The Prenatal Record and the Initial Prenatal Visit

Prenatal care is often the primary way young women access basic health care. With that in mind, one must look at prenatal care in the context of risk assessment, health promotion, and risk-directed intervention in general and not just from an obstetrical perspective. This means that a large range of issues must be systematically and consistently addressed and documented during prenatal care.

If one were to attempt to make an analogy between prenatal care and building a house, the prenatal record might be seen as the blueprint and checklist for construction, and the initial prenatal visit as the foundation and framework on which the rest of the structure is built. Good prenatal care depends on many factors but clearly is facilitated by a good prenatal record. Additionally, the prenatal record both guides and documents the delivery of good prenatal care. Prenatal records have evolved considerably in the past three decades and may be better developed than any other specific medical record-keeping system.

The prenatal record and the initial prenatal evaluation are so closely linked that they must be discussed together. During the initial prenatal visit, the practitioner collects most of the information that will be used to evaluate obstetrical risks and determine what special interventions, if any, are needed. This visit establishes the foundation for the physician–patient relationship, particularly when the patient is new to the physician. This chapter incorporates the elements of the first visit into the discussion of relevant portions of the prenatal record.

The term initial prenatal visit is used here to identify the process of initiating prenatal care. This process actually may require two visits: a first visit for the history and physical examination, at which time laboratory studies or other tests may be ordered, and a second visit to review results, complete the initial database, determine risk status, plan a course for prenatal care, and begin the patient education process. This approach is considerably facilitated by a record system that clearly documents each step of the process and provides guidance for the practitioner so that omissions are avoided and problems are not overlooked.

Many different prenatal record forms are used throughout the United States. Prenatal records vary from simple notes made on blank sheets of paper to highly developed computer-based systems. Many offices and institutions develop their own prenatal record forms to fit the special needs and interests of the physicians using them. The major disadvantage of individually developed record systems is that they often are not updated regularly as prenatal care practices change.¹

There have been a great number of advances in prenatal care standards and screening practices, including first trimester genetic screening, multiple marker screening, universal hepatitis B screen, and an expanded genetics history and screening options.² Over time, individually developed systems that are not consistently updated may actually reinforce the provision of suboptimal prenatal care.³

Standard prenatal record systems offer the following advantages:

  They are used by many institutions around the country and therefore facilitate the transfer of information.
  They are revised and updated regularly, ensuring that the practitioner is using an up-to-date system.
  They incorporate risk assessment into the record system.
  The use of a standardized prenatal care system is one indication that good standardized prenatal care is being provided. This can be beneficial in the event of medical or legal questions regarding the care provided.
  Several excellent standardized prenatal record systems are available. Among the best known are the American College of Obstetricians and Gynecologists (ACOG) prenatal record and the Maternal/Newborn Record System.
  Several other good record systems have been developed and are available commercially either as electronic records or standard paper forms. Examples from nationally available record systems are used throughout this chapter to illustrate important components of the prenatal record. All good prenatal record systems contain several well-defined components. These sections usually are clearly identifiable and provide specific useful information.

Demographic Information

Basic demographic information includes the patient's self-identified ethnicity, religious preference, educational background, age, and contact information. Demographic information can be important in evaluating risk (e.g. partnership status and availability of family support), guiding educational plans (e.g. educational level and preferred language), identifying specific testing needs (e.g. special genetic testing for members of specific racial or ethnic groups), and potential religious restrictions (e.g. blood transfusions are prohibited in a Jehovah's Witness). Patient age will alert the provider to social issues (e.g. a teen who is still in school) or medical concerns (e.g. increased genetic abnormalities in the patient who is older than 35 years of age). It is becoming increasingly important for insurance information to be readily available with the heath record to facilitate appropriate referrals and clearances for testing and consultation for patients who participate in managed care plans.

Menstrual History

The first important historical information that obstetricians usually gather is the date of the first day of the last menstrual period (LMP). The record should reflect the accuracy of the date, cycle length, and normality of the LMP. Information on prior contraception and fertility treatment is important to determine the utility of the LMP to predict the estimated date of delivery (EDD). The accuracy of an EDD calculated from the LMP must be confirmed by clinical examination, ultrasound, and/or auscultation of fetal heart tones.

Some record systems include a specific section for re-evaluating the EDD based on LMP, clinical estimators of gestational age, and ultrasound information (Fig. 1). The first ultrasound in the pregnancy is the most accurate for dating purposes and should be used when establishing EDD. Changes in the EDD and the reasoning behind the change should be documented in the record. Many important management decisions in obstetric care rely on knowledge of the current estimated gestational age (EGA).⁴

Obstetric History

Past pregnancy history is an important predictor of pregnancy risk in multiparous women. The elements that should be recorded include the dates of deliveries, types of deliveries (vaginal or cesarean), indication and type of uterine incision if a cesarean delivery was performed, birth weight and gestational age of previous infants, complications of previous pregnancies, and current state of health of previous children. Additional details should be recorded in cases of complications. For example, a patient who experienced preterm delivery in the past should be queried regarding preterm rupture of membranes, preterm labor versus indicated delivery, or symptoms of an incompetent cervix.

