Editors: Evans, Arthur T. Title: Manual of Obstetrics, 7th Edition Copyright !

!""7 #ippincott $illia%s & $il'ins ( Table of Contents ( ) * Obstetric Care ( + * ,renatal Care

,renatal Care Arthur T. Evans -. $illette #e -e. /ey ,oints ,renatal care is designed to provide preventive care and active intervention for acute %edical proble%s for t.o interdependent patients. Advances in technology have allo.ed the fetus to beco%e a separate and distinct patient.

,atient education about pregnancy issues is as i%portant as %edical %anage%ent during prenatal care.

0ac'ground ,renatal care is uni1ue: o )t provides care si%ultaneously to t.o interdependent patients.
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)t is one of the fe. health care progra%s that focuses on preventive care and that is recogni2ed and funded by virtually all payers.

There are %any co%ponents of prenatal care:

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Confir%ing the diagnosis of pregnancy and establishing the esti%ated gestational age, .hich allo.s the esti%ated date of confine%ent to be accurately assigned. Obtaining a full history and conducting a physical e3a%ination .ith laboratory evaluation. Conducting regular periodic e3a%inations .ith ongoing patient education. Meeting routine health care needs over the length of the pregnancy, solving acute %edical proble%s, and identifying and addressing pregnancy co%plications.

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All infor%ation obtained should be recorded in a concise %anner that is accessible to other %e%bers of the health care tea%. )t is helpful to use a standardi2ed for%at for charting so that i%portant factors are not overloo'ed.

4iagnosis of ,regnancy and Accurate 4ating The diagnosis of pregnancy and accurate dating are essential to avoid ris's during the first .ee's of gestation and for handling possible %edical co%plications, pre%ature labor, or postdates pregnancy. The diagnosis of pregnancy is facilitated by both presu%ptive and probable signs.
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,resu%ptive signs lead a .o%an to believe that she is pregnant. ,robable signs are highly suggestive of the diagnosis of pregnancy. 5ote that these signs do not differentiate bet.een an ectopic and an intrauterine pregnancy.

,resu%ptive 6igns A%enorrhea is often the first sign of possible conception. )t %ust be regarded .ith caution, ho.ever, because lac' of %enses %ay result fro% other factors, such as anovulation, stress, chronic disease, or lactation. ,.7

6ub8ective signs and sy%pto%s of early pregnancy include breast fullness and tenderness, s'in changes, nausea, vo%iting, urinary fre1uency, and fatigue. 0et.een +! and !" .ee's9 gestation, a .o%an .ill note an enlarging abdo%en and perceive fetal %ove%ent.

,robable 6igns :terine enlarge%ent 6oftening of the uterine isth%us ;-egar sign<

=aginal and cervical cyanosis ;Chad.ic' sign< ,regnancy tests:

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:rine pregnancy tests used today are very sensitive and %ay be positive as early as + .ee' after e%bryo i%plantation or .ithin days of the first %issed %enstrual period. The first voided %orning urine is the %ost concentrated speci%en for analysis. >adioi%%unoassay for seru% testing of the beta subunit of hu%an chorionic gonadotropin ;hC?< %ay be accurate up to a fe. days after i%plantation ;or even before the first %issed period<. -u%an chorionic gonadotropin production is at it9s %a3i%u% oct bet.een @" and 7" days of gestation and declines thereafter. These tests do not differentiate bet.een trophoblastic disease ;e.g., %olar pregnancy or choriocarcino%a< and nor%al pregnancy. Other bioassay techni1ues used in the past, such as progesterone .ithdra.al, are of historic interest only. ,rogestin should not be given to a .o%an presu%ed to be pregnant because of potential ;although rare< fetal ano%alies ;especially li%b defects<.

,ositive 4iagnostic 6igns Aetal heart tones can be detected as early as B to +" .ee's fro% the last %enstrual period ;#M,< by 4oppler technology. The nonelectronic fetoscope detects fetal heart tones at +C to !" .ee's fro% the #M,. Aetal %ove%ents ;DEF1uic'eningDEG< are first felt by the patient at appro3i%ately +@ to +C .ee's. They are a valuable indication of fetal .ell*being. 0o.el activity often si%ulates fetal %ove%ents and %ay be confusing to the patient.

:ltrasound e3a%ination .ill de%onstrate an intrauterine gestational sac at H to @ .ee's and a fetal pole .ith %ove%ent and cardiac activity at @ to C .ee's. =aginal probe ultrasonography has %ade these early %easure%ents even %ore accurate. Aetal age can be esti%ated by cro.nDEIru%p length, and the nu%ber of fetuses %ay be identified. 0et.een C and +7 .ee's of gestation, the fetal %easure%ents, including biparietal dia%eter and fe%ur length, can be used to esti%ate fetal age accurately. )n the second tri%ester, fetal anato%y, placental location, and a%niotic fluid volu%e can be evaluated. To date, there is no proof that diagnostic ultrasound e3posure has adverse effects on the developing hu%an fetus.

Esti%ated 4ate of Confine%ent The %ean duration of pregnancy as calculated fro% the #M, is !C" days, or 7" .ee's. 5JKgele9s rule is used to calculate the esti%ated date of confine%ent ;E4C<:
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To the first day of the #M,, add 7 days and then subtract L %onths. 4eviations fro% this calculation %ay be %ade for various reasons ;e.g., irregular or prolonged %enstrual cycles or a 'no. single se3ual e3posure<. )f the date of the #M, is un'no.n or does not correlate .ith uterine si2e at the first visit, ultrasonography should be used to establish the E4C.

Evaluation A co%plete history and physical e3a%ination are perfor%ed after the diagnosis of pregnancy is established. An i%portant goal is to develop a trusting, .or'ing relationship bet.een the patient and the health care tea%. ,.H -istory

Menstrual and contraceptive history: o >eliable %enstrual history is the %ost accurate predictor of delivery date.
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$o%en .ith recent birth control pill usage %ay have postpill a%enorrhea, and therefore pregnancy dating %ay be in error. )ntrauterine device use should be noted, and its presence, absence, or re%oval carefully docu%ented.

?ynecologic history: ,revious gynecologic infections or proble%s should be recorded. Obstetric history:
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The obstetric history is recorded as gravidity and parity. ?ravidity is the total nu%ber of pregnancies. ,arity is e3pressed as four serial nu%bers: ter% deliveries, pre%ature deliveries, abortions ;spontaneous and elective<, and living children.

4etails of previous pregnancies, such as character and length of labor, type of delivery, co%plications, infant status, and birth .eight, should be noted. >ecurrent first*tri%ester losses or history of second*tri%ester losses %ay suggest genetic proble%s or inco%petent cervi3. )f the patient has had a cesarean delivery, reco%%endations about vaginal birth after cesarean delivery can be addressed at this ti%e.

Medical and surgical history and prior hospitali2ations:

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,re*e3siting %edical proble%s or diagnoses are i%portant for ris' assess%ent and %anage%ent. ,revious surgeries and hospitali2ations should be elicited and evaluated.

Environ%ental e3posures, %edications ta'en in early pregnancy, reactions to %edications, legal and illegal drug use, allergic history, and diethylstilbestrol ;4E6< e3posure. Aa%ily history of %edical illnesses, hereditary illness, congenital ano%alies, and %ultiple gestation. 6ocial factors:
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-o%e situation, fa%ily and social support, and history of possible physical or %ental abuse should be assessed and appropriate referrals %ade. Accurate history of substance use is not al.ays easily obtained. :se of legal substances such as cigarettes and alcohol, as .ell as illicit substance use, is pervasive in all social and racial groups. All of these che%icals have serious ra%ifications for fetal develop%ent and pregnancy outco%e.

>evie. of syste%s as related to pregnancy: nausea, vo%iting, abdo%inal pain, constipation, headaches, syncopal episodes, vaginal bleeding or discharge, dysuria or urinary fre1uency, s.elling, varicosities, and he%orrhoids.

,hysical E3a%ination Co%plete physical e3a%ination .ith attention to specific organ syste%s as directed by any positive findings in the history: o Measure%ent of height, .eight, blood pressure, pulseM funduscopic e3a%inationM e3a%ination of thyroid, ly%ph nodes, lungs, heart, breasts, and abdo%en, .ith fundal height and presence of fetal heart tones, e3tre%itiesM and a basic neurologic screening.
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Evaluate the nor%al changes found in pregnancy as .ell as the pathologic changes that %ay develop during pregnancy to properly assess the findings of the physical e3a%ination.

,elvic e3a%ination:

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E3ternal genitaliaDENevidence of previous obstetric in8ury should be noted. =aginaDENunder hor%onal influence of pregnancy, cervical secretions are increased, thus raising the vaginal p-, .hich %ay cause a change in the bacteriologic flora of the vagina. 5o treat%ent is necessary unless diagnosis of a specific infection is %ade ;see DEFTreat%ent of Co%%on #esions and )nfectionsDEG later in this chapter<. 6creening for bacterial vaginosis should be done in .o%en at high ris' for pre%ature labor. ,.@

Cervi3DENA ,apanicolaou test and culture for gonorrhea are routinely perfor%ed unless the ,apanicolaou test has been done recently. A Chla%ydia culture should also be perfor%ed in high*ris' populations. Cervical softening and eversion ;ectropion< is nor%al.

5abothian cysts are of no conse1uence. 4ilatation of the e3ternal os is co%%on in %ultiparous patients and is benign. Efface%ent or dilation of the internal os is abnor%al, e3cept near ter%, and %ay indicate pre%ature labor or inco%petent cervi3. Morphologic cervical changes ;ridges, hood, or collar<, or vaginal adenosis %ay indicate 4E6 e3posure in utero. These .o%en have a higher incidence of inco%petent cervi3 and pre%ature delivery and should be evaluated accordingly.

:terusDENEsti%ating gestational age by gauging uterine si2e is one of the %ost i%portant ele%ents of the first e3a%ination.

A nor%al, nongravid uterus is fir%, s%ooth, and appro3i%ately L 3 7 3 7 c%. The uterus .ill not change noticeably in consistency or si2e until H to @ .ee's after the #M,, or 7 .ee's fro% conception. ?estational age fro% the #M, is esti%ated by uterine volu%e ;i.e., C .ee's, t.ice nor%al si2eM +" .ee's, three ti%es nor%alM +! .ee's, four ti%es nor%al<. At +! .ee's, the uterus fills the pelvis so that the fundus of the uterus is palpable at the sy%physis pubis. 0y +@ .ee's, the uterus is %id.ay bet.een the sy%physis pubis and the u%bilicus. At !" .ee's, it reaches the u%bilicus. Thereafter, there is a rough correlation bet.een .ee's of gestation and centi%eters of fundal curvature .hen %easured fro% the top of the sy%physis pubis to the top of the uterine fundus ;Mac4onald %easure%ent<. After correcting for %inor discrepancies resulting fro% adiposity and variation in body shape, a uterine si2e that e3ceeds the anticipated

gestational age by L .ee's or %ore, as calculated fro% the last nor%al %enstrual period, suggests %ultiple gestation, %olar pregnancy, leio%yo%ata, uterine ano%alies, adne3al %asses, or si%ply an inaccurate date for the #M,. :ltrasonography is the best diagnostic tool for this situation.

6%aller than e3pected uterine si2e for gestational age %ay indicate inaccurate dating, oligohydra%nios, or intrauterine gro.th restriction.

Adne3a are difficult to evaluate because the fallopian tubes and the ovaries are lifted out of the pelvis by the enlarging uterus. Any 1uestionable %asses should be confir%ed by ultrasonogra%. Clinical pelvi%etry is done as part of the initial bi%anual e3a% to assess the general ade1uacy of the pelvis for vaginal delivery.
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Clinical pelvi%etry re1uires e3perience and is inherently inaccurate even .ith a highly e3perienced e3a%iner. Although it is still in use, clinical pelvi%etry, in today9s obstetric environ%ent, yields too %any false*positive and false*negative results to be relied on for clinical decisions. Co%puted to%ography ;CT< pelvi%etry has replaced traditional 3*ray pelvi%etry for obtaining an ob8ective %easure%ent of pelvic si2e. There %ay be situations .here CT pelvi%etry can provide ob8ective infor%ation that contributes to clinical decision %a'ing, such as evaluation for vaginal breech delivery.

#aboratory Evaluation A history positive for certain illness or abnor%alities in other screening tests should be investigated .ith further tests as indicated. A routine initial screen includes a co%plete blood count, A0O blood typing and >h factor, antibody screening, urinalysis and culture, serologic test for syphilis, rubella titer, ,apanicolaou test, cervical culture for gonorrhea, and hepatitis 0 surface*antigen screening. A cervical culture for Chla%ydia is indicated in high*ris' patients. ?roup 0 6treptococcus ;?06< ;see Chapter !L<: ,.7

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6creening is not indicated in early pregnancy, nor is it based on ris' factors. All pregnant .o%en should be screened for ?06 at LH to L7 .ee's9 gestation by a culture obtained fro% a s.ab of the rectu% and the lo.er third of the vagina. ,atients .ith positive results are treated .ith appropriate antibiotics during labor.

,atients presenting .ith preter% labor, pre%ature rupture of %e%branes, or %aternal fever in labor for .ho% no culture results are available should have rectovaginal cultures perfor%ed and receive ?06 antibiotic treat%ent until the culture results are available.

6peciali2ed screening tests:

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-)= screening, .ith appropriate counseling and consent, should be offered to all pregnant .o%en and should be strongly encouraged in high*ris' populations. -e%oglobin electrophoresis should be used to identify he%oglobinopathies in specific groups of .o%en:

6ic'le he%oglobin in African A%ericans 0eta*thalasse%ia in Mediterranean couples Alpha*thalasse%ia in Asian couples.

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Tay*6achs carrier status analysis is indicated in Oe.ish couples. -erpes cultures for purposes of screening are not reco%%ended. Cultures %ay be helpful for confir%ing diagnosis .hen active lesions are presentM ho.ever, they have little value in predicting .hether the fetus is at ris'. :rine or blood to3icology screening %ay be indicated for the evaluation of illicit substance use in selected patients and situations. Aetal ultrasound as a routine screening test .ithout indications is not currently considered a standard of care in unco%plicated pregnancies. -o.ever, %ost physicians consider an obstetric ultrasound e3a%ination to be an essential part of prenatal evaluation and care for all pregnant .o%en. )ndeed, al%ost all pregnancies e3hibit at least one of the indications for ultrasound e3a%ination. 4o.n syndro%e screening can be offered in the first tri%ester at +" to +7 .ee's9 gestation through a co%bination of t.o seru% analytes, pregnancy associated plas%a protein*A ;,A,,*A< and free PQ*hC?, and nuchal translucency by ultrasound.

Mid*tri%ester screening tests:

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>is' assess%ent for 4o.n syndro%e, triso%ies +C and +L, open neural tube defects, ventral .all defects, and a list of other, %ore rare abnor%alities can be acco%plished through the Triple or Ruad screens. These tests evaluate a co%bination of seru% analytes to arrive at a ris' state%ent rather than a diagnosis. The Ruad screen is no. the preferred test because the co%bination of %aternal seru% ;M6<*PS*fetoprotein, PQ*hC?, estriol, and inhibin A provides greater sensitivity. 0lood should be dra.n bet.een the +Hth and !"th .ee's of gestation ;+@ to +C .ee's ispreferred<. Abnor%al results are further evaluated by ultrasonography and a%niocentesis.

At !7 to !C .ee's, a +*hour glucola screen ;blood glucose %easure%ent + hour after a H"*g oral glucose load< is obtained to screen for gestational diabetes.

A +*hour glucola screen value (+7" %g per dl is considered abnor%al and re1uires definitive testing by a L*hour +""*g oral glucose tolerance test. A universal screening approach can be used in .hich all pregnant .o%en are screened. Alternatively, a screening sche%e can be used that e3cludes .o%en .ho are at lo. ris' for gestational diabetes by %eeting all of the follo.ing criteria:

Tounger than !H years of age 5ot a %e%ber of a racial or ethnic group .ith high prevalence of gestational diabetes 0ody %ass inde3 U!H 5o history of abnor%al glucose tolerance 5o previous history of adverse pregnancy outco%es usually associated .ith gestational diabetes 5o 'no.n diabetes in first*degree relatives.

$o%en .ith a particular ris' ;e.g., previous gestational diabetes or fetal %acroso%ia< should receive glucola screening early in pregnancy.

,.C

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>epeat he%oglobin and he%atocrit are obtained at !@ to L" .ee's to deter%ine .hether iron supple%entation is needed. >epeat serologic testing for syphilis is reco%%ended at !C to L! .ee's for high* ris' groups. At !C to L" .ee's, an antibody screen is obtained in >h*negative .o%en, and an >ho;4< i%%unoglobulin ;>ho?AM< is ad%inistered. >epeat third*tri%ester screening for gonorrhea and Chla%ydia is reco%%ended in high*ris' populations.

Treat%ent of Co%%on #esions and )nfections that May 0e Encountered on ,elvic E3a%ination 0artholin ?land Abscess

A painful, erythe%atous, cystic enlarge%ent on either side of the lateral vaginal introitus indicates obstruction and infection of the 0artholin gland. Treat%ent includes sit2 baths, analgesic, and, .hen fluctuant, incision and drainage. Cyst for%ation %ay result fro% inco%plete resolution of an abscess. Marsupiali2ation after the puerperiu% %ay be advisable for recurrent proble%s.

Condylo%ata acu%inata =enereal .arts are hyper'eratotic, flat, or polypoid lesions found in the vulvar or perineal areas, vagina, or cervi3 and caused by infection .ith the hu%an papillo%a virus ;-,=<. Certain viral types are associated .ith the develop%ent of dysplasia and epithelial carcino%a. ,regnancy %ay sti%ulate proliferation of these lesions, .hich %ay beco%e friable. >arely, cesarean delivery is necessary to prevent e3tensive vaginal da%age at delivery.

There is also an ill*defined ris' of trans%ission of -,= to the infant, .ith develop%ent of laryngeal papillo%ata. The %ode of trans%ission is un'no.n, and currently there is no consensus regarding the protective benefit to the ne.born of cesarean versus vaginal delivery. Treat%ent of the lesions is %ore difficult in pregnancy. ,odophyllin resin, trichloroacetic acid, H*fluorouracil, and i%%unotherapy should be avoided. -o.ever, cryotherapy, electrocauteri2ation, or laser %ay be used on e3ternal lesions.

-erpes 6i%ple3 =iral )nfections Characteristic lesions are s%all, painful, superficial, erythe%atous vesicles that ulcerate. Treat%ent is sy%pto%atic. The use of the antiviral agents acyclovir, a%cyclovir, and valacyclovir has not been approved but has been reported. 6uch treat%ent should be considered only on an individual ris'DEIbenefit basis.

)f lesions are present at the ti%e of labor or rupture of %e%branes, cesarean delivery should be perfor%ed.

Monilial =ulvovaginitis Monilial ;also 'no.n as candida or yeast< infection .ith the characteristic curdy, .hite, itchy discharge is co%%on. -yphal structures are seen on .et %ount. This infection can be treated safely during pregnancy .ith nystatin or %icona2ole nitrate crea%s or suppositories in the usual dose regi%ens. Alucona2ole ;4iflucan< should be used only in life*threatening situations. Tricho%onas vaginalis )nfection =ulvar or vaginal burning or itching .ith a frothy, %alodorous discharge is a fre1uent finding .ith this infection. Confir%ation of the diagnosis is by visuali2ation of the organis%s on .et %ount. ,.B

Metronida2ole ;Alagyl< is the treat%ent of choice but is contraindicated during the first tri%ester because of possible teratogenicity. Clotri%a2ole suppositories ;one nightly for + .ee'< have been used, .ith an i%prove%ent in sy%pto%s and a 7"V cure rate. Aor severe cases, %etronida2ole %ay be used during the second and third tri%esters, but the !*g dose should be avoided. The se3ual partner should also be treated.

0acterial =aginosis Also referred to as ?ardnerella vaginalis or -ae%ophilus vaginalis vaginitis, bacterial vaginosis produces a .hite to gray %alodorous discharge that is %ildly irritating. Characteristic clue cells are noted on .et %ount, .ith a%ine discharge on potassiu% hydro3ide preparation. The current drug of choice is %etronida2ole, but its use is restricted in pregnancy, as discussed above. A%picillin, H"" %g for 7 days, %ay be used. )n the second and third tri%esters, treat%ent .ith %etronida2ole, H"" %g by %outh, t.ice a day for H to 7 days, %ay be used. Treat%ent of the se3ual partner has not been found to be useful in routine cases.

6o%e studies have suggested an association bet.een bacterial vaginosis and preter% labor ris', but this association re%ains uncertain.

5eisseria gonorrhoeae )nfection 6y%pto%s %ay include dysuria, burning, or only vaginal or cervical discharge. Many patients are asy%pto%atic. Microscopically, gra%*negative intracellular diplococci are seen in the discharge, but culture confir%ation is i%perative. :sual treat%ent regi%ens %ay be ad%inisteredM ho.ever, tetracycline is contraindicated in pregnancy. The se3ual partner should be treated and a test*of*cure culture obtained after treat%ent.

0ecause of the high rate of coe3istent infection, it is reco%%ended that .o%en .ith gonorrheal infection be treated for Chla%ydia ;see belo.<.

Chla%ydia tracho%atis )nfection 6y%pto%s of the infection fro% this obligatory intracellular parasite range fro% asy%pto%atic to cervicitis, discharge, and disco%fort. 4iagnosis is %ade by special cultureM in so%e areas %ore rapid tests are available. The infection can be passed to the ne.born in the for% of con8unctivitis or pneu%onia.

Treat%ent is erythro%ycin, !H" to H"" %g by %outh, four ti%es per day for +" to +7 days. Tetracycline is effective but it is contraindicated in pregnancy. The se3ual partner %ust be treated, and a test*of*cure culture should be obtained after treat%ent.

Co%plications

>is' Assess%ent >is' assess%ent is one of the %ost i%portant co%ponents of prenatal care. )t is a continuous e3ercise that %ust ta'e into account all aspects of the patient9s %edical, social, and econo%ic status. 4esignation of a pregnancy as lo. ris' or high ris' creates specific e3pectations and re1uire%ents for prenatal %anage%ent. #o. ris' i%plies e3pectation of a favorable outco%e, placing %ore prenatal care focus on health %aintenance and social issues than on specific %edical %anage%ent. -igh ris' i%plies a need for increased surveillance, special care, and appropriate referrals. Categories of increased ris' that should be identified and given appropriate attention include
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,re*e3isting %edical illness ,revious pregnancy co%plications, such as perinatal %ortality, pre%aturity, fetal gro.th retardation, %alfor%ations, placental accidents, and %aternal he%orrhage ,.+"

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Evidence of poor %aternal nutrition Onset of co%plicating events that %ay transfor% a lo.*ris' pregnancy into a high*ris' pregnancy.

?enetics >eferral Congenital ano%alies and diseases are a %a8or cause of infant %orbidity and %ortality. )ndications for genetic referral include
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Maternal age (LH years at the ti%e of the E4C Aa%ily history of congenital ano%alies or inherited disorders Abnor%al develop%ent or %ental retardation of a previous child Ethnic bac'ground associated .ith inheritable diseases 6ubstance use or e3posure to teratogens Three or %ore consecutive spontaneous abortions.

6ubse1uent ,renatal Care >egular prenatal visits allo. ongoing evaluation and assurance that the pregnancy is progressing nor%ally. Aor lo.*ris' pregnancies, the reco%%ended fre1uency of prenatal visits is %onthly up to L! .ee's, every ! .ee's up to L@ .ee's, and then .ee'ly until delivery. 6tandard assess%ent at each prenatal visit includes %aternal .eight, blood pressure, uterine si2e, auscultation of fetal heart tones, and evaluation for ede%a, proteinuria, and

glucosuria. After +C to !" .ee's, the patient should be 1uestioned about fetal %ove%ents. #ate in pregnancy, the presenting fetal part should be deter%ined.

Ongoing patient education appropriate to the gestational age of the fetus is incorporated into these visits. All prenatal care infor%ation should be recorded on a standardi2ed for%.

?uidelines for ,atients 5utrition: A co%%on*sense approach is necessary because there are %any li%itations to our understanding of the nutritional needs of pregnancy. o 6uggestions include eating foods fro% each of the %a8or food groups, consu%ing ade1uate li1uids ;especially .ater<, adding fiber, and ensuring ade1uate calciu% inta'e.
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Aor a .o%an .hose .eight is nor%al before pregnancy, nor%al pregnancy .eight gain is !" to !7 lb ;+" to +! 'g<. This is usually achieved by eating a .ell* balanced diet containing @" to C" g of protein, !,7"" or %ore calories, lo. sugars and fats, high fiber, and at least three glasses of %il' or other dairy e1uivalents daily. An under.eight .o%an is at an increased ris' for a gro.th*retarded infant, and %ore .eight gain is often re1uired. E3cessive .eight gain or pre*e3isting %aternal obesity ;%ore than !"" lb or B" 'g< %ay, in so%e cases, be associated .ith increased ris' of fetal %acroso%ia. This is a significant ris' factor for the infant in ter%s of birth trau%a and cesarean delivery. >outine prescription of prenatal vita%ins is probably not necessary. ,ractically all diets that supply ade1uate caloric inta'e for appropriate .eight gain .ill also provide enough %inerals. There are t.o e3ceptions:

Aolic acid supple%entation preconceptually and throughout the early part of pregnancy has been sho.n to decrease the incidence of fetal neural tube defects. )ron supple%entation is reco%%ended after !C .ee's9 gestation because increased iron re1uire%ents in the latter part of pregnancy are difficult to %eet via a nor%al diet.

$or'ing during pregnancy: Most .o%en can safely .or' until ter% .ithout co%plications.
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A fle3ible approach %ust be ta'en because pregnant .o%en %ay have less tolerance to heat, hu%idity, environ%ental pollutants, prolonged standing, and heavy lifting. ,.++

,regnant .o%en .ho should probably not .or' include those .ith a history of t.o pre%ature deliveries, inco%petent cervi3, fetal loss secondary to uterine abnor%alities, cardiac disease greater than class )), Marfan syndro%e, he%oglobinopathies, diabetes .ith retinopathy or renal involve%ent, third* tri%ester bleeding, pre%ature rupture of the %e%branes, or %ultiple gestation after !C .ee's. E3ercise: $o%en should be encouraged to e3ercise if they have no co%plicating factors.
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E3ercise reco%%endations should be tailored according to the level of physical activity of the patient before she beca%e pregnant and according to her level of physical fitness. A trained athlete can continue rigorous training during pregnancy but should avoid raising her core te%perature or beco%ing dehydrated. E3ercise should be varied during the third tri%ester to avoid too %uch stress on 'nee and an'le 8oints. $al'ing, s.i%%ing, and prenatal aerobic classes can be adapted to the needs of %ost .o%en.

6%o'ing should be discontinued during pregnancy.

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)t is i%portant to counsel patients about antenatal s%o'ing ris's and cessation reco%%endations and to record their co%pliance. The potentially har%ful effects of cigarette s%o'ing during pregnancy include

#o. birth .eight ,re%ature labor 6pontaneous abortion 6tillbirth Crib death 0irth defects )ncreased respiratory proble%s in ne.borns.

6%o'ing %ore than ten cigarettes a day can have a pronounced effect on birth .eight. ,atient education is i%portant because %any .o%en do not understand the severity of the ris's. A pregnant patient9s desire to stop s%o'ing should be supported by a nicotine .ithdra.al progra% or syste% and .ith counseling or referral to appropriate co%%unity groups.

Alcohol use should be discontinued in pregnancy, including social and binge drin'ing.
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There %ay be a linear relationship bet.een alcohol consu%ption and fetal da%age, .hich .ould e3plain .hy even li%ited fetal e3posure to alcohol through social or binge drin'ing can be da%aging.

Aetal alcohol syndro%e ;AA6< is the result of chronic fetal alcohol e3posure.

$ith chronic alcoholis%, the ris' of AA6 is !"V to 7"V. =ariants of AA6 %ay also result fro% binge drin'ing or persistent social drin'ing. AA6 occurs as a characteristic pattern of physical abnor%alities that includes intrauterine gro.th retardation and %ental retardation. As such, it is an i%portant cause of poor fetal gro.th and abnor%al develop%ent. AA6 includes

Cardiac %alfor%ations Central nervous syste% ano%alies such as %icrocephaly and neural tube defects Micrognathia, cleft lipWcleft palate and other facial abnor%alities 6'eletal and truncal abnor%alities including diaphrag%atic hernia ?enitourinary %alfor%ations.

6eat belt use is the sa%e as for the nonpregnant auto%obile passenger: The lap belt is .orn lo. and snugly across the hip bonesM the shoulder harness is .orn over one shoulder and under the opposite ar%, loosely enough to place a clenched fist bet.een the sternu% and the belt. 6e3ual relations: There are no restrictions for the patient .ithout co%plications. $hatever is co%fortable and pleasurable %ay be continued unless and until a pregnancy co%plication occurs ;e.g., undiagnosed bleeding, preter% labor, placenta previa, ,.+! rupture of the %e%branes<. ,atients should be .arned specifically against the forcing of air into the vagina during orogenital se3 because of reports of sudden %aternal death or stro'e.

Aetal %ove%ent is generally discernible by the %other at +C to !" .ee's9 gestation. o Aetal activity is cyclic in nature and .ill nor%ally vary in fre1uency and intensity throughout the day.
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,resence of fetal %ove%ent is considered reassuring to the %other. #ac' of fetal %ove%ent or a %ar'ed decrease in fre1uency is often .orriso%e to the %other but is not a specific %ar'er of fetal co%pro%ise. Most typically, this occurs in con8unction .ith fetal sleep cycles.

