managing-prenatal-care

# Managing Prenatal Care

Structures prenatal visit documentation with gestational age tracking, screening schedules, and risk assessment per ACOG guidelines.

## Why This Skill Exists

Prenatal care is the cornerstone of obstetric practice, directly reducing maternal and neonatal morbidity. ACOG recommends a structured visit schedule — monthly through 28 weeks, biweekly from 28–36 weeks, and weekly from 36 weeks to delivery — with specific screenings at defined gestational windows. Missed screenings, inaccurate gestational dating, or unrecognized risk factors contribute to preventable adverse outcomes including preeclampsia, fetal growth restriction, and preterm birth.

Proper documentation ensures continuity across providers, supports medicolegal defensibility, and satisfies CMS prenatal bundled-payment requirements. This skill enforces the ACOG-recommended screening timeline and risk stratification framework so that every visit is captured with clinical precision.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

Before drafting any prenatal documentation, confirm the following:

1. **Gestational age determination method** — LMP, early ultrasound CRL, or IVF dating? (Default: LMP with ultrasound confirmation)
2. **Gravidity and parity** — Full obstetric history in GTPAL format? (Default: request from chart)
3. **Risk stratification tier** — Low, moderate, or high risk per ACOG criteria? (Default: assess from intake data)
4. **Current visit gestational age** — Weeks + days at this encounter? (Default: calculate from EDD)
5. **Prior screening results** — First-trimester screen, NIPT, anatomy scan, GBS status? (Default: pull from prior visit notes)
6. **Medication list** — Prenatal vitamins, folic acid dose, any ongoing prescriptions? (Default: standard PNV + 0.4 mg folic acid)
7. **Comorbidities** — Chronic HTN, pre-gestational DM, thyroid disease, BMI > 30? (Default: review problem list)
8. **Patient preferences** — Birth plan elements, genetic testing preferences, circumcision wishes? (Default: document if provided)

### Documents to Request

- Initial OB intake / history and physical
- Prior ultrasound reports (dating, NT, anatomy, growth)
- Laboratory results (CBC, type and screen, rubella, hepatitis B, HIV, syphilis, urine culture, GBS)
- Genetic screening results (NIPT, quad screen, carrier screening)
- Prior obstetric records (if multiparous)
- Referral notes (MFM, genetic counseling, social work)
- Glucose tolerance test results (1-hour, 3-hour if applicable)

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## Step 1: Establish Gestational Dating and EDD

Accurate dating is the single most important element of prenatal care.

| Dating Method | Accuracy | When to Use |
|---|---|---|
| IVF transfer date | ± 1 day | Always use if available |
| CRL ultrasound < 9 weeks | ± 5 days | Preferred first-trimester method |
| CRL ultrasound 9–13+6 weeks | ± 7 days | Adjust EDD if discrepancy > 5 days from LMP |
| BPD/FL 14–15+6 weeks | ± 7 days | Adjust if discrepancy > 7 days from LMP |
| BPD/FL 16–21+6 weeks | ± 10 days | Adjust if discrepancy > 10 days from LMP |
| BPD/FL 22–27+6 weeks | ± 14 days | Adjust if discrepancy > 14 days from LMP |
| ≥ 28 weeks | ± 21 days | Do NOT change EDD based on third-trimester US |

Document the final agreed-upon EDD and the basis for dating. Once established, the EDD should not change.

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## Step 2: Apply the ACOG Screening Schedule

Map each visit to its gestational-age-appropriate screenings:

| GA Window | Required Screenings |
|---|---|
| Initial visit | CBC, blood type/Rh/antibody screen, rubella, HBsAg, HIV, RPR, UA/UCx, Pap if due, chlamydia/gonorrhea |
| 10–13 weeks | First-trimester screen (PAPP-A, free β-hCG, NT), NIPT offered if desired |
| 15–20 weeks | Quad screen (if no first-trimester screen or NIPT), AFP for NTD screening |
| 18–22 weeks | Detailed anatomy ultrasound |
| 24–28 weeks | 1-hour GCT (50 g), Rh antibody screen if Rh-negative, RhoGAM administration |
| 28 weeks | Repeat CBC (anemia screen), Tdap vaccine |
| 35–37 weeks | GBS recto-vaginal culture |
| 36+ weeks | Cervical exam if indicated, fetal presentation assessment |

Flag any overdue screening with `[OVERDUE — {test name} due at {GA}]`.

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## Step 3: Assess and Document Risk Factors

Categorize the patient at every visit using the ACOG risk-stratification model:

**High-risk indicators requiring MFM referral or co-management:**
- Prior preterm birth < 37 weeks (consider 17-OHP starting 16–20 weeks)
- Pre-gestational diabetes (Type 1 or Type 2)
- Chronic hypertension on medication
- Prior preeclampsia with severe features
- Multiple gestation
- Known fetal anomaly
- Cervical insufficiency / cerclage history
- Maternal age ≥ 40
- BMI ≥ 40 at booking

**Moderate-risk indicators requiring enhanced surveillance:**
- BMI 30–39.9
- Advanced maternal age (35–39)
- Prior cesarean delivery
- History of gestational diabetes
- Autoimmune conditions (SLE, APS)
- Substance use history

Document risk tier and any referrals initiated. Update risk status if new findings emerge.

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## Step 4: Standard Visit Documentation Template

Each prenatal visit note must include:

1. **Gestational age** — weeks + days, dating method
2. **Maternal vitals** — BP (flag ≥ 140/90), weight (calculate cumulative gain), fundal height (correlate with GA ± 3 cm)
3. **Fetal assessment** — FHR (normal 110–160 bpm), presentation (if ≥ 36 weeks), fetal movement report
4. **Laboratory review** — results received since last visit, interpretation, pending items
5. **Symptoms review** — contractions, bleeding, leaking fluid, headache, visual changes, epigastric pain, decreased fetal movement
6. **Assessment** — Current problems, risk updates
7. **Plan** — Next visit timing, pending orders, referrals, patient education provided

Weight gain targets per IOM guidelines:
| Pre-pregnancy BMI | Total Gain (lbs) | Rate 2nd/3rd Trimester (lbs/wk) |
|---|---|---|
| Underweight (< 18.5) | 28–40 | 1.0 |
| Normal (18.5–24.9) | 25–35 | 1.0 |
| Overweight (25–29.9) | 15–25 | 0.6 |
| Obese (≥ 30) | 11–20 | 0.5 |

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## Step 5: Third-Trimester Planning and Delivery Preparation

Beginning at 36 weeks, document:
- Fetal presentation (Leopold maneuvers, confirm with ultrasound if uncertain)
- Group B Streptococcus status and prophylaxis plan
- Delivery plan (vaginal vs. scheduled cesarean, VBAC candidacy)
- Antenatal testing schedule if indicated (NST, BPP, modified BPP)
- Induction timing per ACOG guidelines (e.g., 39 weeks for uncomplicated, 37 weeks for preeclampsia without severe features)
- Discussion of labor analgesia preferences
- Pediatrician identification and circumcision preferences

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

Before finalizing any prenatal care document, verify:

1. **Is the EDD clearly stated and consistent** across all sections of the document?
2. **Are all GA-appropriate screenings documented** as completed, pending, or declined?
3. **Is the risk tier current** and do referrals match the risk level?
4. **Are abnormal findings flagged** with clear follow-up plans and timeframes?
5. **Does the plan include the next visit date** and interval-appropriate orders?

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## Quality Audit

- [ ] EDD is documented with the dating method and has not been changed after 22 weeks without justification
- [ ] GTPAL obstetric history is complete and accurate
- [ ] Blood type, Rh status, and antibody screen are documented
- [ ] First-trimester or second-trimester aneuploidy screening is addressed (completed, declined, or pending)
- [ ] Anatomy ultrasound status is documented (completed, scheduled, or findings noted)
- [ ] GCT / GTT results are recorded with interpretation
- [ ] GBS status is documented (positive, negative, unknown, or pending — with prophylaxis plan if positive)
- [ ] Rh-negative patients have RhoGAM administration documented at 28 weeks
- [ ] Tdap vaccination is documented as given (27–36 weeks) or declined
- [ ] Weight gain is tracked against IOM targets with notation if off-track
- [ ] Fundal height measurements are documented and correlated with GA
- [ ] Fetal heart rate is documented at every visit after 10–12 weeks
- [ ] All abnormal lab values have documented follow-up plans
- [ ] High-risk patients have documented MFM referral or co-management notes
- [ ] Third-trimester delivery plan is documented by 36 weeks

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## Guidelines

1. **Use ACOG terminology** — refer to Practice Bulletins by number (e.g., PB 162 for prenatal genetic screening) when citing screening recommendations.
2. **Date everything from EDD** — express gestational age in completed weeks + days, never round to the nearest week.
3. **Never alter a confirmed EDD** after 22 weeks unless a clear error in original dating is identified and documented.
4. **Flag overdue items explicitly** — use `[OVERDUE]` tags rather than silently omitting missed screenings.
5. **Distinguish declined from not-offered** — document patient refusal with a notation that risks/benefits were discussed, versus a screening that was never presented.
6. **Track cumulative weight gain** — document both interval and total gain at every visit.
7. **Document fetal movement counseling** — confirm that kick-count instructions were given by 28 weeks.
8. **Use ICD-10 specificity** — code to the highest level (e.g., O09.522 for supervision of elderly multigravida, second trimester) rather than unspecified codes.