prenatal visit guidelines

SARAH INÉS RAMÍREZ, MD, FAAFP

Am Fam Physician. 2023;108(2):139-150

Related AFP Community Blog:   Practice Ancestry-Based Medicine, not Racial Essentialism

Related editorial:   Perinatal Care of Transgender Patients, Adolescent Patients, and Patients With Opioid Use Disorder

Author disclosure: No relevant financial relationships.

Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater satisfaction, and lower pregnancy-associated morbidity and mortality. Care initiated at 10 weeks or earlier improves outcomes. Identification and treatment of periodontal disease decreases preterm delivery risk. A prepregnancy body mass index greater than 25 kg per m 2 is associated with gestational diabetes mellitus, hypertension, miscarriage, and stillbirth. Advanced maternal and paternal age (35 years or older) is associated with gestational diabetes, hypertension, miscarriage, intrauterine growth restriction, aneuploidy, birth defects, and stillbirth. Rh o (D) immune globulin decreases alloimmunization risk in a patient who is RhD-negative carrying a fetus who is RhD-positive. Treatment of iron deficiency anemia decreases the risk of preterm delivery, intrauterine growth restriction, and perinatal depression. Ancestry-based genetic risk stratification using family history can inform genetic screening. Folic acid supplementation (400 to 800 mcg daily) decreases the risk of neural tube defects. All pregnant patients should be screened for asymptomatic bacteriuria, sexually transmitted infections, and immunity against rubella and varicella and should receive tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), influenza, and COVID-19 vaccines. Testing for group B Streptococcus should be performed between 36 and 37 weeks, and intrapartum antibiotic prophylaxis should be initiated to decrease the risk of neonatal infection. Because of the impact of social determinants of health on outcomes, universal screening for depression, anxiety, intimate partner violence, substance use, and food insecurity is recommended early in pregnancy. Screening for gestational diabetes between 24 and 28 weeks is recommended for all patients. People at risk of preeclampsia, including those diagnosed with COVID-19 in pregnancy, should be offered 81 mg of aspirin daily starting at 12 weeks. Chronic hypertension should be treated to a blood pressure of less than 140/90 mm Hg.

Family physicians provide family-centered care for individuals and families before, during, and after the birth of a child. Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater care satisfaction, improved perinatal outcomes, and mitigates pregnancy-associated morbidity and mortality. 1 Family physicians are uniquely positioned to address social determinants of health while ensuring quality of care.

Prenatal Care Visits

Initiation of care between six and 10 weeks allows for identification of preexisting conditions that negatively affect maternal-fetal outcomes (e.g., diabetes mellitus, hypertension, obesity) 2 ; however, 22% of pregnant patients do not receive care during this time. 2 The COVID-19 pandemic resulted in a reevaluation of the number of physician visits needed, with an emphasis on increased flexibility, allowing for a combination of virtual and in-person visits depending on risk. 3 Table 1 outlines the components of prenatal care. 1 , 4 – 22 Table 2 provides opportunities for educating pregnant patients during prenatal care visits. 6 , 8 , 14 – 19 , 23 – 29

PHYSICAL EXAMINATION

Weight, height, and blood pressure should be measured at the first prenatal visit. Early identification of periodontal disease and treatment decreases adverse pregnancy outcomes. 7 Treatment may be performed in the second trimester, and emergent treatment may be completed at any time during pregnancy. 7 A bimanual pelvic examination has poor predictive value for clinical pelvimetry and screening for disease (i.e., sexually transmitted infections and cancer) but may be used as a diagnostic aid in patients with a discrepancy between uterine size and gestational age, which warrants ultrasonography assessment. 30 A pelvic examination is also useful in a symptomatic patient for evaluating spontaneous labor (e.g., cervical dilation, rupture of amniotic membranes). The clinical breast examination is a diagnostic aid in the symptomatic patient and addresses breastfeeding concerns or barriers but does not demonstrate benefit in patients already receiving screening mammograms and does not decrease mortality. 31 – 33

MATERNAL WEIGHT GAIN AND NUTRITION

A prepregnancy body mass index (BMI) greater than 25 kg per m 2 is associated with preterm delivery, gestational diabetes, gestational hypertension, and preeclampsia. A BMI greater than 30 kg per m 2 is also associated with an increased risk of miscarriage, stillbirth, and obstructive sleep apnea. 6 Prepregnancy BMI informs the timing of fetal surveillance, nutritional counseling, and goals for gestational weight gain. Table 3 lists general dietary guidelines for pregnant people. 8 , 17 , 34 , 35 For Black and Hispanic people, a prepregnancy BMI greater than 25 kg per m 2 and the associated poor outcomes are worse compared with non-Hispanic White people. 36

PARENTAL AGE AT CONCEPTION

Advanced maternal and paternal age (35 years and older) is associated with poor outcomes (i.e., aneuploidy, birth defects, gestational diabetes, hypertension, intrauterine growth restriction [IUGR], miscarriage, and stillbirth). Activities focused on improving perinatal outcomes for this group, such as a detailed fetal anatomic screening on ultrasonography, may decrease morbidity and mortality. 37

PREGNANCY DATING AND ULTRASONOGRAPHY

Accurate gestational age estimation is critical to quality care because it enables more precise timing of interventions (e.g., aspirin for preeclampsia prevention, steroids for fetal lung maturity), screening tests, and delivery. Up to 40% of people estimate their last menstrual period incorrectly; therefore, ultrasonography is recommended if uncertainty exists and for patients with irregular menstrual cycles, irregular bleeding, and discrepancy between uterine size and gestational age. 1 , 38 Ultrasonography before 24 weeks decreases missed multiple gestations and post-term inductions. 39 Although routine third-trimester ultrasonography may increase detection of IUGR, it does not improve outcomes. 40 If malpresentation is suspected on physical examination, confirmation with ultrasonography is recommended. 4

ALLOIMMUNIZATION

For patients who are RhD-negative and carrying a fetus who is RhD-positive, the alloimmunization risk is 1.5% to 2% in the setting of spontaneous abortion and 4% to 5% with dilation and curettage. The risk is decreased by 80% to 90% with anti-D immune globulin. 41 Testing for the ABO blood group and RhD antibodies should be performed early in pregnancy. A 300-mcg dose of anti-D immune globulin is recommended for RhD-negative pregnant patients at 28 weeks and again within 72 hours of delivery if the infant is RhD-positive. 41

Iron deficiency anemia increases the risk of preterm delivery, IUGR, and perinatal depression. The U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening for anemia in pregnancy. 42 Screening is recommended by the American College of Obstetricians and Gynecologists early in pregnancy, with iron treatment if deficient. 43 Intravenous iron should be considered for patients who cannot tolerate oral iron or in whom oral iron has been ineffective at correcting the deficiency. 43 Patients with non–iron deficiency anemia, or if iron repletion is ineffective within six weeks, should be referred to a hematologist for further evaluation. Iron supplementation in the first trimester decreases the prevalence of iron deficiency. 43

INHERITED CONDITIONS

Pregnant patients should be counseled and offered aneuploidy (extra or missing chromosomes) screening in early pregnancy, regardless of age. 44 In the United States, 1 in 150 infants has a chromosomal condition, the most common being trisomy 21 (Down syndrome). 44 Table 4 compares screening tests for Down syndrome. 1 , 45 , 46 If a screening test is positive, amniocentesis at 15 weeks or more or chorionic villous sampling between 11 and 13 weeks is recommended. Both procedures have similar rates of fetal loss. 47 At 35 years of age, the risk of Down syndrome (1 in 294 births) is similar to that of fetal loss from amniocentesis. 47 Serum and nuchal translucency testing can screen for other trisomies, including 13 and 18, the protocols for which have lower sensitivities and higher specificities compared with screening protocols for trisomy 21 because they are rarer. 47

Additional genetic screening should be based on maternal and paternal personal and family histories. Race is a social construct, necessitating a shift in genetic risk stratification from race-based to ancestry-based. Sickle cell disease affects up to 100,000 people in the United States, but its inheritance pattern (1:10) is based on people with African ancestry, which includes much of the world. 48 Cystic fibrosis is inherited mainly by people of European ancestry (1:25), but ignoring the possibility of European ancestry in certain racial and ethnic groups results in an underestimation of its prevalence: African (1:61), Hispanic (1:40), and Mediterranean (1:29). 49

NEURAL TUBE DEFECTS

In the United States, neural tube defects affect approximately 2,600 infants per year, with the highest prevalence in Hispanic populations. 35 , 50 All pregnant patients should be counseled and offered screening with maternal serum alpha fetoprotein. 35 Folic acid, 400 to 800 mcg daily, started at least one month before conception and continued until the end of the first trimester, decreases the incidence of neural tube defects by nearly 78%. 35 Patients taking folic acid antagonists (e.g., carbamazepine, methotrexate, trimethoprim) or who have a history of carrying a fetus with a neural tube defect should take 4 mg of folic acid daily, starting at least three months before conception. 35

THYROID DISORDERS

There is no evidence that screening for thyroid disorders improves pregnancy outcomes. Thyroid-stimulating hormone levels should be measured if there is a history of thyroid disease or symptoms of disease. If the level is abnormal, a free thyroxine test helps determine the etiology. 51 Hypothyroidism complicates 1 to 3 per 1,000 pregnancies and increases the risk of fetal loss, preeclampsia, IUGR, and stillbirth. Hyperthyroidism occurs in 2 per 1,000 pregnancies and is associated with miscarriage, preeclampsia, IUGR, preterm delivery, thyroid storm, and congestive heart failure. 51 The effect of subclinical hypothyroidism on a child's neurocognitive development is not well understood, and the effectiveness of treatment with levothyroxine is unproven. 51

CERVICAL CANCER

Intervals for cervical cancer screening are based on patient age, cytology history, and history of the presence of high-risk human papillomavirus (HPV). Routine screening for people at average risk of cervical cancer should begin at 21 years of age. Screening can be performed with either cytology alone every three years, HPV screening alone every five years, or cytology plus HPV screening every five years starting at 25 years of age. Screening is not indicated for people 65 years and older with negative screening in the previous 10 years, and no history of cervical intraepithelial neoplasia grade 2 or higher in the past 25 years. 52 Colposcopy is indicated when the risk of cervical intraepithelial neoplasia grade 3 is greater than 4%. Surveillance of high-grade lesions should be performed every 12 to 24 weeks. 52 , 53 Although colposcopy and cervical biopsy can be safely performed during pregnancy, endocervical sampling should be deferred until postpartum. 53

Infectious Disease

Bacteriuria.

Asymptomatic bacteriuria complicates up to 15% of pregnancies in the United States, 30% of which progress to pyelonephritis if untreated. 54 All pregnant patients should be screened for bacteriuria at the first prenatal visit. 54 A culture from a midstream or clean-catch sample with greater than 100,000 colony-forming units per mL of a single pathogen is considered positive and treated to decrease the risk of pyelonephritis and subsequent preterm delivery. 54

SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections can affect prenatal outcomes. 55 – 57 Table 5 lists routine screening and treatment for sexually transmitted infections in pregnancy. 55 , 56

Rubella immunity screening during the first prenatal visit is recommended. Postpartum vaccination should also be offered if the patient is not immune to prevent congenital rubella syndrome in subsequent pregnancies. 1 , 58 The presence of rubella immunoglobulin G should be interpreted with caution in patients recently migrating from areas where rubella is endemic because this may indicate a recent infection. 58 Rubella is a live vaccine and should not be administered during pregnancy but is safe during lactation after delivery. 59 , 60

Maternal varicella can result in congenital varicella syndrome (i.e., IUGR and limb, ophthalmologic, and neurologic abnormalities) and neonatal varicella; infection can occur from approximately five days before to two days after birth. A negative history of varicella infection or vaccination warrants serologic testing, and if immunoglobulin G is negative, varicella exposure should be avoided. Postpartum vaccination should be offered. 61

Although tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination is recommended for anyone in close contact with the infant, only antenatal maternal vaccination ensures increased protection against neonatal pertussis. 62 Pregnant patients should receive a Tdap vaccine beginning at 27 weeks to maximize time for passive immunity to the fetus through the placental transfer of maternal antibodies; vaccination is recommended in each subsequent pregnancy. 62

INFLUENZA AND COVID-19

Influenza and COVID-19 infection in pregnancy increase the risk of intensive care unit admission, preterm delivery, stillbirth, and maternal death. 63 , 64 COVID-19 infection almost doubles the risk of developing preeclampsia 64 ; therefore, initiating low-dose aspirin (81 mg daily) starting at 12 weeks should be considered. 5 Pregnant patients and their household contacts should be vaccinated for influenza and COVID-19. 63 , 64

GROUP B STREPTOCOCCUS

In the United States, group B Streptococcus (GBS) is the leading cause of infection in the first three months of life; 25% of all pregnant patients are GBS carriers. 65 , 66 Screening with a vaginal-rectal swab for culture between 36 and 37 weeks is recommended. 67 Intrapartum antibiotic prophylaxis decreases neonatal mortality. Antibiotics are recommended when there is GBS bacteriuria with the current pregnancy, a history of a previous infant affected by GBS (e.g., septicemia, meningitis, pneumonia, death), or unknown GBS status and risk factors (e.g., preterm labor, rupture of membranes more than 18 hours before delivery, GBS in previous pregnancy). 67 Patients with GBS bacteriuria in the current pregnancy are assumed to be colonized and do not need subsequent screening. 67

Social Determinants of Health

Social determinants of health represent up to 80% of the factors that directly affect a person's health. 68 Physicians who provide prenatal care play a critical role in mitigating the burden that social determinants of health play on maternal-child health without compromising the quality of care delivered. 69 An increased burden from social determinants of health increases the risk of depression, anxiety, intimate partner violence, substance use, and food insecurity 70 , 71 ; therefore, universal screening is recommended early in pregnancy.

