Clinical Practice Guidelines

2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE

THE PHYSICIAN’S CLINICAL JUDGMENT MUST ULTIMATELY DETERMINE THE APPROPRIATE TREATMENT FOR EACH INDIVIDUAL
IDENTIFICATION OF PREGNANCY
1. Preconception counseling is documented for all patients who make it known that they are planning pregnancy.
2. Pregnancy is appropriately diagnosed prior to the end of the first trimester and the first prenatal visit occurs during the first trimester (on or between 176 and 280 days prior to delivery or estimated date of delivery [EDD*]).
*National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) definition
FIRST PRENATAL VISIT
Patient Information including:
1. Menstrual history
2. Comprehensive health history with information on the current pregnancy
3. Family history
4. Obstetrical history including:
· Previous deliveries and/or operations on the uterus/cervix
· Congenital abnormalities
· Therapeutic, spontaneous, or elective abortions
· Previous infertility
· Risk for multiple gestation
· Previous fetal demise
· Premature onset of labor or prolonged pregnancy
· History of pulmonary, cardiac, metabolic, endocrine, neurological urinary tract, hematological, or psychological disease
· History of sexually transmitted disease
· Neonatal mortality/morbidity
· Maternal age <15 or >35
· Nutritional disease or hyperemesis gravidarum
· HIV infection
5. Social history including:
· Social/economic stress factors
· Physical or sexual abuse
· Maternal use of drugs, alcohol or tobacco
· Nutrition
· Assessment of workplace risk factors / Physical examination including:
· Height and weight
· Blood pressure
· Evaluation of nutritional status
· Pelvic exam / Laboratory tests as follows:
· Urinalysis (including microscopic exam or culture)
· Antibody screen
· Pap smear
· Complete blood count
· Rubella antibody titer measurement
· Screening for Hepatitis B surface antigen
· HIV counseling and offer of screening
· Blood type and D (Rh) type determination, with notation of any prior RhoGAM administration
· Serological test for Syphilis (VDRL or RPR)
FOLLOW-UP VISITS
Visit schedule:
· Every 4 weeks for the first 28 weeks of gestation
· Every 2 weeks until 36 weeks gestation
· Weekly after 36 weeks
The following should be performed and recorded at each visit:
· Weight
· Blood pressure
· Measured fundal height
· Fetal heart beat
The following should be performed and recorded within the following time ranges:
· Repeat hematocrit at 28 to 32 weeks
· Fetal presentation (>36 weeks)
· Repeat antibody test at approximately 26 weeks for unsensitized Rh negative women (if patient still unsensitized, RhoGAM should be administered)
· Cervix check (≥ 28 weeks)
· Flu shots for women in 2nd and 3rd Trimester; except if contraindicated.
·
· Gestational Diabetes Mellitus at 28 weeks
Expected weight gain:
· First trimester - 2 to 5 lbs. total
· After first trimester - ¾ to 1 lb. per week
· Average total weight gain - 25 lbs. +/- 5 lbs
OPTIONAL TESTING FOR PATIENTS ASSESSED TO BE AT RISK
· Maternal serum alpha-fetoprotein or multiple marker screen between 15 and 18 weeks gestation
· Oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening or an initial glucose challenge test (GCT) (serum level 1 hour post 50g glucose load) followed by an OGTT (for those whose GCT exceeds glucose threshold value on GCT) at 24 to 28 weeks
· Glucose tolerance test for abnormal glucose screen (>140mg/l)
· Group B streptococcal screening at 35 to 37 weeks
· Cytomegalovirus (CMV) titers
· Screening for sickle cell and other inheritable diseases
· Skin testing for tuberculosis
· Gonorrhea culture
· Chlamydia culture
· Obstetrical ultrasound at 18 to 20 weeks
· Toxoplasmosis antibody test
· Hemoglobin electrophoresis if patient is clearly anemic (Hgb <10 or Hct <32; a Hgb between 10 and 11 may not be worrisome)
· Offer chorionic villus sampling (CVS) (-12 weeks) or amniocentesis (15 to 18 weeks) for women age >35, family history of chromosomal abnormalities, mental retardation or inborn errors of metabolism
· Tests of fetal well-being
Ø Assessment of fetal movement (e.g., kick counts) - 10 movements/2 hours
Ø Non-stress testing (≥28 weeks)
Ø Contraction stress Testing (≥26 weeks)
Ø Biophysical testing (≥26 weeks)
Ø Doppler ultrasound of umbilical arterial flow
Ø
Ø Varicella Immunity Status
Ø Oral Health
Ø Genetic Risks: History of both parents should be reviewed for genetic disorders

DOCUMENTING COUNSELING AND EDUCATION IN THE MEDICAL RECORD

Documentation should include and address information about the pregnancy:
· Discussion of upcoming tests
· Safe exercise and physical activity in pregnancy
· Premature labor symptoms
· Nutrition during pregnancy, including adequate intake of calcium, iron, and folic acid
· Travel and pregnancy
· Genetic counseling, if appropriate
· Use of safety belts
· Sexuality during pregnancy (including STD prevention)
· Avoidance of alcohol, tobacco and drugs
· Childbirth classes
· Environmental/work hazards
· Warning signs of potential problems
· HIV screening, prenatal transmission of HIV, and antiretroviral treatment alternatives
Documentation should include and address information about the delivery:
· Signs of labor
· VBAC counseling
· Obstetrical anesthesia and analgesia
· Labor and delivery process
· Relaxation techniques
· Tubal sterilization
·
Documentation should include and address information about post delivery:
· Breast/bottle feeding
· Circumcision
· Newborn/infant safety car seats
· Psychosocial Services
POSTPARTUM CARE
· Postpartum visit on or between days 21 and 56 after delivery*
· Pelvic exam
· Evaluation of weight, blood pressure, breasts, and abdomen
· Birth control counseling, if appropriate
· Exercise and nutrition counseling, if appropriate
· Postpartum vaccinations
*National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) definition
RESOURCES
American College of Obstetricians and Gynecologists
www.acog.org / Oxford Health Plans
www.oxfordhealth.com
Agency for Healthcare Quality and Research
www.ahrq.gov / Oxford Healthy Mother Healthy Baby® program
888-200-9234

Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US Preventive Services Task Force (1996)

Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July 2004..