Medical and Surgical History

It is important that a thorough medical history, covering conditions that could affect the pregnancy, be taken. Patients should be asked specifically about common medical conditions as well as uncommon conditions that are known to have a serious effect on pregnancy. Common problems include diabetes, chronic hypertension, asthma, cardiac diseases including mitral valve prolapse, and hemoglobinopathies. Less common but equally important issues include lupus, thyroid disorders, chronic hepatitis, tuberculosis, bleeding disorders, chronic renal disease, cancer, or thromboembolic disorders.

A surgical history with emphasis on abdominal procedures or orthopedic procedures involving the pelvis should be taken. A history of prior ectopic pregnancy increases the risk of the current pregnancy being in an ectopic location. A history of uterine perforation or incision (cornual resection or myomectomy) may increase the need for a cesarean section as mode of delivery. A hip replacement may present limitations in range of motion for patient positioning during delivery.

In addition to questions about medical and surgical problems, complete prenatal care requires careful attention to specific areas (e.g. perinatal infections, genetic problems). Certain infections increase the risk of preterm delivery, congenital anomalies, and delivery complications. Advances in the Human Genome Project have made increasing numbers of genetic screening tests available for patients at risk. These questions are covered the in ACOG prenatal record system, which lists specific screening criteria (Fig. 2).

Physical Examination

Although most pregnant women are healthy, illnesses that affect the reproductive age group can occur in pregnancy and include thyroid disorders, hepatitis, adnexal neoplasms, uterine fibroids, and even cancer (e.g. breast, colon, cervix). Therefore, a careful physical examination with clear documentation of findings is an important part of the initial prenatal visit. Because the examination performed at this visit may be the first physical examination the patient has had in years, a complete screening examination is indicated. During the first examination, the physician can also provide education regarding any findings. For example, a patient may have a number of dental caries that they have not had treated for fear of injuring the fetus; the physician can inform this patient that such treatment is not harmful. A cardiac examination for murmurs or arrhythmia is important to rule out an acquired cardiac problem (e.g. rheumatic heart disease with mitral stenosis). Marked scoliosis may increase symptoms of back problems throughout the pregnancy as well as increase the risk of bony pelvis abnormalities. It is useful to note the presence of nipple abnormalities that may affect breastfeeding. A detailed pelvic examination is useful for documenting and confirming the gestational age determined by the LMP. The pelvic examination should include cervical cytology if this study has not been performed within the past year. Assessments for gonorrhea and chlamydia are recommended by many clinicians. The role of clinical pelvimetry in current practice is not clear and has not been studied in recent years. However, this brief, simple examination can be performed at the initial visit or be delayed until closer to delivery.

Nutritional and Psychosocial Evaluation

The initial nutritional status and the ongoing quality of maternal nutrition during pregnancy are widely believed to affect the outcome of pregnancy. Unfortunately, most physicians are poorly trained in assessing nutritional needs. Patients with some medical problems have specific nutritional needs (e.g. diabetes mellitus, phenylketonuria); in other situations, nutrition problems are recognized only as a result of taking a careful history (e.g. vegetarian) or physical examination (e.g. bulimia). Referral to appropriate personnel for nutrition assessment and recommendations should be considered if there is concern about the nutritional status of the patient at the initial visit.⁵ Otherwise, it is typical that serial changes in weight (or lack thereof) throughout the pregnancy prompt further nutritional evaluation.^{6, 7}

Increasing evidence suggests that psychosocial problems and social support may affect the occurrence of complications of pregnancy.⁸ Providing optimal medical care for pregnant women includes identifying significant psychosocial problems and stressors in the home or workplace.^{9, 10, 11} Interventions can include smoking cessation programs, drug abuse programs, counseling regarding safe homes for domestic violence victims, and counseling regarding a crisis pregnancy.^{12, 13, 14, 15, 16} A description of the workplace and the woman's job responsibilities should be elicited to rule out any significant exposure to toxins or ergonomic stressors that could have a negative impact on the pregnancy.¹⁷ Paying appropriate attention to these problems and recommending ancillary services to patients who need them can improve the outcome of the pregnancy (Fig. 3).¹⁸

Laboratory Studies

The most commonly ordered prenatal laboratory studies for the initial visit are listed in Table 1. A good prenatal record system lists these studies in an organized format so that none will be overlooked by the practitioner. This practice reduces the likelihood of missing significant findings and facilitates retrieval of data by any other practitioner who cares for the patient. A useful approach is to record the results of basic laboratory studies as they are performed (e.g. initial studies, midtrimester genetic screening, third-trimester screening). Additional space should be available to record the results of any necessary follow-up or serial studies. One recent addition to the initial laboratory testing is the universal offering of human immunodeficiency virus (HIV) screening for all pregnant women.

Table 1. Guidelines for prenatal laboratory evaluation

  Initial Prenatal Visit
  Blood type
  D (Rh) type
  Antibody screen
  Hemoglobin or hematocrit
  Papanicolaou smear
  Rubella titer
  Serologic test for syphilis
  Gonorrhea screening (risk-based)
  HIV counseling/testing
  Urine culture or screen
  Hepatitis B surface antigen
  Estimated Gestational Age 14–20 Weeks (When Indicated)
  Maternal serum α-fetoprotein or multiple marker screen
  Special genetic testing (amniocentesis or chorionic villous sampling)
  Estimated Gestational Age 24–28 Weeks
  Hemoglobin or hematocrit
  Glucose screen for gestational diabetes
  Rh antibody screen and Rh immune globulin administration if Rh (D)—negative
  Estimated Gestational Age 32–36 weeks
  Serologic test for syphilis (risk-based)
  Gonorrhea screening (risk-based)
  Hemoglobin or hematocrit
  Group B streptococcus culture (if using culture strategy)
  Optional Laboratory Studies (When Indicated)
  Hemoglobin electrophoresis
  Chlamydia screening
  Purified protein derivative
  Tay-Sachs screening of parents
  Cystic fibrosis screening of parents

(Adapted from ACOG Antepartum Record. Washington, DC, American College of Obstetricians and Gynecologists, 1997.)

The findings of the initial ultrasound evaluation should be documented and should include fetal number, EGA, placental location, and amniotic fluid volume. Depending on the EGA, the fetal presentation also may be important. It has become typical for a woman to receive at least one ultrasound examination during her pregnancy. In fact, this procedure is often included in the global fee for obstetrical care. The timing of the initial ultrasound in an otherwise uncomplicated pregnancy should be early enough to allow confirmation of gestational dating (20 weeks) but late enough to do a basic anatomy screen (16 weeks). Scans done in the 16- to 20-week range are optimal for these reasons and also provide an opportunity to determine fetal gender.

Risk Assessment

As regionalization of perinatal care developed in the 1970s, risk assessment was introduced as part of prenatal evaluation. Risk assessment is important for the identification of patients who require special care or referral to specialized facilities. Early risk-assessment systems divided patients into high-risk and low-risk groups. This classification may be useful in systems in which basic obstetric services are delivered by nurse practitioners, midwives, or family physicians, but it provides little specific guidance about diagnostic or therapeutic interventions. It is more useful to identify the risk of specific conditions (e.g. preterm labor, gestational diabetes). Many published reports discuss specific factors that predict the risks of various conditions. The chapter on prenatal risk (Toward perinatal electronic medical records for obstetrics) assessment provides further information on this topic.

Education

Patient education commonly is cited as important to achieving a good pregnancy outcome but often is overlooked in the course of a busy private practice.¹⁹ It is wise to document educational interventions as further evidence of the provision of high-quality prenatal care. It probably is not necessary to document detailed educational material; it is sufficient to note the topics covered. A separate manual of protocols details the actual information that is provided when a topic is covered. A report of the Public Health Service Expert Panel on the Content of Prenatal Care provides excellent recommendations for health education during prenatal care (Fig. 4).²⁰

Management Plan

After the initial database is collected and evaluated, a management plan should be developed. For patients with an uncomplicated, low-risk pregnancy, this plan may be a standard prenatal care package. Specific risks and problems should be documented and a plan of evaluation and management developed for each patient. This plan should be reviewed and updated at each subsequent visit.

At each prenatal visit, a series of standard measurements is performed. The findings should be recorded in a sequential flow-sheet to facilitate the identification of adverse trends. The usual parameters are current EGA, weight, blood pressure, urine protein and glucose, fetal heart rate, and fundal height. Other information that may be collected at specific times during the pregnancy includes fetal presentation and activity, symptoms of preterm labor, and cervical findings.

Additional laboratory studies are recommended at specific times during pregnancy (see Table 1). Other studies may be indicated in women who are at risk for a specific condition. It is helpful if the prenatal record provides cues to remind the clinician to order standard screening tests. As additional information is gathered from ongoing prenatal visits and laboratory evaluation, risk assessment, education plans, and management plans should be reviewed and updated as necessary.

Trends in prenatal care utilization are commonly collected using the prenatal care record. Critical data include EGA at the initiation of care and number of visits. The prenatal care record serves to document data that are commonly used as indicators of quality and adequacy of care. These in turn can be used in quality-assurance reviews and by third-party payors to evaluate the care provided.

Good prenatal care depends on careful surveillance for and assessment of risks, thoughtful interventions to address any identified risks, and education of the prospective parents to promote well being. A clear, concise, well-documented prenatal record contributes to the quality of this process and facilitates communication among all members of the health care team.