If the patient presents for entry for prenatal care in the third trimester, complete all of the first and second trimester evaluations at the initial visit.
Physical Examination
A.General assessment:
1.Vital signs.
2.Weight and height.
3.Blood pressure.
4.Fetal heart tones (120–160 bpm).
5.Fetal movement (fetal kick counts).
6.Fundal height.
7.Maternal heart rate.
B.Abdomen:
1.Fetal presentation.
C.Skin:
1.Striae distensae.
2.Varicose veins.
D.Extremities:
1.Bishop
E.Cervix-Bishop score
1.Dilation.
2.Effacement.
3.Station.
4.Position.
5.Consistency.
Common Diagnostic Tests
A.Vaginal and rectal culture to identify the presence of group B Streptococcus (GBS) infection at 35 to 36 weeks; repeat the culture every 5 weeks if indicated.
B.Fetal growth ultrasounds (US); if indicated.
C.Antenatal testing consisting of biophysical profile (BPP) and nonstress test (NST), if indicated.
D.Complete blood count (CBC) with platelets.
E.HIV.
F.Rapid plasma reagin (RPR) with reflex to TP-PA or FTA-ABS or TP-EIA (treponemal test).
Pharmaceutical Therapies
A.Tdap vaccine given to all pregnant women during each pregnancy. Advise all family members who will be in contact with newborn to also have the Tdap vaccine.
B.Anemia: Increase elemental iron by 30 to 120 mg/d and instruct the patient to take the iron with orange juice to increase the absorption in the stomach.
C.Rho(D) immune globulin (RhoGAM) is given to pregnant patients who are Rh negative at 28 weeks’ gestational age.
Patient Education
A.Fetal kick counts.
B.Breastfeeding/bottle feeding.
C.Circumcision.
D.Infant sibling preparation.
E.Safety/car seat.
F.Birth plan.
G.Postpartum birth control options.
H.Labor and delivery expectations.
I.Choosing a pediatrician.
J.Review symptoms to report immediately and/or to go to the hospital to labor and delivery.
Complications
A.Intrauterine growth restriction (IUGR).
B.Preeclampsia and eclampsia.
C.Gestational diabetes.
D.Fetal demise.
E.Oligohydramnios.
F.Polyhydramnios.
G.Fetal abnormality.
H.Pruritic urticarial papules and plaques of pregnancy (PUPPP).
I.Cholestasis.
J.Preterm labor (PTL).
K.Placenta previa.
L.Placenta accreta.
M.Placenta abruption.
N.Anemia.
O.GBS.
Consultations
A.Genetic consultation is needed with abnormal genetic testing, advanced maternal age (AMA), and abnormal US findings.
B.High-risk consultation is needed with gestational diabetes, thyroid disorder, asthma exacerbation in pregnancy, severe anemia, HIV positive, acute tuberculosis infection, congenital syphilis, positive antibody, fetal abnormalities, and maternal cardiac complications.
C.Vaginal birth after cesarean section counseling, if the patient wants to attempt a vaginal delivery after having one to two prior cesarean sections.
Emergent Issues/Instructions
A.Abdominal pain, contractions, backache, pelvic pressure, or other pain needs to be evaluated and sent to the ER if PTL needs to be ruled out.
B.Vaginal bleeding with or without pain needs to be evaluated and sent to the ER.
C.Fever greater than 100.4°F.
D.Evaluate fetal movement and daily fetal kick counts. If she reports decreased fetal movement send to the ER to have BPP and NST to evaluate fetal well-being.
E.Headaches with or without blurry vision need to be addressed. Blood pressure (BP) should be monitored; if she has elevated BP with or without headaches and blurry vision, she needs to be sent to the ER.
F.Leaking of clear fluid from the vagina needs to be assessed; if she has unexplained fluid from the vagina, she needs to go to ER.
G.Pruritis on hands and feet causing her to wake up at night because of the pruritis needs to be evaluated and sent to the ER.