Objective Health! — Resources for Canadian clinicians

Prenatal Care Flowsheet

Also see the BC Maternity Care Pathway (PDF).

Naegele's Rule (280 days):

LMP Gestation on This Day EDD
Before pregnancy:
  • Recommend smoking cessation, weight loss if obese, STD screening.
  • Vaccinations: tetanus/pertussis (Tdap), MMR, Varicella, Hep B.
  • Stop or replace teratogenic drugs, manage pre-existing conditions (optimize diabetes, HTN).
  • Advise accurate recording of menstrual dates.
  • Start taking folic acid 0.4-1mg starting 3 months prior to pregnancy and continue 6 weeks post-partum — Take 5mg if previous NTD, BMI > 35, IDDM, epilepsy, or FHx throughout 1st trimester, then 1mg/day in the rest of pregnancy.
  • All women should be screened for pre-eclampsia and those at risk (including those with chronic hypertension) should be started on ASA 81mg OD and should be receiving at least 1 g daily of calcium supplementation irrespective of dietary intake.
Weeks Investigations / Procedures Physical Exam / Counselling
1 Visits every 4 weeks Initial Visit should be within first 12 weeks (usually between 8-10 weeks):
  • Confirm diagnosis of pregnancy
  • CBC, TSH, Rubella IgG, Hep B, Hep C, HIV, Syphilis, Type and screen
  • CMV/Toxo/Varicella if indicated (not routine)
  • UA for glycosuria, MSU for urine culture (for asymptomatic bacteriuria)
  • If at risk screen for G&C
  • For normal pregnancies, f/u q4-6 weekly until 28 weeks, then q2 weekly until 36 weeks, then qweekly until delivery.
1st visit: Pap, Physical Exam
3 Counsel re: nutrition, caffeine, vitamins (PNV +/- vit D), seatbelts, exercise, sexual intercourse, travel, smoking (NRT is a safe option but ineffective), alcohol, substance abuse. Screen for: domestic violence, depression
6 Vaginal U/S:
  • fetal heart motion visible after 6 weeks GA
  • gestational sac should be visible at BhCG > 1500
8 Dating U/S (8-12 weeks) Common symptoms:
  • nausea/vomiting (ginger, Diclectin 2 tabs QHS)
  • heartburn (lifestyle change, Rantidine 150mg BID)
  • constipation, hemorrhoids (fiber!)
  • varicose veins (pressure stockings)
  • vaginal discharge
  • backache (massage, exercise, physio)
9 Discuss fetal aneuploidy screening options early on
10 May consider NIPT testing (patient preference (unfunded) or high-risk (funded in some prov.)) CVS (10-13+6 wks): same indication as amnio, but can be performed earlier
11 1st trimester serum screen (11-13+6 wks): hCG, PAPP-A
  • 58% sensitive, 5% FP (inadequate alone)
Optional: NT scan (11-13+6 weeks)
  • For mothers at increased risk, parental request
  • Can delay dating scan until 11 weeks if both scans indicated
  • Fetal viability, gestational age, location, multiple gestation, major fetal defects
14 Each visit: weight, BP, FHR (no predictive value, but does confirm fetus is alive), UA (asymptomatic bacteriuria), SFH, Leopold's
15 Quad Screen (15-20+0 wks)
  • Quad Screen: 77% sensitive, 5.2% FP
  • Integrated Serum Screen: 85% sensitive, 4.4% FP
  • ISS = 1st Tri SS + Quad Screen
Amniocentesis: if age > 35, abnormal serum screen, anomalies on U/S or previously affected fetus
18 Anatomy/comprehensive (18-22 wks) scan: placental location, SDVP, # of fetuses, location, viability, anatomy, biometry. Should feel fetal movement (18-20 wks), 14-16 wks if multip
20 Start measuring SFH with empty bladder
23 Fetal cardiac echo (if indicated)
24 Screen for GDM (24-28 weeks):75g OGTT, perhaps 50g OGCT if low-risk BP may start increasing
25 Normal weight gain: 2kg in 1st trimester, then 400g/week
27 Fetal movement counts: should be >10 per 2h
28 Visits every 2 weeks Recheck HgB. Ab screen and give WinRho (if Rh negative). Give Tdap (if more than 10 years since last; give between 27-32wks, or 13wks onward if risk of preterm birth). Discuss possibility of VBAC (if applicable)
30 Encourage patients to report PVB, leaking, contractions, decreased fetal movement (give kick chart if appropriate)
32 Repeat U/S if indicated: f/u abnormal placentation, multiples, gHTN, DM, FGR, PVB, PROM
(Routine 3rd trimester U/S not indicated in low-risk)
34 Leopold's manoeuvres - offer ECV if 36 weeks and breech, but confirm with U/S before!
35 GBS (35-37wks): Swab result valid for 5 wks Fax a copy of prenatal record to L&D after each visit
36 Visits every week Check for favourable cervix
37 At term! Education re: when to present to hospital
38 Women should be offered the option of membrane sweeping commencing at 39 wks, following a discussion of risks/benefits. No demonstrated increased risk in trials, but little benefit: 1 in 8 will avoid a formal IOL.
40 Post-term > 42 wks: IOL routinely booked for 41+3. If refused, BPP and NST weekly
Labour Get baby out!
Delivery of Placenta If GDM, BG should return to normal
Day 1 Rhogam Check Hgb, start iron + folic acid needed Encourage breastfeeding (colostrum lasts for 5 days and contains IgA), early ambulation, oral analgesia and fiber
Day 2
Day 7 Lochia rubra for 4 days then paler lochia serosa then eventually white lochia alba, lasts up to 8 wks Baby blues: incidence 20%, usually mild. Monitor for depression
2 weeks Post partum psychosis: starts around wk 3, usually associated with bipolar disorder
3 weeks Mastitis: may develop starting wk 1-4 PP. Pain, fever, chills. Usually S. aureus. Dicloxacillin 500mg PO QID x 10-14 days
4-6 weeks Puerperium: from third stage until 6 wks PP. Pap smear at 6 wks (if indicated)
If GDM, f/u 75g OGTT to rule out Type 2 DM
42 days Gestation HTN: usually resolves here; if not, needs assessment
6 months Fertility in breastfeeding women returns 4-6 months