DEPRESSION AND ANXIETY-RELATED DISORDERS

After the COVID-19 pandemic, rates of perinatal depression and anxiety have increased. People who are non-White, 24 years or younger, or who have 12 years or less of education, lower socioeconomic status, or a history of intimate partner violence or sexual trauma are at higher risk. 11 , 72 , 73 If untreated, depression and anxiety-related disorders increase the risk of preeclampsia, preterm delivery, IUGR, substance use, maternal suicide, infanticide, psychosis, and homicide. 11

INTIMATE PARTNER VIOLENCE

Intimate partner–related homicide is the leading cause of death in the United States in pregnancy. Screening is recommended at the first prenatal visit and once per trimester. 13 Intimate partner violence increases the risk of miscarriage, placental abruption, premature rupture of membranes, IUGR, and preterm delivery. 13 Family physicians should be aware of the signs of intimate partner violence (e.g., frequent sexually transmitted infections, repeated requests for pregnancy tests when pregnancy is not desired, fear of asking a partner to use a condom), the effect of violence on health, and the increased risk of child abuse after delivery. 13

SUBSTANCE USE

Substance use during pregnancy increases the risk of IUGR, preterm delivery, stillbirth, fetal malformations, and maternal death. 74 The use of prescription opioids complicates 7% of pregnancies in the United States; of these, 20% of patients report misuse. 75 Opioid use in pregnancy increased by 131% from 2010 to 2017 in the United States, and the incidence of babies born with withdrawal symptoms in that time increased by 82%. 76 Fetal alcohol exposure is the leading cause of preventable neurodevelopmental disorders in the United States. 14 However, 14% of pregnant patients report current drinking, and 5% report binge drinking in the past 30 days. 77 Exposure to cigarette smoking in utero increases the risk of sudden intrauterine and infant death. 15

FOOD INSECURITY

Maternal food insecurity increases the risk of poor outcomes (e.g., IUGR, preterm delivery, gestational diabetes, hypertension, depression, anxiety). However, few patients disclose this due to concerns about social stigma; therefore, a universal approach to screening is encouraged. The Hunger Vital Sign tool may be used. 12

Complications of Pregnancy

Gestational diabetes.

Gestational diabetes complicates up to 14% of U.S. pregnancies, with up to 67% of patients developing type 2 diabetes later in life. 78 Racial and ethnic minorities are at the highest risk. 79 Gestational diabetes is associated with hypertension, macrosomia, shoulder dystocia, and cesarean deliveries. 80 Screening for undiagnosed type 2 diabetes at the initial prenatal visit is recommended for people at increased risk 80 ( Table 6 5 , 80 ) . Universal screening for gestational diabetes should occur between 24 and 28 weeks with a one-hour (50-g) glucose tolerance test and, if results are abnormal, should be followed by a confirmatory, fasting, three-hour (100-g) test. 80

HYPERTENSION

Blood pressure should be monitored at each prenatal visit, and education should be provided on preeclampsia warning signs. 5 Patients at increased risk of preeclampsia should be screened for thrombocytopenia, transaminitis, and renal insufficiency, including proteinuria, during the first or second trimester and started on prophylactic daily low-dose aspirin (81 mg) between 12 and 16 weeks 5 , 85 ( Table 6 5 , 80 ) . [Updated] Screening for proteinuria in isolation has little predictive value for detecting preeclampsia. 5 Chronic hypertension (hypertension before 20 weeks) is treated to less than 140/90 mm Hg. 81

PRETERM DELIVERY

Preterm delivery (between 20 and 37 weeks) is a significant cause of neonatal morbidity and mortality, complicating 10.5% of U.S. pregnancies. 2 Modifiable risk factors include prepregnancy BMI (less than 18.5 kg per m 2 and greater than 25 kg per m 2 ), substance use, and short interval between pregnancies (i.e., less than 18 months). 82 Several options are available for the prevention of preterm labor in a singleton pregnancy. 82 Patients with a previous preterm delivery before 34 weeks should have a cervical length assessment starting at 16 weeks through 24 weeks. 82 These patients should be treated with progesterone supplementation (vaginal or intramuscular). In the asymptomatic patient with a short cervix and without a history of spontaneous birth before 34 weeks, vaginal progesterone (200 mg) started between 16 and 20 weeks and continued through 36 weeks is recommended. 82

POST-TERM DELIVERY

Stillbirth complicates 3 per 1,000 post-term (42 weeks or greater) pregnancies. 20 Antenatal testing should be initiated at 41 weeks; if the results are not reassuring, induction of labor is recommended. 20 , 21

Cultural Considerations

Maternity care improves outcomes; however, vulnerable populations (i.e., racial, ethnic, and religious minorities) are less likely to engage in care if it is not culturally centered, which acknowledges the effect of culture on health conditions (e.g., depression) and enhances patient-physician trust. 83 Addressing cultural needs (e.g., doula, community health workers, interpreters) throughout pregnancy helps mitigate barriers and improves outcomes.

This article updates previous articles on this topic by Zolotor and Carlough 1 ; Kirkham, et al. 17 ; and Kirkham, et al. 84

Data Sources: A search was completed using the key terms prenatal care, COVID-19, oral health, pelvic examination, prepregnancy body mass index, pregnancy dating and ultrasound, maternal and paternal age and impact on pregnancy outcomes, aneuploidy screening, inheritance patterns of sickle cell disease and cystic fibrosis, anemia, cell-free DNA analysis, thyroid disease, cervical cancer screening, management of abnormal cervical cytology, screening guidelines for sexually transmitted infections in pregnancy, group B Streptococcus screening, social determinants of health and prenatal outcomes, intimate partner violence, polysubstance abuse, food insecurity, maternity care deserts, hypertension in pregnancy, progesterone for preterm birth prevention, post-term delivery, and preconception care. Also searched were PubMed, Essential Evidence Plus, the Cochrane database, U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Cancer Society, American Family Physician , and reference lists of retrieved articles. Search dates: July 1, 2022; February 19, 2023; and June 16, 2023.

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Jamieson DJ, Rasmussen SA. An update on COVID-19 and pregnancy. Am J Obstet Gynecol. 2022;226(2):177-186.

Nanduri SA, Petit S, Smelser C, et al. Epidemiology of invasive early-onset and late-onset group b streptococcal disease in the United States, 2006 to 2015: multistate laboratory and population-based surveillance [published corrections appear in JAMA Pediatr . 2019; 173(3): 296, and JAMA Pediatr . 2019; 173(5): 502]. JAMA Pediatr. 2019;173(3):224-233.

Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report. Emerging infections program network, group B Streptococcus , 2018. May 19, 2020. Accessed October 12, 2022. https://www.cdc.gov/abcs/reports-findings/survreports/gbs18.pdf?CDC_AA_refVal= https%3A%2F%2Fwww.cdc.gov%2Fabcs%2Freports-findings%2Fsurvreports%2Fgbs18.html

Prevention of group b streptococcal early-onset disease in newborns: ACOG committee opinion, no. 797 [published correction appears in Obstet Gynecol . 2020; 135(4): 978–979]. Obstet Gynecol. 2020;135(2):e51-e72.

Institute for Clinical Systems Improvement. Going beyond clinical walls: solving complex problems. October 2014. Accessed October 11, 2022. https://www.icsi.org/wp-content/uploads/2019/08/1.SolvingComplexProblems_BeyondClinicalWalls.pdf

Partin M, Sanchez A, Poulson J, et al. Social inequities between prenatal patients in family medicine and obstetrics and gynecology with similar outcomes. J Am Board Fam Med. 2021;34(1):181-188.

Compton MT, Shim RS. The social determinants of mental health. Focus. 2015;13(4):419-425.

Kuhrau C, Kelly E, DeFranco EA. Social determinants of health associated with intimate partner violence in an urban obstetric population. Am J Obstet Gynecol. 2023;228(1):S110-S111.

Bauman BL, Ko JY, Cox S, et al. Vital signs: postpartum depressive symptoms and provider discussions about perinatal depression - United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(19):575-581.

Lombardi BN, Jensen TM, Parisi AB, et al. The relationship between a lifetime history of sexual victimization and perinatal depression: a systematic review and meta-analysis. Trauma Violence Abuse. 2023;24(1):139-155.

Yazdy MM, Desai RJ, Brogly SB. Prescription opioids in pregnancy and birth outcomes. J Pediatr Genet. 2015;4(2):56-70.

Ko JY, D'Angelo DV, Haight SC, et al. Vital signs: prescription opioid pain reliever use during pregnancy–34 U.S. jurisdictions, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(28):897-903.

Hirai AH, Ko JY, Owens PL, et al. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010–2017 [published correction appears in JAMA . 2021; 325(22): 2316]. JAMA. 2021;325(2):146-155.

Gosdin LK, Deputy NP, Kim SY, et al. Alcohol consumption and binge drinking during pregnancy among adults aged 18–49 years–United States, 2018–2020 [published correction appears in MMWR Morb Mortal Wkly Rep . 2022; 71(4): 156]. MMWR Morb Mortal Wkly Rep. 2022;71(1):10-13.

Diaz-Santana MV, O'Brien KM, Park YM, et al. Persistence of risk for type 2 diabetes after gestational diabetes mellitus. Diabetes Care. 2022;45(4):864-870.

Bower JK, Butler BN, Bose-Brill S, et al. Racial/ethnic differences in diabetes screening and hyperglycemia among US women after gestational diabetes. Prev Chronic Dis. 2019;16:E145.

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Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386(19):1781-1792.

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Gopalkrishnan N. Cultural diversity and mental health: considerations for policy and practice. Front Public Health. 2018;6:179.

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INTRODUCTION

This topic will discuss the initial prenatal assessment (which may require more than one visit) in the United States. Most of these issues are common to pregnancies worldwide. Preconception care, ongoing prenatal care after the initial prenatal assessment, and issues related to patient counseling are reviewed separately.

● (See "The preconception office visit" .)

● (See "Prenatal care: Second and third trimesters" .)

● (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs" .)

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Please call 911 or go to the nearest emergency room if you are experiencing a medical emergency.

Prenatal care and tests

Medical checkups and screening tests help keep you and your baby healthy during pregnancy. This is called prenatal care. It also involves education and counseling about how to handle different aspects of your pregnancy. During your visits, your doctor may discuss many issues, such as healthy eating and physical activity, screening tests you might need, and what to expect during labor and delivery.

Choosing a prenatal care provider

You will see your prenatal care provider many times before you have your baby. So you want to be sure that the person you choose has a good reputation, and listens to and respects you. You will want to find out if the doctor or midwife can deliver your baby in the place you want to give birth , such as a specific hospital or birthing center. Your provider also should be willing and able to give you the information and support you need to make an informed choice about whether to breastfeed or bottle-feed.

Health care providers that care for women during pregnancy include:

• Obstetricians (OB) are medical doctors who specialize in the care of pregnant women and in delivering babies. OBs also have special training in surgery so they are also able to do a cesarean delivery . Women who have health problems or are at risk for pregnancy complications should see an obstetrician. Women with the highest risk pregnancies might need special care from a maternal-fetal medicine specialist .
• Family practice doctors are medical doctors who provide care for the whole family through all stages of life. This includes care during pregnancy and delivery, and following birth. Most family practice doctors cannot perform cesarean deliveries.
• A certified nurse-midwife (CNM) and certified professional midwife (CPM) are trained to provide pregnancy and postpartum care. Midwives can be a good option for healthy women at low risk for problems during pregnancy, labor, or delivery. A CNM is educated in both nursing and midwifery. Most CNMs practice in hospitals and birth centers. A CPM is required to have experience delivering babies in home settings because most CPMs practice in homes and birthing centers. All midwives should have a back-up plan with an obstetrician in case of a problem or emergency.

