First Prenatal Visit
First Prenatal Visit
First Prenatal Visit
First Prenatal Visit · EDC · Laboratory Tests · Subsequent Visits · Weight · Blood Pressure · Urine Protein/Glucose ·
Edema · Fundal Height · Fetal Heartbeat · Fetal Movement · Fetal Orientation
Many providers use a questionnaire, filled out by the patient, as a starting point for this
evaluation. A sample Prenatal Registration and Obstetrical Questionnaire form can be used
for this purpose.
One important aspect of prenatal care is education of the pregnant woman about her
pregnancy, danger signs, things she should do and things she should not do.
Many providers find it useful to give the woman printed material covering these issues that
she can take with her. This allows her to read the material at a later time and to refer to it
whenever she has questions. A sample Prenatal Information form can be printed and used.
Early in pregnancy, often at the first prenatal visit, a complete physical exam is performed. At
that time, a Pap smear and cervical cultures are obtained. In many practices, an ultrasound
scan is done at or shortly after the first visit to:
There are so many issues to cover during the first prenatal visit (history, physical, labs,
patient education, paperwork), that many physicians schedule two "first prenatal visits."
•
EDC
Based on the history, physical exam and ultrasound scan (if done), it is important to establish
a gestational age and estimated date of confinement (EDC, or "Due Date").
You may use the last menstrual period, if known, reliable, and the patient has a history of
regular periods. Add 280 days (40 0/7 weeks) to the LMP and this will give you her EDC.
This assumes that she ovulated on day #14 of her last menstrual cycle. To assist you in
making this calculation, I'm enclosing a LMP to EDC conversion chart here:
You may measure the fundal height (distance from the symphysis to the top of the uterus).
That distance in centimeters is roughly equal to the weeks gestation of the patient.
Estimates of gestational age and EDC are best done early in pregnancy when the patient's
memory is the best, and the variation is uterine size and fetal size is small.
Subsequent Visits
At these visits, you will want to ask the patient about any interval changes. You'll also want to
know about any vaginal discharge or bleeding, fetal movements, and uterine contractions.
At each visit, perform a limited physical exam, consisting of weight, blood pressure, edema,
fundal height, fetal heart rate, and note the presence or absence of proteinuria and glucosuria.
At times, it may be important to determine fetal orientation.
Check weight
Typical weight gain is about a pound a
week. This means 30 to 40 pounds for
the entire pregnancy, although some
physicians feel the ideal weight gain
should be closer to 25 pounds.
Too much weight gain leads to concerns about soft tissue dystocia during labor and difficulty
with restoring normal weight after delivery.
If there is sudden weight gain (more than 2 pounds in a week or more than 6 pounds in a
month), this may be associated with the development of fluid retention due to pre-eclampsia
(toxemia of pregnancy).
Pregnancy Video
Blood Pressure
Measure the blood pressure at each prenatal visit. Significant cardiovascular changes occur
during pregnancy, including a 50% increase in blood volume, 50% increase in cardiac output,
significant reduction in peripheral resistance, and a mild, sustained tachycardia. While these
changes are taking place, I would make the following generalizations about blood pressure:
Fundal Height
Use a tape measure to record the size
of the uterus. The fundal height,
measured in cm, should be
approximately equal to the weeks
gestation, from mid-pregnancy until
near term (MacDonald's Rule).
Measurements falling within 1-3 cm of
the expected value are considered
normal. Fundal heights 4 cm different
than expected are considered abnormal
and suggest the need for further
investigation.
The rates are typically higher (140-160) in early pregnancy, and lower (120-140)
toward the end of pregnancy.
Past term, some normal fetal heart rates fall to 110 BPM.
There is no correlation between heart rate and the gender of the fetus.
Use a coupling agent (eg, Ultrasound jel, surgical lubricant, or even water) to make a good
acoustical connection between the transducer and the skin.
Doppler fetal heartbeat detectors are moderately directional, so unless you happen to aim it
directly at the fetal heart initially, you will need to move it or angle it to find the heartbeat.
Confirm a normal rate, and listen for any abnormalities in the rhythm of the fetal heart beat.
Facial edema, severe pedal edema, or any sudden increase in edema can be a sign of
developing pre-eclampsia, so the BP should be checked. Usually, rapid accumulation of
extracellular fluid is accompanied by a significant weight gain in a very short time.
It is not necessary to treat simple edema, in the absence of pre-eclampsia. However, some
patients are so uncomfortable or their edema is so substantial that you may feel compelled to
treat the patient. One effective treatment for edema is bed rest for 2-3 days, while drinking
plenty of plain water and avoiding excessive salt. This technique:
Negative Trace 1+ 2+ 3+ 4+
Category
Protein Protein Protein Protein Protein Protein
Dipstick
<15 mg/dL 15-29 mg/dL 30 mg/dL 100 mg/dl 300 mg/dl >2000 mg/dL
Results
Equivalent
1000-2999
24-hour <150 mg 150-299 mg 300-999 mg 3-20 g >20 g
mg
Protein
For glucose, urine normally shows negative or trace. If persistently 1/4 (250 gm/dl) or more,
it is considered significant.
Fetal Orientation
The presentation (head first, breech
first, transverse lie) and position
(anterior, posterior, transverse) can be
determined in several ways: