choices, quitting smoking, and abstaining from alcohol. The goal of prenatal care is to promote the birth of a healthy baby while also promoting the health of the mother and minimizing risk to her.

General Considerations

There are several key components to prenatal care including the establishment of an accurate gestational age and estimated date of delivery, the initial assessment of maternal risk factors for the development of complications, the ongoing assessment of maternal and fetal health and well-being, and patient education. Pregnant women receive 13–15 office visits for a typical low-risk pregnancy when care begins in the first trimester. After her initial visit a woman will see her provider every 4 weeks until 28 weeks’ gestation, and then every 2 weeks until 36 weeks’ gestation, followed by weekly visits until delivery. Women at higher risk for complications, or those who develop complications in pregnancy, may be seen more frequently. Despite a general acceptance and widespread adoption of prenatal care, there is little evidence that demonstrates proven effectiveness in reducing maternal and fetal morbidity and mortality. Observational studies comparing women who receive prenatal care and those who do not are confounded by selection bias regarding socioeconomic status, maternal education, substance abuse and other factors that affect health and risk status. A 2010 Cochrane review comparing fewer prenatal visits with the standard schedule demonstrated that in high-income countries there was no difference in perinatal mortality in the reduced visit group; however, there was increased perinatal mortality in the reduced visit group in low-income countries. Women in all countries were less satisfied with the reduced-visits schedule. Further research to determine and define “adequate” prenatal care is ongoing.

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Carroli  G, Dowswell  T, Duley  L  et al.. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews. 2010, Issue 10. Art. No.:CD000934. 10.1002/14651858.CD000934.pub2

PRENATAL VISITS

Initial Visit

The initial visit should include a detailed history and physical exam establish an accurate estimated date of confinement (EDC) and identify risk factors that will require additional testing and monitoring (Table 17-1). History of the current pregnancy should include establishing the date of the last menstrual period (LMP). According to Nagle’s rule, the average pregnancy is 280 ± 14 days from a reliable last menstrual period (LMP). Criteria for a reliable ...

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