Managing Prenatal Care

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)

Step 1: Establish Gestational Dating and EDD

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

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

Step 2: Apply the ACOG Screening Schedule

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

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

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.

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:

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?

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

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.