Ask your primary care doctor, friends, and family members for provider recommendations. When making your choice, think about:

• Personality and bedside manner
• The provider's gender and age
• Office location and hours
• Whether you always will be seen by the same provider during office checkups and delivery
• Who covers for the provider when she or he is not available
• Where you want to deliver
• How the provider handles phone consultations and after-hour calls

What is a doula?

A doula (DOO-luh) is a professional labor coach, who gives physical and emotional support to women during labor and delivery. They offer advice on breathing, relaxation, movement, and positioning. Doulas also give emotional support and comfort to women and their partners during labor and birth. Doulas and midwives often work together during a woman's labor. A recent study showed that continuous doula support during labor was linked to shorter labors and much lower use of:

• Pain medicines
• Oxytocin (ok-see-TOHS-uhn) (medicine to help labor progress)
• Cesarean delivery

Check with your health insurance company to find out if they will cover the cost of a doula. When choosing a doula, find out if she is certified by Doulas of North America (DONA) or another professional group.

Places to deliver your baby

Many women have strong views about where and how they'd like to deliver their babies. In general, women can choose to deliver at a hospital, birth center, or at home. You will need to contact your health insurance provider to find out what options are available. Also, find out if the doctor or midwife you are considering can deliver your baby in the place you want to give birth.

Hospitals are a good choice for women with health problems, pregnancy complications, or those who are at risk for problems during labor and delivery. Hospitals offer the most advanced medical equipment and highly trained doctors for pregnant women and their babies. In a hospital, doctors can do a cesarean delivery if you or your baby is in danger during labor. Women can get epidurals or many other pain relief options. Also, more and more hospitals now offer on-site birth centers, which aim to offer a style of care similar to standalone birth centers.

Questions to ask when choosing a hospital:

• Is it close to your home?
• Is a doctor who can give pain relief, such as an epidural, at the hospital 24-hours a day?
• Do you like the feel of the labor and delivery rooms?
• Are private rooms available?
• How many support people can you invite into the room with you?
• Does it have a neonatal intensive care unit (NICU) in case of serious problems with the baby?
• Can the baby stay in the room with you?
• Does the hospital have the staff and set-up to support successful breastfeeding?
• Does it have an on-site birth center?

Birth or birthing centers give women a "homey" environment in which to labor and give birth. They try to make labor and delivery a natural and personal process by doing away with most high-tech equipment and routine procedures. So, you will not automatically be hooked up to an IV. Likewise, you won't have an electronic fetal monitor around your belly the whole time. Instead, the midwife or nurse will check in on your baby from time to time with a handheld machine. Once the baby is born, all exams and care will occur in your room. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers. Healthy women who are at low risk for problems during pregnancy, labor, and delivery may choose to deliver at a birth center.

Women can not receive epidurals at a birth center, although some pain medicines may be available. If a cesarean delivery becomes necessary, women must be moved to a hospital for the procedure. After delivery, babies with problems can receive basic emergency care while being moved to a hospital.

Many birthing centers have showers or tubs in their rooms for laboring women. They also tend to have comforts of home like large beds and rocking chairs. In general, birth centers allow more people in the delivery room than do hospitals.

Birth centers can be inside of hospitals, a part of a hospital or completely separate facilities. If you want to deliver at a birth center, make sure it meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. Accredited birth centers must have doctors who can work at a nearby hospital in case of problems with the mom or baby. Also, make sure the birth center has the staff and set-up to support successful breastfeeding.

Homebirth is an option for healthy pregnant women with no risk factors for complications during pregnancy, labor or delivery. It is also important women have a strong after-care support system at home. Some certified nurse midwives and doctors will deliver babies at home. Many health insurance companies do not cover the cost of care for homebirths. So check with your plan if you'd like to deliver at home.

Homebirths are common in many countries in Europe. But in the United States, planned homebirths are not supported by the American Congress of Obstetricians and Gynecologists (ACOG). ACOG states that hospitals are the safest place to deliver a baby. In case of an emergency, says ACOG, a hospital's equipment and highly trained doctors can provide the best care for a woman and her baby.

If you are thinking about a homebirth, you need to weigh the pros and cons. The main advantage is that you will be able to experience labor and delivery in the privacy and comfort of your own home. Since there will be no routine medical procedures, you will have control of your experience.

The main disadvantage of a homebirth is that in case of a problem, you and the baby will not have immediate hospital/medical care. It will have to wait until you are transferred to the hospital. Plus, women who deliver at home have no options for pain relief.

To ensure your safety and that of your baby, you must have a highly trained and experienced midwife along with a fail-safe back-up plan. You will need fast, reliable transportation to a hospital. If you live far away from a hospital, homebirth may not be the best choice. Your midwife must be experienced and have the necessary skills and supplies to start emergency care for you and your baby if need be. Your midwife should also have access to a doctor 24 hours a day.

Prenatal checkups

During pregnancy, regular checkups are very important. This consistent care can help keep you and your baby healthy, spot problems if they occur, and prevent problems during delivery. Typically, routine checkups occur:

• Once each month for weeks four through 28
• Twice a month for weeks 28 through 36
• Weekly for weeks 36 to birth

Women with high-risk pregnancies need to see their doctors more often.

At your first visit your doctor will perform a full physical exam, take your blood for lab tests, and calculate your due date. Your doctor might also do a breast exam, a pelvic exam to check your uterus (womb), and a cervical exam, including a Pap test. During this first visit, your doctor will ask you lots of questions about your lifestyle, relationships, and health habits. It's important to be honest with your doctor.

After the first visit, most prenatal visits will include:

• Checking your blood pressure and weight
• Checking the baby's heart rate
• Measuring your abdomen to check your baby's growth

You also will have some routine tests throughout your pregnancy, such as tests to look for anemia , tests to measure risk of gestational diabetes , and tests to look for harmful infections.

Become a partner with your doctor to manage your care. Keep all of your appointments — every one is important! Ask questions and read to educate yourself about this exciting time.

Monitor your baby's activity

After 28 weeks, keep track of your baby's movement. This will help you to notice if your baby is moving less than normal, which could be a sign that your baby is in distress and needs a doctor's care. An easy way to do this is the "count-to-10" approach. Count your baby's movements in the evening — the time of day when the fetus tends to be most active. Lie down if you have trouble feeling your baby move. Most women count 10 movements within about 20 minutes. But it is rare for a woman to count less than 10 movements within two hours at times when the baby is active. Count your baby's movements every day so you know what is normal for you. Call your doctor if you count less than 10 movements within two hours or if you notice your baby is moving less than normal. If your baby is not moving at all, call your doctor right away.

Prenatal tests

Tests are used during pregnancy to check your and your baby's health. At your fist prenatal visit, your doctor will use tests to check for a number of things, such as:

• Your blood type and Rh factor
• Infections, such as toxoplasmosis and sexually transmitted infections (STIs), including hepatitis B , syphilis , chlamydia , and HIV
• Signs that you are immune to rubella (German measles) and chicken pox

Throughout your pregnancy, your doctor or midwife may suggest a number of other tests, too. Some tests are suggested for all women, such as screenings for gestational diabetes, Down syndrome, and HIV. Other tests might be offered based on your:

• Personal or family health history
• Ethnic background
• Results of routine tests

Some tests are screening tests. They detect risks for or signs of possible health problems in you or your baby. Based on screening test results, your doctor might suggest diagnostic tests. Diagnostic tests confirm or rule out health problems in you or your baby.

Understanding prenatal tests and test results

If your doctor suggests certain prenatal tests, don't be afraid to ask lots of questions. Learning about the test, why your doctor is suggesting it for you, and what the test results could mean can help you cope with any worries or fears you might have. Keep in mind that screening tests do not diagnose problems. They evaluate risk. So if a screening test comes back abnormal, this doesn't mean there is a problem with your baby. More information is needed. Your doctor can explain what test results mean and possible next steps.

Avoid keepsake ultrasounds

You might think a keepsake ultrasound is a must-have for your scrapbook. But, doctors advise against ultrasound when there is no medical need to do so. Some companies sell "keepsake" ultrasound videos and images. Although ultrasound is considered safe for medical purposes, exposure to ultrasound energy for a keepsake video or image may put a mother and her unborn baby at risk. Don't take that chance.

High-risk pregnancy

Pregnancies with a greater chance of complications are called "high-risk." But this doesn't mean there will be problems. The following factors may increase the risk of problems during pregnancy:

• Very young age or older than 35
• Overweight or underweight
• Problems in previous pregnancy
• Health conditions you have before you become pregnant, such as high blood pressure , diabetes , autoimmune disorders , cancer , and HIV
• Pregnancy with twins or other multiples

Health problems also may develop during a pregnancy that make it high-risk, such as gestational diabetes or preeclampsia . See Pregnancy complications to learn more.

Women with high-risk pregnancies need prenatal care more often and sometimes from a specially trained doctor. A maternal-fetal medicine specialist is a medical doctor that cares for high-risk pregnancies.

If your pregnancy is considered high risk, you might worry about your unborn baby's health and have trouble enjoying your pregnancy. Share your concerns with your doctor. Your doctor can explain your risks and the chances of a real problem. Also, be sure to follow your doctor's advice. For example, if your doctor tells you to take it easy, then ask your partner, family members, and friends to help you out in the months ahead. You will feel better knowing that you are doing all you can to care for your unborn baby.

Paying for prenatal care

Pregnancy can be stressful if you are worried about affording health care for you and your unborn baby. For many women, the extra expenses of prenatal care and preparing for the new baby are overwhelming. The good news is that women in every state can get help to pay for medical care during their pregnancies. Every state in the United States has a program to help. Programs give medical care, information, advice, and other services important for a healthy pregnancy.

Learn more about programs available in your state.

You may also find help through these places:

• Local hospital or social service agencies – Ask to speak with a social worker on staff. She or he will be able to tell you where to go for help.
• Community clinics – Some areas have free clinics or clinics that provide free care to women in need.
• Women, Infants and Children (WIC) Program – This government program is available in every state. It provides help with food, nutritional counseling, and access to health services for women, infants, and children.
• Places of worship

More information on prenatal care and tests

Read more from womenshealth.gov.

• Pregnancy and Medicines Fact Sheet - This fact sheet provides information on the safety of using medicines while pregnant.

Explore other publications and websites

• Chorionic Villus Sampling (CVS) (Copyright © March of Dimes) - Chorionic villus sampling (CVS) is a prenatal test that can diagnose or rule out certain birth defects. The test is generally performed between 10 and 12 weeks after a woman's last menstrual period. This fact sheet provides information about this test, and how the test sample is taken.
• Folic Acid (Copyright © March of Dimes) - This fact sheet stresses the importance of getting higher amounts of folic acid during pregnancy in order to prevent neural tube defects in unborn children.
• Folic Acid: Questions and Answers - The purpose of this question and answer sheet is to educate women of childbearing age on the importance of consuming folic acid every day to reduce the risk of spina bifida.
• For Women With Diabetes: Your Guide to Pregnancy - This booklet discusses pregnancy in women with diabetes. If you have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon, you can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy.
• Genetics Home Reference - This website provides information on specific genetic conditions and the genes or chromosomes responsible for these conditions.
• Guidelines for Vaccinating Pregnant Women - This publication provides information on routine and other vaccines and whether they are recommended for use during pregnancy.
• How Your Baby Grows (Copyright © March of Dimes) - This site provides information on the development of your baby and the changes in your body during each month of pregnancy. In addition, for each month, it provides information on when to go for prenatal care appointments and general tips to take care of yourself and your baby.
• Pregnancy Registries - Pregnancy registries help women make informed and educated decisions about using medicines during pregnancy. If you are pregnant and currently taking medicine — or have been exposed to a medicine during your pregnancy — you may be able to participate and help in the collection of this information. This website provides a list of pregnancy registries that are enrolling pregnant women.
• Pregnancy, Breastfeeding, and Bone Health - This publication provides information on pregnancy-associated osteoporosis, lactation and bone loss, and what you can do to keep your bones healthy during pregnancy.
• Prenatal Care: First-Trimester Visits (Copyright © Mayo Foundation) - This fact sheet explains what to expect during routine exams with your doctor. In addition, if you have a condition that makes your pregnancy high-risk, special tests may be performed on a regular basis to check the baby's health.
• Ten Tips for a Healthy Pregnancy (Copyright © Lamaze International) - This easy-to-read fact sheet provides 10 simple recommendations to help mothers have a healthy pregnancy.
• Ultrasound (Copyright © March of Dimes) - This fact sheet discusses the use of an ultrasound in prenatal care at each trimester.

