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

2. 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

3. 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

4. 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

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

6. 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

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

8. 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

9. 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

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

11. Visit 2: 10-12 weeks Screening –Weight –Blood Pressure –Fetal Heart Tones –Chromosomal/Neural Tube Defect Screening

12. Visit 2: 10-12 weeks Counseling & Education –Fetal Growth –Review Lab results –Breastfeeding –Body Mechanics

13. Visit 3: 16-18 weeks Screening –Triple Screen –OB U/S* –Fundal Height Counseling and Education –Second trimester growth –Quickening

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

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

16. 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*

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

18. 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

19. Visit 8-11: 38-41 weeks Counseling and Education –Postpartum vaccination –Infant CPR –Post-term management –Labor and Delivery update Strip membranes

20. 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

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