,rolonged absence of fetal %ove%ent is best evaluated by a nonstress test .ith ultrasound biophysical profile as bac'up assess%ent.

$arning signs of preter% labor.

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6tudies have suggested that patient education regarding the .arning signs for preter% labor leads to i%proved rates of early diagnosis of preter% labor. 6elf* identification allo.s these patients to see' the attention of the health care staff earlier in their preter% delivery course. Creasy et al. ;+< noted the follo.ing .arning signs:

A feeling that the baby is DEFballing upDEG that lasts %ore than L" seconds and occurs %ore than four ti%es per hour Contractions or inter%ittent pains or sensations bet.een nipples and 'nees lasting %ore than L" seconds and recurring four or %ore ti%es per hour Menstrual*li'e sensations, occurring inter%ittently Change in vaginal discharge, including bleeding )ndigestion or diarrhea

Co%%on co%plaints are a significant part of pregnancy. After investigating to rule out a serious pathologic condition, treat%ent %ay be directed to sy%pto%atic relief.
o

-eadache and bac'ache. Aceta%inophen ;Tylenol<, L!H to @H" %g every L to 7 hours, is usually sufficient. Mild narcotics such as codeine should be reserved for refractory severe headaches or %igraines. Aspirin should be avoided during pregnancy ;!<. 5ausea and vo%iting:

Airst*tri%ester %orning sic'ness %ay be treated sy%pto%atically and relieved by eating fre1uent, s%all %eals and avoiding spicy or greasy foods. 6evere, persistent, sy%pto%s %ay re1uire hospitali2ation and intravenous fluids. The antie%etics, pro%etha2ine ;,henergan<, diphenhydra%ine ;0enadryl<, and several other antihista%ines ;!< are considered safe for use in pregnancy and have no 'no.n association .ith birth defects. 0endectin, the traditional antinausea %edication for pregnancy, has been re%oved fro% the %ar'et by the %anufacturer, but an e1uivalent substitute is available through the use of pyrido3ine ;vita%in 0@< and :niso%.

Constipation:

A high*fiber diet, increased fluid inta'e, and regular e3ercise are reco%%ended. 6tool softeners such as docusate sodiu% ;Colace< or psylliu% hydrophilic %ucilloid ;Meta%ucil< %ay help. Mild la3atives should be used sparingly and only if the prior %easures fail.

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=aricosities: 6upport stoc'ings and leg elevation are reco%%ended. Other i%portant infor%ation for patients to 'no.:

$hen and .here to call if they have 1uestions or proble%s Availability of childbirth classes 6igns of the onset of labor Obstetric analgesic options )ndications for cesarean delivery -o%e safety )nfant care and feeding, including breast*feeding Access to consu%er education ;e.g., infant safety products, furniture, car seats< 0irth control counseling.

,.+L ,atient Education Effective prenatal care re1uires patient education. One of the pri%ary goals of prenatal care is to encourage patient responsibility through active participation in their prenatal care plan.

)n order for .o%en to %a'e effective choices, they need infor%ation about pregnancy and prenatal care before beco%ing pregnant. $o%en desire %ore control of the birthing process. To achieve this control, they need specific infor%ation and interactive discussion .ith their health care providers. Each .o%an9s personal socioecono%ic situation and support syste% %ust be e3plored and ta'en into account as part of her prenatal plan of care.

>eferences +. Creasy >/, ?u%%er 0A, #iggins ?C. 6yste% for predicting spontaneous preter% birth. Obstet ?ynecol +BC"MHH:@B!DEI@BH.

!. 0riggs ??, Aree%an >/, et al. 4rugs in pregnancy and lactation. 7th ed. ,hiladelphia: #ippincott $illia%s & $il'insM !""H. 6elected >eadings ?ilstrap #C, Oh $, eds. ?uidelines for perinatal care. Hth ed. Chicago: A%erican Acade%y of ,ediatrics and the A%erican College of Obstetricians and ?ynecologistsM !""!. Cu%%ingha% A?, ?ant 5A, #eveno /O, et al., eds. $illia%s obstetrics. !+st ed. 5e. Tor': Mc?ra.*-illM !""+. Cefalo >C, Moos M/, eds. ,reconceptional health care, a practical guide. !nd ed. 6t. #ouis: MosbyM +BBH.