Connect with other organizations

• American Academy of Family Physicians
• American Association of Birth Centers
• American College of Obstetricians and Gynecologists
• Center for Research on Reproduction and Women's Health, University of Pennsylvania Medical Center
• Dona International
• March of Dimes
• Maternal and Child Health Bureau, HRSA, HHS
• National Association for Down Syndrome
• National Center on Birth Defects and Developmental Disabilities, CDC
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• Pregnancy week by week

Prenatal care: 3rd trimester visits

During the third trimester, prenatal care might include vaginal exams to check the baby's position.

Prenatal care is an important part of a healthy pregnancy, especially as your due date approaches. Your health care provider might ask you to schedule prenatal care appointments during your third trimester about every 2 or 4 weeks, depending on your health and pregnancy history. Starting at 36 weeks, you'll need weekly checkups until you deliver.

Repeat routine health checks

You'll be asked if you have any signs or symptoms, including contractions and leakage of fluid or bleeding. Your health care provider will check your blood pressure and weight gain, as well as your baby's heartbeat and movements.

Your health care provider might ask you to track of how often you feel the baby move on a daily basis — and to alert your health care team if the baby stops moving as much as usual.

Also, talk to your health care provider about any vaccinations you might need, including the flu shot and the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine. Ideally, the Tdap vaccine should be given between 27 and 36 weeks of pregnancy.

Test for group B strep

Expect to be screened for group B streptococcus (GBS) during the third trimester. GBS is a common bacterium often carried in the intestines or lower genital tract that's usually harmless in adults. But babies who become infected with GBS from exposure during vaginal delivery can become seriously ill.

To screen for GBS , your health care provider will swab your lower vagina and anal area. The sample will be sent to a lab for testing. If the sample tests positive for GBS — or you previously gave birth to a baby who developed GBS disease — you'll be given intravenous antibiotics during labor. The antibiotics will help protect your baby from the bacterium.

Check the baby's position

Near the end of pregnancy, your health care provider might check to see if your baby is positioned headfirst in the uterus.

If your baby is positioned rump-first (frank breech) or feet-first (complete breech) after week 36 of pregnancy, it's unlikely that the baby will move to a headfirst position before labor. You might be able to have an external cephalic version. During this procedure, your health care provider will apply pressure to your abdomen and physically manipulate your baby to a headfirst position. This is typically done with ultrasound guidance by an experienced doctor. If you prefer not to have this procedure, or if your baby remains in a breech position, your health care provider will discuss planning a C-section delivery.

Keep asking questions

You will likely have plenty of questions as your due date approaches. Is it OK to have sex? How will I know when I'm in labor? What's the best way to manage the pain? Should I create a birth plan? Ask away! Feeling prepared can help calm your nerves before delivery.

Also, be sure to discuss signs that should cause you to call your health care provider, such as vaginal bleeding or fluid leaking from the vagina, as well as when and how to contact your health care provider once labor begins.

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• Frequently asked questions. Pregnancy FAQ079. If your baby is breech. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/If-Your-Baby-Is-Breech. Accessed July 13, 2018.
• Prenatal care and tests. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests. Accessed July 9, 2018.
• Cunningham FG, et al., eds. Prenatal care. In: Williams Obstetrics. 25th ed. New York, N.Y.: McGraw-Hill Education; 2018. https://www.accessmedicine.mhmedical.com. Accessed July 9, 2018.
• Hofmeyr GJ. External cephalic version. https://www.uptodate.com/contents/search. Accessed July 10, 2018.
• Lockwood CJ, et al. Prenatal care: Second and third trimesters. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
• AskMayoExpert. Vaccination during pregnancy. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018.

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Your First Prenatal Visit

If you did not meet with your health care provider before you were pregnant, your first prenatal visit will generally be around 8 weeks after your LMP (last menstrual period ). If this applies to you, you should schedule a prenatal visit as soon as you know you are pregnant!

Even if you are not a first-time mother, prenatal visits are still important since every pregnancy is different. This initial visit will probably be one of the longest. It will be helpful if you arrive prepared with vital dates and information. This is also a good opportunity to bring a list of questions that you and your partner have about your pregnancy, prenatal care, and birth options.

What to Expect at Your First Pregnancy Appointment

Your doctor will ask for your medical history, including:.

• Medical and/or psychosocial problems
• Blood pressure, height, and weight
• Breast and cervical exam
• Date of your last menstrual period (an accurate LMP is helpful when determining gestational age and due date)
• Birth control methods
• History of abortions and/or miscarriages
• Hospitalizations
• Medications you are taking
• Medication allergies
• Your family’s medical history

Your healthcare provider will also perform a physical exam which will include a pap smear , cervical cultures, and possibly an ultrasound if there is a question about how far along you are or if you are experiencing any bleeding or cramping .

Blood will be drawn and several laboratory tests will also be done, including:

• Hemoglobin/ hematocrit
• Rh Factor and blood type (if Rh negative, rescreen at 26-28 weeks)
• Rubella screen
• Varicella or history of chickenpox, rubella, and hepatitis vaccine
• Cystic Fibrosis screen
• Hepatitis B surface antigen
• Tay Sach’s screen
• Sickle Cell prep screen
• Hemoglobin levels
• Hematocrit levels
• Specific tests depending on the patient, such as testing for tuberculosis and Hepatitis C

Your healthcare provider will probably want to discuss:

• Recommendations concerning dental care , cats, raw meat, fish, and gardening
• Fevers and medications
• Environmental hazards
• Travel limitations
• Miscarriage precautions
• Prenatal vitamins , supplements, herbs
• Diet , exercise , nutrition , weight gain
• Physician/ midwife rotation in the office

Possible questions to ask your provider during your prenatal appointment:

• Is there a nurse line that I can call if I have questions?
• If I experience bleeding or cramping, do I call you or your nurse?
• What do you consider an emergency?
• Will I need to change my habits regarding sex, exercise, nutrition?
• When will my next prenatal visit be scheduled?
• What type of testing do you recommend and when are they to be done? (In case you want to do research the tests to decide if you want them or not.)

If you have not yet discussed labor and delivery issues with your doctor, this is a good time. This helps reduce the chance of surprises when labor arrives. Some questions to ask include:

• What are your thoughts about natural childbirth ?
• What situations would warrant a Cesarean ?
• What situations would warrant an episiotomy ?
• How long past my expected due date will I be allowed to go before intervening?
• What is your policy on labor induction?

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What happens during prenatal visits?

What happens during prenatal visits varies depending on how far along you are in your pregnancy.

Schedule your first prenatal visit as soon as you think you are pregnant, even if you have confirmed your pregnancy with a home pregnancy test. Early and regular prenatal visits help your health care provider monitor your health and the growth of the fetus.

The First Visit

Your first prenatal visit will probably be scheduled sometime after your eighth week of pregnancy. Most health care providers won't schedule a visit any earlier unless you have a medical condition, have had problems with a pregnancy in the past, or have symptoms such as spotting or bleeding, stomach pain, or severe nausea and vomiting. 1

You've probably heard pregnancy discussed in terms of months and trimesters (units of about 3 months). Your health care provider and health information might use weeks instead. Here's a chart that can help you understand pregnancy stages in terms of trimesters, months, and weeks.

Because your first visit will be one of your longest, allow plenty of time.

During the visit, you can expect your health care provider to do the following: 1

• Answer your questions. This is a great time to ask questions and share any concerns you may have. Keep a running list for your visit.
• Check your urine sample for infection and to confirm your pregnancy.
• Check your blood pressure, weight, and height.
• Calculate your due date based on your last menstrual cycle and ultrasound exam.
• Ask about your health, including previous conditions, surgeries, or pregnancies.
• Ask about your family health and genetic history.
• Ask about your lifestyle, including whether you smoke, drink, or take drugs, and whether you exercise regularly.
• Ask about your stress level.
• Perform prenatal blood tests to do the following:
• Determine your blood type and Rh (Rhesus) factor. Rh factor refers to a protein found on red blood cells. If the mother is Rh negative (lacks the protein) and the father is Rh positive (has the protein), the pregnancy requires a special level of care. 2
• Do a blood count (e.g., hemoglobin, hematocrit).
• Test for hepatitis B, HIV, rubella, and syphilis.
• Do a complete physical exam, including a pelvic exam, and cultures for gonorrhea and chlamydia.
• Do a Pap test or test for human papillomavirus (HPV) or both to screen for cervical cancer and infection with HPV, which can increase risk for cervical cancer. The timing of these tests depends on the schedule recommended by your health care provider.
• Do an ultrasound test, depending on the week of pregnancy.
• Offer genetic testing: screening for Down syndrome and other chromosomal problems, cystic fibrosis, other specialized testing depending on history.

Prenatal Visit Schedule

If your pregnancy is healthy, your health care provider will set up a regular schedule for visits that will probably look about like this: 1

Later Prenatal Visits

As your pregnancy progresses, your prenatal visits will vary greatly. During most visits, you can expect your health care provider to do the following:

• Check your blood pressure.
• Measure your weight gain.
• Measure your abdomen to check your developing infant's growth—"fundal height" (once you begin to "show").
• Check the fetal heart rate.
• Check your hands and feet for swelling.
• Feel your abdomen to find the fetus's position (later in pregnancy).
• Do tests, such as blood tests or an ultrasound exam.

Talk to you about your questions or concerns. It's a good idea to write down your questions and bring them with you.

Several of these visits will include special tests to check for gestational diabetes (usually between 24 and 28 weeks) 3 and other conditions, depending on your age and family history.

In addition, the Centers for Disease Control and Prevention and the American Academy of Pediatrics released new vaccine guidelines for 2013 , including a recommendation for pregnant women to receive a booster of whooping cough (pertussis) vaccine. The guidelines recommend the shot be given between 27 and 36 weeks of pregnancy. 4

• Centers for Disease Control and Prevention. (2013). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (TDAP) in pregnant women―Advisory Committee on Immunization Practices (ACIP), 2012. Retrieved September 20, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm

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Priorities for the Prenatal Visit

Health supervision, surveillance of development, review of systems, observation of the family dynamic, physical examination, immunizations, anticipatory guidance, risks: living situation and food security, risks: environmental risks—dampness and mold, risks: environmental risks—lead, risks: environmental risks—pica, risks: pregnancy adjustment, risks: intimate partner violence, risks: maternal drug and alcohol use, risks: maternal tobacco use, strengths and protective factors: becoming well informed, strengths and protective factors: family constellation and cultural traditions, mental health (perinatal or chronic depression), diet and physical activity, prenatal care, complementary and alternative medicine, introduction to the practice as a medical home, circumcision, newborn health risks (handwashing, outings), breastfeeding guidance, prescription or nonprescription medications or drugs, family support of breastfeeding, formula-feeding guidance, financial resources for infant feeding, car safety seats, heatstroke prevention, firearm safety, safe home environment, infancy: prenatal visit.

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2017. "Infancy: Prenatal Visit", Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Joseph F. Hagan, Jr, MD, FAAP, Judith S. Shaw, EdD, MPH, RN, FAAP, Paula M. Duncan, MD, FAAP

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A Prenatal Visit is recommended for all expectant families as an important first step in establishing a child’s medical home. Some parents use this opportunity to select a health care professional, and this first visit is about establishing a relationship. It provides an opportunity to introduce parents to the practice, gather basic information, provide guidance, identify high-risk situations, and promote parenting skills. 1 The Prenatal Visit is especially valuable for first-time parents; single parents; families with high-risk pregnancies, pregnancy complications, or multiple pregnancies; parents who anticipate health problems for the newborn; parents who have experienced a perinatal or infant death; and parents who are planning to adopt a child. Health evaluation for newly adopted children has been reviewed, with recommendations provided. 2

Optimally, the Prenatal Visit entails a full office visit during which the expectant parents have the opportunity to meet with the health care professional. Among issues for discussion are the importance of early skin-to-skin contact and routine newborn screening, including blood, bilirubin, hearing, and critical congenital heart disease tests. Other issues for discussion are the anticipated timing of the newborn’s discharge from the nursery, common health care concerns for a newborn during the first week of life, and normal early newborn behaviors. This visit also provides an opportunity to provide an overview of health supervision during the first year and to discuss the practice’s routines for handling telephone or electronic communication for questions, the procedure for scheduling appointments, and after-hours care.

