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INTRODUCTION

Many family physicians assist pregnant women and deliver their infants as a routine part of their practice. According to a 2017 study by the Robert Graham Center, there has been a steady decline in the number of family medicine physicians practicing obstetrics. About 8% of family physicians are practicing obstetrics, and an even smaller number are practicing high-volume obstetrics. The shortage of obstetricians and family medicine physicians delivering babies has put a strain on the access to maternal and fetal care, particularly in rural areas. Practicing maternity care provides an opportunity to establish relationships with an entire family, developing lifelong continuity of care. During pregnancy, women have incentive to initiate preventive care, adopt a healthier lifestyle, quit smoking, and abstain from alcohol consumption. The goal of prenatal care is to promote a healthy pregnancy while minimizing risk to both mother and baby.

GENERAL CONSIDERATIONS

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, every 2–3 weeks between 28 and 36 weeks’ gestation, and weekly visits from 36 weeks’ gestation until delivery. Women at higher risk for complications, or those who develop complications in pregnancy, may be seen more frequently. The World Health Organization (WHO) guidelines from November 2016 for antenatal care recommend a minimum of eight visits: one visit in the first trimester, two visits in the second trimester, and five visits in the third trimester. Eight or more visits for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to four visits.

A 2015 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; this confirmed similar findings to the WHO that there was increased perinatal mortality in the reduced visit group in low- and middle-income countries. Women in all countries were less satisfied with the reduced-visit schedule.

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Barreto  T, Peterson  L, Petterson  S, Bazemore  A. Family physicians practicing high-volume obstetric care have recently dropped by one-half. Am Fam Physician. 2017;95(12):762.
[PubMed: 28671420]  
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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 Syst Rev. 2015;7:CD000934.
[PubMed: 26184394]
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World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. Accessed November 11, 2019.

PRENATAL VISITS

Initial Visit

The initial visit should include a detailed history and physical exam, establish an accurate estimated date of confinement/estimated due date/expected date of delivery, and identify risk factors that will require additional testing and monitoring (Table 17–1).

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