Download - Evidence-based Prenatal Care: Oxymoron or “Best Practice?” Francesco Leanza, MD FACTS 3/5/04
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Evidence-based Prenatal Care: Oxymoron or “Best Practice?”Francesco Leanza, MD FACTS 3/5/04
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Objectives: To understand the historical context of
prenatal care To understand prenatal care from a population
health perspective To evaluate prenatal care from an evidence
based perspective To distinguish between standard of care and
evidence based practice
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Levels of Evidence I Primary Reports of New Data Collection
– Class A: Randomized, controlled trial– Class B: Cohort study– Class C: Non-randomized trial with concurrent or
historical controls Case control study Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study– Class D: Cross-sectional study, Case series, Case
report
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Levels of Evidence II Reports that Synthesize or Reflect upon
Collections of Primary Reports– Class M: Meta-analysis
Systematic review Decision analysis
Cost-effectiveness analysis
– Class R: Consensus statement Consensus report Narrative review
– Class X: Medical opinion
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Routine Prenatal Care Frequency of visits* Screening Counseling and Education Immunization and Chemoprophylaxis
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Frequency of visits Low risk First trimester: 6-8, 10-12 Second trimester: 16-18, 22, Third trimester: 28, 32, 36, 38-41(4) POPRAS
– 4 extra visits at 24-28 weeks, 30, 34, 37– UA dip each visit, family ppd if + in mother– cumbersome form
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Visit 1: 6-8 weeks Screening
– Risk Profiles– Height and Weight– OB H &P– Hemoglobin*– Rubella/rubeola– Varicella– ABO/Rh/Ab*– RPR
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Visit 1: 6-8 weeks Screening
– Urine Culture*– Hepatitis B S Ag– HIV*– Domestic Violence Screening– STI screening: GC, Chlamydia– TB/ppd– POPRAS: Lead, UA Dip
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Visit 1: 6-8 weeks Counseling and Education
– Lifestyle*– Nutrition– Warning Signs of PTL– Course of care– Physiology of Pregnancy– Testing for risks in pregnancy
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Visit 1: 6-8 weeks Immunization and chemoprophylaxis
– Td booster– Nutritional supplements*– High risk groups
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Visit 2: 10-12 weeks Screening
– Weight– Blood Pressure– Fetal Heart Tones– Chromosomal/Neural Tube Defect
Screening
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Visit 2: 10-12 weeks Counseling & Education
– Fetal Growth– Review Lab results– Breastfeeding– Body Mechanics
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Visit 3: 16-18 weeks
Screening– Triple Screen– OB U/S*– Fundal Height
Counseling and Education– Second trimester growth– Quickening
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Visit 4: 22 weeks Counseling and Education
– PTL signs– Class– Family issues– Length of stay– GDM– RhoGAM
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Visit 5: 28 weeks Screening
– PTL risk– Check cervix– Domestic abuse screening– Rh Antibody status
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Visit 5: 28 weeks Counseling and Education
– Work– Preregistration– Fetal Growth– Awareness of Fetal Movement*– PTL Symptoms
Immunization and Chemoprophylaxis– ABO/Rh/Ab (RhoGAM)*– Influenza*
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Visit 6: 32 weeks Counseling and education
– Travel – Sexuality– Provider for newborn– Episiotomy– Labor and Delivery issues– Warning signs/PIH
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Visit 7: 36 weeks Screening
– Confirm fetal position– Culture for Group B Streptococcus
Counseling and Education– Postpartum Care– Management of late pregnancy symptoms– Contraception– When to call provider
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Visit 8-11: 38-41 weeks Counseling and Education
– Postpartum vaccination– Infant CPR– Post-term management– Labor and Delivery update
Strip membranes
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Summary So… Oxymoron or “Best Practice?” Standard of Care
– know what it is– what to do when you deviate
Resources for Best Practices– Texts– institutionally/regionally based– USPTF, Cochrane Data Base, ICSI
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Resources ICSI- Institute for Clinical Systems
Improvement– www.icsi.org
• “Routine Prenatal Care”
Ratcliffe et al., “Family Practice Obstetrics”