During the Prenatal Visit, the health care professional can review the importance of a healthy maternal diet for fetal development as well as identify any unique dietary concerns for the family, including any food allergies or intolerances, cultural feeding practices, and the use of herbal or complementary products. The Prenatal Visit also presents an opportunity to inquire about, and document, important aspects of pregnancy history, including potential exposures to toxins (eg, lead, alcohol, drugs) as well as to reiterate messages about healthy behaviors. Breastfeeding promotion is a key aspect of this visit, in particular for expectant mothers who have not yet decided on a feeding method or who are unsure about the benefits or their ability to successfully breastfeed. The benefits of breastfeeding for the mother and baby can be emphasized and parental questions or concerns about breastfeeding and human milk can be addressed.

The health care professional also can inquire about the family constellation; the family’s genetic history and health beliefs; the mother’s health and wellness, including her mental health, life stressors, status of health insurance coverage for the mother and other family members, and support systems; and the couple’s developmental adaptation to becoming parents. The family’s preparations for the newborn’s birth and homecoming can be assessed during this discussion, as can potential safety concerns and resource needs. This will help the health care professional determine the availability of support for the family at home and within the community.

The health care professional should reach out to the prospective parents, emphasizing the importance of each parent’s role in the health, development, and nurturing of the child, and encouraging the parents and other important caregivers to attend subsequent health supervision visits, if possible.

Before a baby’s birth, many parents do not have the opportunity to meet their baby’s health care professional during a full prenatal office visit. However, a practice may use alternative strategies to obtain information once the parents have decided to use the practice for their primary care and medical home. These strategies can include group prenatal visits, a prenatal/family history completed by the parents, or telephone contact.

The first priority is to attend to the concerns of the parents.

In addition, the Bright Futures Infancy Expert Panel has given priority to the following topics for discussion in this visit:

▶ Social determinants of health a (risks [living situation and food security, environmental risks, pregnancy adjustment, intimate partner violence, maternal drug and alcohol use, maternal tobacco use], strengths and protective factors [becoming well informed, family constellation and cultural traditions])

▶ Parent and family health and well-being (mental health [perinatal or chronic depression], diet and physical activity, prenatal care, complementary and alternative medicine)

▶ Newborn care (introduction to the practice as a medical home, circumcision, newborn health risks [handwashing, outings])

▶ Nutrition and feeding (breastfeeding guidance, prescription or nonprescription medications or drugs, family support of breastfeeding, formula-feeding guidance, financial resources for infant feeding)

▶ Safety (car safety seats, heatstroke prevention, safe sleep, pets, firearm safety, safe home environment)

a Social determinants of health is a new priority in the fourth edition of the Bright Futures Guidelines. For more information, see the Promoting Lifelong Health for Families and Communities theme .

The Bright Futures Tool and Resource Kit contains Previsit Questionnaires to assist the health care professional in taking a history, conducting developmental surveillance, and performing medical screening.

The prenatal history may be obtained according to the concerns of the family and the health care professional’s preference or style of practice.

General Questions

How has your pregnancy gone so far? What are similarities and differences from what you expected? From previous pregnancies? Have you had any prenatal testing done?

What questions do you or other family members have about your baby after you deliver? Are there any concerns about the health of your baby?

What have you heard about the purpose of routine child health care? What have you heard about immunizations?

What do you think might be the most delightful aspect of being a parent? What do you think might be the most challenging aspect of being a parent?

Where do you get information when you have questions about health issues or caring for your baby? How do you prefer to receive information?

Family History

Obtain a comprehensive family health history. A family history questionnaire can be found in the Bright Futures Tool and Resource Kit .

Social History

See the Social Determinants of Health priority in Anticipatory Guidance for social history questions.

What have you heard about what newborns can do at birth?

Newborns are able to smell (especially their mother’s breast milk), hear their parents’ voices, see up to a distance of under 1 foot (eg, they can see their parent’s face when being held), and respond to different types of touch (soothing touch and alerting touch).

Newborns communicate through crying and through behaviors such as facial expressions, body movements, and movement of their arms and legs. Initially, these behaviors may seem random, but, gradually, it will be possible to understand this early nonverbal language.

Newborns learn to anticipate and trust their world through their parents’ consistent and predictable caregiving (eg, through feeding and how parents respond to their cries).

For the first months of life, newborns learn to live in a world that is very different from the womb. In the womb, the baby is in a dark environment, is in a curled-up position with arms and legs close to the body, and feels swaying movements when you walk. The baby is used to a small space with limited movements. Your baby hears constant swishing sounds of the placenta and your heartbeat.

During the first month after birth, babies have a lot to learn—how to feed well and how to coordinate sucking, swallowing, and breathing while breastfeeding or feeding from a bottle. They also must learn how to handle the world around them—the sights, sounds, tactile stimulation (touch)—while learning to control their movements. All these are important steps in a young infant’s development.

Not applicable.

During the visit, the health care professional acknowledges and reinforces positive parent interactions and discusses any concerns. Observation focuses on

Who asks questions and who provides responses to questions? (Observe mother’s relationship with her partner, other children, or support people present during the visit.)

Verbal and nonverbal behaviors and communication between family members indicating support and understanding, or differences and conflicts.

Discuss the purpose and importance of the routine newborn screening tests, including newborn blood screening (metabolic, endocrine, hemoglobinopathy), jaundice, congenital heart disease, and hearing, that will be performed in the hospital before the baby is discharged. Explain that the hospital, state health department, and the health care professional work together to ensure that family gets these test results and the appropriate follow-up if any test results are not normal or are not able to be completed before the baby goes home.

Inquire about any maternal prenatal testing (eg, alpha fetoprotein, diabetes [GTT/GCT, HgA1 c ], hepatitis B, syphilis, human immunodeficiency virus [HIV], cytomegalovirus, group B Streptococcus ), any abnormal findings seen on ultrasound, and any maternal conditions that may affect the developing fetus or newborn.

Discuss the importance of routine initiation of immunizations, including routine newborn hepatitis B immunization and any state-specific recommendations for immunization before discharge.

Infants younger than 6 months are at risk of complications from influenza, but are too young to be vaccinated for seasonal influenza. Encourage influenza vaccine for caregivers of infants younger than 6 months and recommend pertussis immunization (Tdap) for adults who will be caring for the infant. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends that every pregnant woman receive Tdap with each pregnancy. The Tdap is safe after 20 weeks’ gestation and immediately postpartum for women who have not received Tdap in the previous year.

The health care professional also can use this opportunity to assess vaccination status for other children in the family. Their vaccination status not only affects their health but also that of the newborn.

Consult the CDC/ACIP or American Academy of Pediatrics (AAP) Web sites for the current immunization schedule.

CDC National Immunization Program www.cdc.gov/vaccines

AAP Red Book:   http://redbook.solutions.aap.org

The following sample questions, which address the Bright Futures Infancy Expert Panel’s Anticipatory Guidance Priorities, are intended to be used selectively to invite discussion, gather information, address the needs and concerns of the family, and build partnerships. Use of the questions may vary from visit to visit and from family to family. Questions can be modified to match the health care professional’s communication style. The accompanying anticipatory guidance for the family should be geared to questions, issues, or concerns for that particular infant and family. Tools and handouts to support anticipatory guidance can be found in the Bright Futures Tool and Resource Kit.

Risks: Living situation and food security, environmental risks (dampness and mold, lead, pica), pregnancy adjustment, intimate partner violence, maternal drug and alcohol use, maternal tobacco use

Strengths and protective factors: Becoming well informed, family constellation and cultural traditions

Parents in difficult living situations or with limited means may have concerns about their ability to care for their newborn. Suggest community resources that help with finding quality child care, accessing transportation, or getting an infant car safety seat and crib, or addressing issues such as financial concerns, inadequate resources to cover health care expenses, parental inexperience, or lack of social support. Other community groups or agencies can address inadequate or unsafe housing and limited food resources (eg, food or nutrition assistance programs, such as the Commodity Supplemental Food Program, Supplemental Nutrition Assistance Program [SNAP], or Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]).

Sample Questions

Tell me about your living situation. Do you live in an apartment or a house? Is permanent housing a worry for you?

Do you have the things you need to take care of the baby, such as a crib, a car safety seat, and diapers? Does your home have enough heat, hot water, electricity, and working appliances? Do you have health insurance for yourself? How about for the baby?

Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more? Within the past 12 months, did the food you bought not last and you did not have money to get more?

Community agencies are available to help you with concerns about your living situation.

Programs and resources are available to help you and your baby. You may be eligible for the WIC or housing or transportation assistance programs. Several food programs, such as the Commodity Supplemental Food Program and SNAP, the program formerly known as Food Stamps, can help you. If you are breastfeeding and eligible for WIC, you can get nutritious food for yourself and support from peer counselors.

Explain the risks of dampness and mold and discuss strategies for minimizing these risks.

Are you aware of any health concerns in your family related to dampness or mold in your home? Have you had problems with bugs, rodents, or peeling paint or plaster in your home?

Some homes may have health risks that may affect your baby. Exposure to damp and moldy environments can cause a variety of health effects in people sensitive to mold. Mold exposure can cause nasal stuffiness, throat irritation, coughing or wheezing, eye irritation, or, in more severe cases, breathing difficulties.

Mold will grow in places with a lot of moisture, such as around leaks in roofs, windows, or pipes, or where there has been flooding. Mold grows easily on paper products, cardboard, ceiling tiles, and wood products.

To control mold, prevent water leaks, ventilate well, clean gutters, and drain water away from your house’s foundation.

Mold can be removed from hard surfaces with commercial cleaners, soap and water, or a bleach solution of 1 part bleach in 4 parts of water.

Exposure to lead, whether during pregnancy or after the baby’s birth, can have harmful effects on the health and developmental of the baby. Prenatal lead exposure affects children’s neurodevelopment, placing them at increased risk for developmental delay, reduced IQ, and behavioral problems. Risk factors for lead exposure above normal day-to-day environmental levels differ in pregnant women from those described in young children.

Women and children with iron deficiency anemia are at particularly high risk for lead poisoning. Other risk factors for lead exposure in pregnant women include recent immigration; pica practices; occupational exposure (eg, working at a battery manufacturing plant); culturally specific practices, such as the use of traditional remedies or imported cosmetics; and the use of traditional lead-glazed pottery for cooking and storing food. Lead-based paint is less likely to be an important exposure source for pregnant women than it is for children, except during renovation or remodeling in older homes.

Some states have lead screening guidelines and follow-up requirements for pregnant women by physicians or other health care professionals. The CDC encourages mothers with blood lead levels less than 40 μg/dL to breastfeed. However, mothers with higher blood lead levels are encouraged to pump and discard their breast milk until their blood lead levels drop below 40 μg/dL.

Do you have concerns about lead exposure in your home or neighborhood? How old is your home or apartment building? Was it built before 1978? Do you know if there have been any recent renovations on your house, or have you done any? Is your house near a freeway or busy roadway? Does anyone in your house work in a job that exposes him or her to lead?

If your home was built before 1978, it will likely have lead-based paint. You can obtain information about testing your home for lead by contacting the National Lead Information Center at 800-424-LEAD or calling your local state or city health department.

You can protect your baby and other young children from lead exposure. Avoid using traditional home remedies and cosmetics that may contain lead. When you store or cook foods or liquids, avoid using containers, cookware, or tableware that is not shown to be lead-free. Use only cold water from the tap for drinking, cooking, and making baby formula because hot water is more likely to contain higher levels of lead.

Avoid exposing children and women who are pregnant or breastfeeding to areas where old paint is being sanded or chipped. Wait until the work is completed and area completely wiped down.

Lead dust can come into your home on your clothes or body of people who work with lead. After people who live with a woman who is pregnant or breastfeeding finish a task that involves working with lead-based products, such as renovating older housing, stained glass work, bullet making, or using a firing range, they should change their clothes before they enter the home and shower as soon as they return home. Women who are pregnant or breastfeeding should avoid activities that involve working with lead.

The most common source of lead exposure in pregnant women is pica, or a craving to eat nonfood items. In addition to dirt, clay, and plaster, pregnant women with pica may consume burnt matches, stones, charcoal, mothballs, cornstarch, toothpaste, soap, sand, coffee grounds, baking soda, and cigarette ashes. Pica can interfere with the body’s ability to absorb nutrients from healthy foods and actually cause a nutrient deficiency. Pica cravings are a concern because nonfood items may contain toxic elements, like lead or parasitic organisms. In some instances, pica cravings may indicate an underlying physical or mental disorder.

Sample Question

Do you ever have the urge to eat dirt, clay, plaster, or other nonfood items? Tell me about them.

Eating nonfood substances can harm both you and your baby. Please let me know if you have these cravings. I can help you understand why it can be risky.

If you do have these cravings, talk with your own health care professional. He or she will check your iron status and review your vitamin and mineral intake.

When a pica craving occurs, try chewing sugarless gum instead. Tell family members or friends about your cravings so they can help you avoid nonfood items.

Discuss the parents’ feelings about the pregnancy and gauge whether disagreements or conflicts in the parents’ relationship are likely to be a problem. Suggest community sources of help, if appropriate.

How do you feel about your pregnancy? What has been the most exciting aspect? What has been the hardest part? Pregnancy can be a stressful time for expectant families; do you have any specific worries? How have you been feeling physically and emotionally? Is this a good time for you to be pregnant? How does your family feel about it? Is it a wanted pregnancy? How does your partner feel about it? Is your pregnancy a source of discord between you and your partner? What works in your family for communicating with each other, making decisions, managing stress, and handling emotions?

It’s great that you are happy about having your baby. Working on open communication with your partner and making decisions together will help you both get through the stresses of introducing a new baby into your home and family.

Taking advantage of support from family and friends and community groups can be a big help in the first few days after you get home with your new baby.

Pregnancy is a time of personal growth and learning about yourself and your partner. If you and your partner disagree a lot or have many conflicts, consider contacting community resources that can help you work out these difficulties. It is important to work on resolving differences or conflicts because of the stress they may cause. Resolving these problems also can help you be emotionally ready for the baby’s birth.

According to the CDC, 1.5 million women are battered by their intimate partner every year, and 324,000 of those women are pregnant. Homicide is the leading cause of death for pregnant and recently pregnant women. 3 When inquiring, avoid asking about abuse or domestic violence. Instead, use descriptive terms, such as hit, kicked, shoved, choked, and threatened. Provide information on the effect of intimate partner violence on the fetus and children and the community resources that provide assistance. Recommend resources and support groups.

To avoid causing upset to families by questioning about sensitive and private topics, such as family violence, alcohol and drug use, and similar risks, it is recommended to begin screening about these topics with an introductory statement, such as, “I ask all patients standard health questions to understand factors that may affect health of their child as well as their own health.”

Because violence is so common in so many people’s lives, I’ve begun to ask about it. I don’t know if this is a problem for you, but many children I see have parents who have been hurt by someone else. Some are too afraid or uncomfortable to bring it up, so I’ve started asking all my patients about it routinely. Do you always feel safe with your partner? Has your partner, or another significant person in your life, ever hit, kicked, or shoved you, or physically hurt you in any way? Has he or she ever threatened to hurt you or someone close to you? Do you have any questions about your safety at home? What will you do if you feel afraid? Do you have a plan? Would you like information on where to go or who to contact if you ever need help? Can we help you develop a safety plan for you and your other children?

If your partner, or another significant person in your life, is hitting or threatening you, one way that I and other health care professionals can help you is to support you and provide information about local resources that can help you.

You can also call the toll-free National Domestic Violence Hotline at 800-799-SAFE (7233).

Any substance taken during pregnancy should be evaluated for its risk to the developing fetus, including prescription drugs, over-the-counter preparations, pain relievers, herbal substances, marijuana, and other illegal substances.

Alcohol is a particular risk in pregnancy. During medical screening at this visit, if the pregnant woman acknowledges alcohol use, discuss the concerns about both neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) and fetal alcohol spectrum disorder (FASD) to the developing fetus. Both ND-PAE and FASD have lifelong effects on the baby that can include physical problems and problems with behavior and learning. Fetal alcohol exposure, including the timing during the pregnancy, quantity, and duration, is important to document for later diagnosis of FASD. The pregnant woman should be advised to stop drinking and a brief intervention and referral for drug and alcohol counseling is recommended. Referrals to community social service agencies and drug and alcohol treatment programs can be provided if the mother is not already linked to these services.

If the mother acknowledges illicit drug or alcohol use, also discuss state- and hospital-specific policies related to child protection referrals and practices related to child custody.

The newborn will need referral to the state Early Intervention Program, often referred to as IDEA Part C, based on the newborn’s clinical findings at birth and state-specific policy.

How often do you drink beer, wine, or liquor in your household?

For any response other than “Never,” ask the following questions:   In the 3 months before you knew you were pregnant, how many times did you have 4 or more drinks in a day? After you knew you were pregnant, how many times did you have 4 or more drinks in a day?

Depending on the responses to any of the above questions, the health care professional can, if desired, follow up to determine frequency and extent of consumption by asking the following questions:

During your pregnancy on average, how many days per week have you had a drink? During your pregnancy on a typical day when you’ve had an alcoholic beverage, how many drinks did you have?

Are you using marijuana, cocaine, pain pills, narcotics, or other controlled substances? What have you heard about the drug’s effects on the baby during pregnancy or after the baby is born? Are you getting any help to cut down/stop your drug use?

If any maternal at-risk drinking is identified, a brief intervention and referral is recommended.

Are you taking any medicines or vitamins now? Are you using any prescription or over-the-counter medications or pain relievers? Have you used any health remedies or special herbs or teas to improve your health since you have been pregnant? Is there anything that you used to take, but stopped using when you learned that you were pregnant?

The reason we are concerned about a pregnant woman’s use of alcohol or drugs is because of the effects on the baby’s mental, physical, and social development. We know that a mother’s alcohol or drug use affects her unborn baby and we have no way to know whether any alcohol is safe. Therefore, our recommendation is that women not drink alcohol while they are pregnant. If you are drinking alcohol, we encourage you to stop.

Alcohol and drug cessation programs are available in our community and we would like to help you connect to these services.

Community agencies are available to help women during their pregnancy as well as after their baby arrives so that they can safely care for their baby and themselves. Your obstetrics provider also can refer you to programs that help pregnant women stop using drugs and alcohol.

To understand how over-the-counter medications or herbal products may affect your baby, it is important to know what, if any, of these products you are taking.

It is important that you have accurate information about the safety in pregnancy of any over-the-counter drugs or remedies that you are using.

Address how smoking affects the baby, including increasing the risk of low birth weight, preterm delivery, premature rupture of the membranes, placental abruption, sudden infant death syndrome (SIDS), asthma, cleft lip and palate, acute otitis media and middle ear effusion, and respiratory infections. Provide smoking cessation strategies and make specific referrals. Consider the safety of various treatments during pregnancy for patients who are committed to smoking cessation.

800-QUIT-NOW (800-784-8669); TTY 800-332-8615 is a national telephone triage and support service that is routed to local resources. Additional resources are available at www.cdc.gov . Specific information for women is available at http://women.smokefree.gov . Health care professionals also may investigate what is available in their own communities, through their hospitals and health departments and through Internet-based resources such as the American Cancer Society ( www.cancer.org ) or the American Lung Association ( www.lungusa.org ).

Have you smoked during this pregnancy? Do you use any other forms of nicotine delivery, such as e-cigarettes? Does anyone else in your home smoke or use e-cigarettes? Have you thought about cutting down or quitting now that you are pregnant? Have you been able to cut down the daily number of cigarettes or even quit? Do you know where to get help with stopping smoking?

It is important to keep your car, home, and other places where your baby spends time free of tobacco smoke and e-cigarette vapor. Smoking affects the baby by increasing the risk of sudden infant death, asthma, ear infections, and respiratory infections.

Discuss the parents’ support system at home and access to health information.

Be ready to provide parents with trusted sources of maternal and child health information, and provide these links on your own Web site.

Parents of hospitalized babies or whose babies have special health care needs may be more likely to seek out virtual networks for support and information. Trusted Web sites with accurate information can be recommended.

Tell me about whom you ask for information and where else you go for answers about health questions. How do you decide if the information you get is something you can trust? Are going to believe? To try? Do you enjoy connecting with other parents using social media? What sites, including blogs and birth groups, do you use for networking and finding information about pregnancy, birth, parenting, and caring for a new baby?

Social media tools can be useful in building social networks, but they should not be relied on for maternal and child health advice.

The AAP HealthyChildren.org is one resource that you may find helpful. Its Web site is www.HealthyChildren.org , and its Twitter address is @healthychildren.

New parents look to family and friends for support and answers to their questions about their children’s health and development.

Inquire about other children, older family members and others living in the home, family routines, and relationships. Anticipatory guidance regarding the infant’s health and safety will vary, based on the specific cultural traditions of the family.

Tell me about yourself and your family. Are there other children in your home? How old are they? How have they responded to your pregnancy and the thought of becoming a big brother or sister? Do you have any children or family members living with you who have special health care needs?

Who will be helping you take care of the baby and yourself when you go home from the hospital? How will you handle your other children’s needs? Are you working outside the home or attending school now? Who do you go to for help when you need a hand? Do you have friends or relatives that you can call on for help? Do they live near you? How are decisions made in your family? Is there anyone that you rely on to help you with decisions? Is there anyone that you want me to include in our discussions about the baby? If you are returning to school or work, do you have child care arrangements?

It can be a challenge to provide care to several children at once, especially knowing and understanding the unique needs of each family member.

Older children in the home at any age may express a variety of feelings—from happiness and excitement to anger, sadness, or guilt—about the new baby or your need to devote extra time and attention to the baby. Make the most of your other children’s positive feelings and support their emotional needs as they adapt to a new sibling. Helping your other children feel that they have a role in the care and emotional support of the baby is a good way to strengthen family bonds.

It is important to take the time to get to know your new baby and her personality. This will help you and the rest of your family learn how to help her grow and develop.

Take advantage of your support network, whether it’s friends, family members, or community contacts. This network can be an important strength for you as you prepare to welcome a new baby into your life.

The information you share with me about your family traditions and your sources of support and assistance will help me learn about your family, its strengths, and how we can best partner in your baby’s health care decisions.

Mental health (perinatal or chronic depression), diet and physical activity, prenatal care, complementary and alternative medicine

An estimated 10% to 20% of women struggle with major depression before, during, and after delivery of a baby. Perinatal depression has substantial personal consequences and interferes with quality of child-rearing, adversely affecting parent-child interactions, maternal responsiveness to infant vocalizations and gestures, and other stimulation essential for optimal child development. Fathers also can experience depression.

New mothers may wonder why they are being asked about signs of depression. Because pregnancy and childbirth are supposed to be a joyous occasion, women may feel that they are going to be bad mothers if they are depressed. It is important for apprehensive patients to understand what perinatal depression is, to know that many women experience similar feelings, and to realize that untreated perinatal depression may have adverse effects on women’s health and their children’s health and development.

Over the past 2 weeks, have you ever felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?

Although a birth of a baby is considered a wonderful experience, it is important not to ignore the stress that often occurs during parenting a newborn, and the life changes that come with this responsibility. In addition to taking care of your baby and family, you need to make sure to take care of yourself. This stress can take a toll on any parents’ mental health and their interactions with the child. It can affect your partner as well.

It is common for women during and after pregnancy to feel down or depressed. Fathers can also be affected in similar ways. It is very important to address these feelings to ensure your health and your baby’s health.

Emphasizing healthy life behaviors, like getting enough sleep, eating healthy foods, and finding time for walking or other light physical activity, can help you feel better.

If you are sad or down for more than 2 days in a row, please speak with me about options for treatment. Talk therapy or counseling generally helps very quickly.

Pregnant women need a balanced diet and should also take a prenatal vitamin containing folic acid, vitamin D, choline, and iron in amounts that will help protect the mother’s and baby’s health.

A pregnant woman’s diet should include an average daily intake of 200 to 300 mg of the omega-3 long-chain polyunsaturated fatty acid (PUFA) docosahexaenoic acid (DHA) to guarantee a sufficient concentration of preformed DHA in the milk. Consumption of one to two 3-oz portions of seafood weekly will supply sufficient DHA. Women who are pregnant and breastfeeding should avoid the 4 types of fish that are high in mercury. These are tilefish, shark, swordfish, and king mackerel.

Additionally, a pregnant woman’s diet should include 550 mg/day of choline because human milk is rich in choline and depletes the mother’s tissue stores. Eggs, milk, chicken, beef, and pork are the biggest contributors of choline in the diet. For vegan mothers, who consume no animal products in the diet, a daily multivitamin including iron, zinc, vitamin B 12 , omega-3 fatty acids, and 550 mg/day of choline is recommended.

