Prenatal care (second and third trimesters)
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Urania Magriples, MD
Urania Magriples, MD
- Associate Professor of Obstetrics and Gynecology
- Yale University School of Medicine
The goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother. After the initial prenatal assessment, prenatal care is directed at ongoing evaluation of the health status of both mother and fetus, anticipation of problems, and intervention, if possible, to prevent or minimize morbidity.
INITIAL PRENATAL ASSESSMENT
FREQUENCY OF PRENATAL VISITS
Observational data suggest that prenatal care saves lives compared to no prenatal care  and show an association between the number of antenatal visits and/or early gestational age at the initiation of care and pregnancy outcomes, after controlling for confounding factors (eg, length of gestation) . However, there are limited data as to what constitutes the optimal number and frequency of prenatal visits, or the optimal content of those visits.
In the United States, the typical intervals for prenatal visits for nulliparous women with uncomplicated pregnancies are every 4 weeks until 28 weeks of gestation, every 2 weeks from 28 to 36 weeks, and then weekly until delivery . Parous women with uncomplicated medical and obstetrical histories can be seen less frequently. Women with problems are seen more frequently, depending on the nature of the problems. According to this schedule, an uncomplicated pregnancy where the first visit is at six weeks of gestation and the last visit is at 41 weeks will comprise 16 prenatal visits. While the above visit schedule is commonly followed, it requires significant effort and planning on the part of the patient without clear evidence of benefit. In a cohort study of over 7200 women with low-risk pregnancies, there were no differences in neonatal intensive care unit admissions, five-minute Apgar score <7, neonatal demise, or small for gestational age infants among women who had more than 10 prenatal visits and those who had 10 or fewer prenatal visits . While the women in the high utilization group were 33 percent more likely to undergo induction of labor and 50 percent more likely to have a cesarean delivery than the women in the low utilization group, there are insufficient data to conclude a causal relationship.
The National Institute of Health and Clinical Excellence (NICE) suggests a reduced frequency of visits: 10 appointments for nulliparous women and 7 appointments for parous women, and each visit should have a specific purpose/goal . This approach takes into account the cost and time constraints of modern society and lack of proven efficacy of frequent prenatal visits in randomized trials. The 2016 World Health Organization (WHO) antenatal care guidelines suggest a minimum of eight antenatal visits for all women, regardless of parity . The WHO advises one visit in the first trimester, two in the second trimester, and five in the third trimester. This represents a four-visit increase from prior recommendations in response to a systematic review that reported a 15 percent increase in perinatal deaths for women in middle- and lower-income countries who had reduced antenatal visits (typically fewer than five visits) compared with more visits .
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- INITIAL PRENATAL ASSESSMENT
- FREQUENCY OF PRENATAL VISITS
- Higher risk pregnancies
- SIGNS AND SYMPTOMS THAT SHOULD BE REPORTED TO THE HEALTH CARE PROVIDER
- FOLLOW-UP VISITS
- Ongoing assessments
- Periodic assessments
- - First trimester
- - 15 to 24 weeks of gestation
- Neural tube defects
- Trisomy 21
- Fetal anomalies
- Cervical length
- - 24 to 28 weeks of gestation
- Gestational diabetes
- RBC antibodies
- Hemoglobin or hematocrit
- - 28 to 36 weeks of gestation
- Sexually transmitted disease
- Group B beta-hemolytic streptococcus testing
- Estimated fetal weight
- Fetal assessment
- External cephalic version
- - 36 to 41 weeks of gestation
- Patient education in preparation for labor and delivery
- Patient education regarding postpartum issues
- MANAGEMENT OF PREGNANCY COMPLICATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS