Evidence-based Prenatal Care: Oxymoron or “Best Practice?” Francesco Leanza, MD FACTS 3/5/04

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

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

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

Routine Prenatal Care Frequency of visits* Screening Counseling and Education Immunization and Chemoprophylaxis

Frequency of visits Low risk First trimester: 6-8, Second trimester: 16-18, 22, Third trimester: 28, 32, 36, 38-41(4) POPRAS –4 extra visits at weeks, 30, 34, 37 –UA dip each visit, family ppd if + in mother –cumbersome form

Visit 1: 6-8 weeks Screening –Risk Profiles –Height and Weight –OB H &P –Hemoglobin* –Rubella/rubeola –Varicella –ABO/Rh/Ab* –RPR

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

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

Visit 1: 6-8 weeks Immunization and chemoprophylaxis –Td booster –Nutritional supplements* –High risk groups

Visit 2: weeks Screening –Weight –Blood Pressure –Fetal Heart Tones –Chromosomal/Neural Tube Defect Screening

Visit 2: weeks Counseling & Education –Fetal Growth –Review Lab results –Breastfeeding –Body Mechanics

Visit 3: weeks Screening –Triple Screen –OB U/S* –Fundal Height Counseling and Education –Second trimester growth –Quickening

Visit 4: 22 weeks Counseling and Education –PTL signs –Class –Family issues –Length of stay –GDM –RhoGAM

Visit 5: 28 weeks Screening –PTL risk –Check cervix –Domestic abuse screening –Rh Antibody status

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*

Visit 6: 32 weeks Counseling and education –Travel –Sexuality –Provider for newborn –Episiotomy –Labor and Delivery issues –Warning signs/PIH

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

Visit 8-11: weeks Counseling and Education –Postpartum vaccination –Infant CPR –Post-term management –Labor and Delivery update Strip membranes

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

Resources ICSI- Institute for Clinical Systems Improvement – “Routine Prenatal Care” Ratcliffe et al., “Family Practice Obstetrics”