Pregnant women also should be encouraged to engage in moderate-intensity physical activity for at least 30 minutes at least 5 days of the week to help ensure appropriate prenatal weight gain and to improve blood glucose levels. Pregnant women who habitually engage in vigorous-intensity aerobic activity or who are highly active can continue physical activity during pregnancy and the postpartum period, provided that they remain healthy and discuss with their health care professional how and when activity should be adjusted over time.

Are you able to eat a healthy diet? Has your obstetrician or nurse midwife prescribed a vitamin for you to take every day? Do you eat fish at least 1 to 2 times per week? Do you have protein-containing foods every day, such as eggs, chicken, beef or pork, or dairy? Are you able to exercise most days?

Eating a small serving of fish 1 to 2 times a week provides important nutrients to your baby. Canned light tuna, salmon, trout, and herring are the best choices to give your baby the neurobehavioral benefits of an adequate intake of an important fat called DHA.

It is best to avoid 4 kinds of fish that are high in mercury. These fish are tilefish, shark, swordfish, and king mackerel.

Consuming small amounts of milk, eggs, or meat every day is recommended.

Talk with your own health care professional about how physically active you should be now and how to adjust your activity after the baby is born.

Reinforce adherence to recommended prenatal care and encourage the mother to share her concerns with her obstetrician or other health care professional. If she has not already been tested for HIV during this pregnancy or if she does not know her HIV status, encourage her to seek HIV testing and counseling.

What have you been doing to keep yourself and your baby healthy during your pregnancy?

It is important to maintain your own health by getting prenatal care and going to all your prenatal care appointments, getting enough sleep, and regular physical activity, as well as eating a healthy diet with an appropriate weight gain.

It also is important to maintain good oral health care and to make sure that you get regular dental checkups.

All mothers should know their HIV status because early treatment for themselves, and particularly for their baby, is so important. If you do not know your status already, we recommend that you get tested, because proper treatment before, during, and after delivery can protect your baby from getting the virus.

A family’s health beliefs and use of any complementary and alternative health practices need to be examined and, if safe, considered for incorporation into the child’s health care plan.

Are there any special family health concerns that I should know about to better care for your baby and family? What health practices do you follow to keep your family healthy?

Recognizing your family values, health beliefs, health practices, and learning styles will allow me to better answer your questions about the care of your baby.

Introduction to the practice as a medical home, circumcision, newborn health risks (handwashing, outings)

Families new to the practice will want to learn information about the practice. This information includes the need for follow-up visits within 48 to 72 hours of nursery discharge and 24-hour access phone numbers to call in case of any particular concerns (eg, jaundice, breastfeeding problems or questions, concerns about infant’s intake or feeding skills, fever or suspected illness). Information about the practice policies for after-hours and weekend routines and when parents should contact the health care professional should be included as well.

First-time parents may need detailed information about typical early infant care and supply needs for their newborn. Mothers who have had a cesarean delivery may have additional information and referral needs. Special considerations may also be necessary depending on the number of other children in the home or if any individuals in the home have special health care needs to which the new mother must attend. If the mother is ill herself, it may limit or constrain her ability to fully care for her infant. These should be assessed and plans developed to support the needs of the infant and mother. Home health care or public health nursing referrals for post-discharge assessment and supportive care may be appropriate.

Most new parents worry that they may not be ready to care for a baby. Do you have any concerns about being ready to take care of your baby? What are you looking forward to? What challenges do you think you will face as new parents?

Because your family is new to the practice, we will give you information about the practice, such as names and background of the health care professionals, staff, appointment scheduling, and urgent and emergency access information.

Preparing to become a parent can seem daunting, but the best way to be a terrific parent to your baby is to learn as much about your baby as possible. You will learn to read your baby’s personality and understand how to help her adjust to her new environment.

If you have other children in the home, you will also figure out how best to help them adapt to having another family member who needs a lot of your time and attention.

Discussion about the parents’ views on circumcision would be appropriate at this time, but must be handled in a culturally sensitive manner. The parents’ decision may be based on family beliefs and cultural or religious practices. If parents are interested in having their baby circumcised, provide information about methods for performing circumcisions, pain relief during the procedure, and early care of the circumcised penis. If parents choose not to circumcise their son, provide information about early care of the uncircumcised penis.

If you have a son, have you decided about circumcision? If you are planning on circumcision, who will be performing the procedure?

Circumcision has potential medical benefits and advantages, as well as risks. A recent analysis by the AAP concluded that the medical benefits of circumcision outweigh the risks. 4

The AAP recommends that the decision to circumcise is one best made by parents in consultation with their pediatrician, taking into account what is in the best interests of the child, including medical, religious, cultural, and ethnic traditions and personal beliefs.

Remind all family members or guests to wash their hands before handling the baby. Remind the family to protect the baby from anyone with colds or illnesses, especially for the first couple of months.

What other suggestions have you heard about that will keep your baby healthy? How do you plan to protect your baby from getting infections?

Wash your hands frequently with soap and water or a non-water antiseptic, and always after diaper changes and before feeding the baby.

For the first few weeks, it is important to limit the baby’s exposure to people with colds or to large groups where people may have illnesses.

Breastfeeding provides important protection for the baby and reduces the frequency of illnesses in babies.

Breastfeeding guidance, prescription or nonprescription medications or drugs, family support of breastfeeding, formula-feeding guidance, financial resources for infant feeding

Feeding guidance will be based on the mother’s plan for feeding her baby (ie, breastfeeding, formula feeding, or a combination of both) and any perceived barriers or contraindications to breastfeeding. The Prenatal Visit is a perfect opportunity to address any concerns parents have about breastfeeding their newborn, provide information, and dispel any myths the parents may have heard. A woman’s knowledge about newborn feeding is significantly linked with a decision to breastfeed. Potential barriers to successfully meeting the mother’s breastfeeding goals, such as pain, worry about how much the baby is getting, returning to work, embarrassment, and family influences, should be discussed along with strategies to overcome them. Relevant information and appropriate resources should be given. Maternal history of breast surgery or implants or past breastfeeding concerns may need in-depth discussions, and a lactation consultant may be a resource to provide support and answer these questions. In addition, pregnant women may benefit from attending local community breastfeeding support group meetings, such as through the health department or La Leche League ( www.llli.org ). These meetings provide role models and peer support for breastfeeding.

Mothers with a strong family history of allergies need to understand that their babies may benefit from breastfeeding through the first year of life.

Mothers who are considering combining breastfeeding and formula feeding should be counseled to wait until lactation is well established (usually 2–4 weeks) before introducing formula. Discuss the benefits of exclusive breastfeeding and breastfeeding duration. Ultimately, the decision is up to the mother (parents), and the health care professional should respect the decision and understand that the mother may change her mind by the time the baby arrives.

What are your plans for feeding your baby? What have you heard about breastfeeding? Do you have questions about breastfeeding that I can answer for you? What kinds of experiences have you had feeding babies? Did you breastfeed your other children? How did that go? Do you have concerns about these experiences that we should talk about if they will affect the new baby? Do you have any concerns about having support for breastfeeding, privacy, having enough breast milk, or changes in your body? Have you had any breast surgery? Do you or does anyone in your family have a history of food allergy or intolerance?

Have you attended any classes that taught you how to breastfeed your baby? Do you know anyone who breastfeeds her baby? Did any of your family or friends breastfeed? Would you be able to get help from them as you are learning to breastfeed? Will they support your decision? Do you have a breast pump? If you plan to return to work, do you have time, space, and enough privacy to use a breast pump?

Successful breastfeeding begins with knowledge and information. Prenatal classes through local hospitals can be very helpful for new parents. In addition, many communities have lactation consultants and nurses who are available to assist with breastfeeding. Having these resources available helps you be comfortable with breastfeeding and can help you get off to a good start.

Put your baby to the breast as soon as possible after the baby is born. Start in the delivery room if you can.

Breastfeeding exclusively for about the first 6 months of life, and then combining it with solid foods from 6 to 12 months of age, provides the best nutrition and supports the best possible growth and development. You can continue to breastfeed for as long as you and your baby want.

Share information about the known effects for an expectant mother of any drugs, medications, or herbal or traditional health remedies that she may be taking. If the mother is planning on breastfeeding, provide information about the safety of continued medication or herbal use while breastfeeding. (Many herbal teas contain ephedra and other substances that may be harmful to the baby.)

A general vitamin-mineral supplement that contains 100% of the daily recommended intake for iron, vitamin D, folic acid, and vitamin B 12 is recommended for all women who are breastfeeding. Women should also be encouraged to drink plenty of fluids and to eat a healthy diet while breastfeeding. Docosahexaenoic acid supplements are generally safe to consume during pregnancy and lactation.

Are you taking any prescribed or over-the-counter medications now or have you taken any in the past? Have you used any special or traditional health remedies to improve your health since you have been pregnant? Do you drink alcohol, drink any special teas, or take any herbs? Is there anything that you were taking, but stopped using when you learned that you were pregnant?

Because some medications, herbs, or, especially, alcohol can be passed into human milk, it is important to know what these might be so that you can be advised appropriately when you are breastfeeding.

Most mothers are able to successfully breastfeed their babies. Babies with medical conditions that make breastfeeding challenging may still breastfeed. Their mothers benefit greatly from appropriate breastfeeding consultation and close monitoring. Babies who have a very low birth weight or have special health care needs particularly benefit from expressed human milk if they are unable to breastfeed from their mother.

Describe actions that the other parent or caregiver can take to support breastfeeding, including cuddling, bathing, and diapering the baby. Family members, significant others, or friends should be included in breastfeeding education. Share options for engaging family members in the care of both the mother and baby. Provide information about community resources if the mother does not have an adequate, positive family and friend support network.

Emphasize the need for a follow-up visit within 48 to 72 hours of discharge at the health care professional’s office, to check on the baby’s feeding, weight, and how the mother is doing and whether she has any questions or concerns. Other options for breastfeeding follow-up may include a visit by a home health nurse, if this is covered by insurance, or by a public health nurse, if available. Provide parents with specific information about who they may contact with questions. Encourage parents with phrases such as, “From our discussion, it seems you are going to do very well with breastfeeding.”

Do you know how to contact support groups or lactation consultants?

Resources for help with breastfeeding are available through the hospital, lactation consultants, and some public health programs.

We will be able to answer your breastfeeding questions and help you get the support that you need to be successful.

For babies who are unable to breastfeed or tolerate expressed human milk (classic galactosemia), or parents who choose not to breastfeed, iron-fortified formula is the recommended alternative for feeding the baby during the first year of life.

An explanation of the rationale for iron fortification, that iron-fortified formulas are well tolerated, and that studies show that iron-fortified formulas do not cause constipation, can help ensure that parents choose iron-fortified formula.

Encourage parents to discuss choice of formula and any proposed changes in formula with the health care professional. Review steps for preparing formula and reinforce the need to carefully read the directions on the cans. Mixing directions differ among powdered formulas. Provide written information about the importance of food safety with formula, including heating and cleaning bottles and nipples.

What have you read or heard about the different infant formulas, such as iron-fortified, soy, lactose-free, and others? Would you like some guidance about choosing an appropriate formula for your baby? How do you plan to prepare the formula? What have you heard about formula safety? Do you have any other questions about formula feeding?

If you are unable to breastfeed or choose not to breastfeed your baby, iron-fortified formula is the recommended substitute for breast milk for feeding your full-term baby during the first year of life.

Parents may need referrals about resources for community food or nutrition assistance programs for which they are eligible (eg, Commodity Supplemental Food Program, SNAP, or WIC), and housing or transportation, if needed. The WIC provides nutritious foods for infants and children, foods for mothers who breastfeed, nutrition education, peer support for breastfeeding, and referrals to health and other social services. Mothers who choose to breastfeed can receive enhanced food packages, breast pumps, breastfeeding supplies, and support through peer counselors.

Are you concerned about having enough money to buy food or infant formula? Would you be interested in resources that may help you afford to care for you and your baby?

Programs and resources are available to help you and your baby. You may be eligible for food, nutrition, or housing or transportation assistance programs. Several food programs, such as the Commodity Supplemental Food Program and SNAP, can help you. The SNAP used to be called Food Stamps. If you are breastfeeding and eligible for WIC, you can get nutritious food for yourself and support from peer counselors.

Car safety seats, heatstroke prevention, safe sleep, pets, firearm safety, safe home environment

Although the rate of motor vehicle crash injury deaths has declined over time, it is still the leading cause of death in childhood. Car safety seats significantly reduce the risk of death and injury and are essential for every trip in any vehicle, starting with the first ride home from the hospital. The type of transportation the family uses will determine counseling about car safety seats. Many families rely on other family members or friends for transportation and may not be familiar with car safety seat information. It is important to explore the parents’ beliefs about seat belt use and their understanding of car safety seat use for infants. The family must obtain a car safety seat and learn how to install it properly before the birth, so this visit is a good opportunity to review this information.

The parents’ own safe driving behaviors (including using seat belts at all times, not driving under the influence of alcohol or drugs, and not using a cell phone or other handheld device) are important to the health of their children. The use of seat belts during pregnancy is especially critical. Lap belts should be worn below the belly and shoulder belts across the mid-chest.

Do all members in the family use a seat belt every time they ride in the car? What type of car safety seat do you have for the baby? Have you tried installing it?

Using a seat belt during pregnancy is the best way to protect you and your unborn baby, even if your vehicle has an air bag and even when you ride in the back seat. Wear the lap belt across your hips/pelvis and below your belly; place the shoulder belt across your chest between your breasts and away from your neck; and move your seat as far away from the steering wheel as you can while still allowing you to drive easily.

All babies and children younger than 2 years should always ride in a rear-facing car safety seat in the back seat of the car. There are different types of rear-facing car safety seats. Rear-facing–only seats have a carry handle and typically attach to a base that stays installed in the vehicle. Convertible and 3-in-1 car safety seats are used in the rear-facing position and later convert in the forward-facing position. They typically have higher height and weight limits for the rear-facing position, allowing you to keep your child rear facing for a longer period of time. However, they may not fit small newborns as well as rear-facing–only seats. Do not use any extra products, like cold-weather buntings or inserts, that did not come in the box with the car safety seat. If the weather is cold, tuck a blanket around the baby over the straps.

Bring your newborn home from the hospital in a rear-facing car safety seat, as this provides the best protection for infants and toddlers. You can choose either a rear-facing–only seat or a convertible car safety seat. The car safety seat should be installed in the back seat of the vehicle at the angle recommended by the manufacturer. If you use a convertible seat, choose one with a lower weight limit for rear facing that is no more than the weight of your baby.

Even if you do not own a vehicle, you should still have a car safety seat for your child and know how to install it when you are riding in a taxi or in someone else’s vehicle.

Learn how the car safety seat straps are adjusted and how to install the seat in your vehicle. You can get help from a local certified Child Passenger Safety Technician. The National Highway Traffic Safety Administration (NHTSA) also has information for parents on its Web site that includes videos on how to install and use a child’s car safety seat.

Your own safe driving habits are important to the health of your children. Always use a seat belt and never drive under the influence of alcohol or drugs. Don’t text or use cell phones or other handheld devices while you are driving.

Never put a rear-facing car safety seat in the front seat of a vehicle.

For information about car safety seats and actions to keep your baby safe in and around cars, visit the NHTSA Web site at www.safercar.gov/parents .

Find a Child Passenger Safety Technician: http://cert.safekids.org . Click on “Find a Tech.”

Toll-free Auto Safety Hotline: 888-327-4236

Each year, children die of heatstroke after being left in a car that becomes too hot. More than half of the deaths are infants and children younger than 2 years. In most cases, the parent or caregiver forgot the child was in the car, often because there was a change in the usual routine or schedule. Even very loving and attentive parents can forget a child in the car. Additionally, some children have died while playing in the vehicle or after getting in the vehicle without the caregiver’s knowledge.

The temperature inside a car can rise to a dangerous level quickly, even when the temperature outside is as low as 60 degrees. Leaving the windows open will not prevent heatstroke. Because children have proportionally less surface area than adults and less ability to regulate internal temperature, their bodies overheat up to 5 times more quickly than adults’ bodies.

Parents should establish habits early to help prevent their baby from being forgotten in a vehicle.

Every year, babies die of heatstroke after being left in a hot car. Would you like to talk about creating a plan so this doesn’t happen to you?

Never leave your child alone in a car for any reason, even briefly.

Start developing habits that will help prevent you from ever forgetting your baby in the car. Consider putting your purse, cell phone, or employee identification in the back seat to help form the habit of checking the back seat before you walk away.

Check the back seat before walking away, every time you park your vehicle.

The incidence of sleep-related infant death has been dramatically reduced by safe sleep policies promoted in the past 15 years. 5 , 6 Sudden unexpected infant death (SUID) describes sudden infant death that is explained or unexplained. After autopsy, case review, and death scene investigation, a SUID may be determined to be caused by asphyxiation, suffocation, parental overlie, infection, or other medical causes. The diagnosis of SIDS is reserved for infant deaths that are unexpected and unexplained. Culturally sensitive information should be provided about what is known about safe sleep environments for babies.

A supine position (“back to sleep”) is best for babies, including premature babies, because of the reduction of SIDS. However, parents should avoid using wedges or other positioning devices, as they are a suffocation hazard. Room sharing is recommended, with the baby in a separate, but nearby, sleep space. Bed sharing (sleeping in the same bed as the parents, another adult, or a child) is not recommended. Bed sharing increases the risk of SUID. Likewise, sleeping together on a non-bed surface, such as a sofa or chair, places a baby at risk for entrapment, suffocation, and death. It is important to explore the parents’ intended infant sleep practices at home and to offer guidance to ensure the safest sleep environment for the newborn.

Common beliefs and concerns expressed by families as justification for not placing their babies to sleep in the supine position include the fear of infant choking/aspiration, perceived uncomfortable/less peaceful sleep, concern about a flat occiput and hair loss, and family beliefs about appropriate infant sleep patterns, position, and sleep location. Different cultures may view infant sleep differently than current safe sleep recommendations. These concerns should be sought and discussed with the parents.

Swaddling can be a useful calming technique with an awake infant and is appropriately used for positioning in early breastfeeding. However, swaddling is no longer generally recommended and it is not for sleep. Swaddled infants have been associated with a 3-fold increase in SUID when compared to infants in a footed blanket sleeper or a sleepsack. Before 2 months of age, if parents swaddle their awake infant, they should be encouraged to remove the wrap before putting their baby down for sleep because this can establish a habit that can be hard to change and the risk of harm appears to increase with age. After 2 months of age, swaddling should never be used for sleep. Deaths have been reported among babies 2 to 2½ months of age who are swaddled and end up on their stomachs. Tight swaddling for a prolonged period of time is a risk factor for worsening of developmental hip dysplasia. Recommendations for what is now referred to as “modern swaddling” for awake infants in their parent’s arms are based on the principle that infants have startle reflexes they are not able to control. If the blanket is snug around the chest, but loose around the legs, infants have the benefits of swaddling without the risk to the hips. The blanket should be loose enough at the chest that a hand can fit between the blanket and the baby’s chest, but not so loose that it unravels. There is currently no evidence supporting a safe swaddling technique for sleep.

Parents need strategies that will assist them in engaging relatives, friends, and child care providers to follow safe sleep practices for the baby. A consistent message about back to sleep provides family members with the best information.

What have you heard about safe sleep for infants? Where will your baby sleep? How about at naptime?

It is best to always have your baby sleep on her back because it reduces the risk of sudden infant death. We recommend this sleep position for babies even if they are born premature or have problems with reflux, which is frequent vomiting after feeding. Do not use a wedge or other product to keep your baby on her back, as the baby can wiggle down and suffocate against the wedge.

For at least the first 6 months, your baby should sleep in your room in her own crib, but not in your bed. Think about some strategies you might use to soothe your baby without bringing her into your bed, where the risks of suffocation, entrapment, and death are increased.

If possible, use a crib purchased after June 28, 2011, as cribs sold in the United States after that date are required to meet a new, stronger safety standard. If you use an older crib, choose one with slats that are no more than 2⅜ inches (60 mm) apart and with a mattress that fits snugly, with no gaps between the mattress and the crib slats. Drop-side cribs are no longer recommended.

If you choose a mesh play yard or portable crib, consider choosing one that was manufactured after a new, stronger safety standard was implemented on February 28, 2013. If you use an older product, the weave should have openings less than ¼ inch (6 mm) and the sides should always stay fully raised.

The baby’s sleep space should be kept empty, with no toys or soft bedding, such as pillows, bumpers, or blankets.

The safest cover for the baby is a sleepsack or footed pajamas that can keep the baby warm without concern about suffocating under a blanket. This also allows the baby to move her legs as opposed to swaddling, which has the potential to cause poor development of her hips and increases your baby’s risk of suffocation and death.

Some babies with very sensitive startle reflexes appear more comfortable having their arms close to their body. Swaddling can help with this sensitivity. If you swaddle your baby, be sure to keep it loose around her legs, but snug—not tight—around her chest. To make sure your baby can breathe, leave enough space so that you can fit your hand between the blanket and her chest. Also, be sure that there are no loose ends of blanket around her neck, as these can increase your baby’s risk of suffocating.

Swaddling should only be used with babies younger than 2 months and is recommended only when your baby is awake. Older babies can roll over and risk suffocation if they are swaddled.

Pet guidance is based on the specific animals in the home (eg, domestic and exotic birds, cats, dogs, ferrets, or reptiles). Discussion points may include the need for maintaining physical separation of the pet from the child, introducing the pet to the new baby, avoiding contact with animal waste, the importance of handwashing, and limiting indoor air contamination with animal dander or waste products.

Do you have any pets at home or do you handle any animals? If you have handled cats, have you ever been tested for antibodies to a parasitic infection called toxoplasmosis that some cats are infected with?

Pets may be dangerous for babies and young children. Cats and dogs can become jealous just like humans. Learn about the risks that may occur with your pets and determine the best method of protecting your baby.

If you work with or handle cats, we suggest that you talk to your own health care professional about getting tested for toxoplasmosis.

Discuss firearm safety in the home and the danger to family members and children. Homicide and suicide are more common in homes in which firearms are kept. The AAP recommends that firearms be removed from the places children live and play, and that, if it is necessary to keep a firearm, it should be stored unloaded and locked, with the ammunition locked separately from the firearm.

Do you keep firearms at home? Are they unloaded and locked? Is the ammunition locked and stored separately? Are there firearms in the homes where you visit, such as the homes of grandparents, other relatives, or friends?

Homicide and suicide and unintentional firearm injuries are more common in homes that have firearms. The best way to keep your child safe from injury or death from firearms is to never have a firearm in the home.

If it is necessary to keep a firearm in your home or if the homes of people you visit have firearms, they should be stored unloaded and locked, with the ammunition locked separately from the firearm. Make sure the firearm is stored safely before your baby starts crawling and exploring your home.

Discuss other home safety precautions with parents, including appropriate water heater setting and smoke and carbon monoxide detector/alarms.

What home safety precautions have you taken for your unborn baby or any children in your home?

To protect your child from tap water scalds, the hottest temperature at the faucet should be no higher than 120°F. In many cases, you can adjust your water heater.

Milk and formula should never be heated in the microwave because they can heat unevenly, causing pockets of liquid that are hot enough to scald your baby’s mouth.

Make sure you have a working smoke alarm on every level of your home, especially in the furnace and sleeping areas. Test the alarms every month. It’s best to use smoke alarms that use long-life batteries, but, if you don’t, change the batteries at least once a year. Plan several escape routes from the house and conduct home fire drills.

Install a carbon monoxide detector/alarm, certified by Underwriters Laboratories (UL), in the hallway near every separate sleeping area of the home.

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• Prenatal and Postpartum Care (PPC)

Prenatal and Postpartum Care (PPC)

Assesses access to prenatal and postpartum care:

• Timeliness of Prenatal Care. The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization.
• Postpartum Care. The percentage of deliveries in which women had a postpartum visit on or between 7 and 84 days after delivery.

Why It Matters

Each year, about four million women in the U.S. give birth, with one million women having one or more complications during pregnancy, labor and delivery or the postpartum period. 1 Studies indicate that as many as 60% of all pregnancy-related deaths could be prevented if women had better access to health care, received better quality of care and made changes in their health and lifestyle habits. 1  Timely and adequate prenatal and postpartum care can set the stage for the long-term health and well-being of new mothers and their infants. 2

Joint guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend a prenatal visit in the first trimester for all women. 3 ACOG also recommends that all women have contact with their obstetrician-gynecologists or other obstetric providers within 3 weeks postpartum, followed by ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. 2

Results – National Averages

Timeliness of prenatal care, postpartum care.

This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.

Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via  my.ncqa.org  for analysis that accounts for trend breaks.

• CDC Review to Action. (2018). Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs
• American College of Obstetricians and Gynecologists (ACOG). (2018). Optimizing Postpartum Care. ACOG Committee Opinion No. 736. Obstet Gynecol, 131:140-150.
• American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care. 8th ed. Elk Grove Village, Ill. American Academy of Pediatrics, and Washington, DC.

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