Re-examining Prenatal Care No Disclosures Antepartum and - - PowerPoint PPT Presentation

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Re-examining Prenatal Care No Disclosures Antepartum and - - PowerPoint PPT Presentation

Dec 13, 2022 39 likes •131 views

Re-examining Prenatal Care No Disclosures Antepartum and Intrapartum Management Conference San Francisco, CA Kate Frmeta, CNM Assistant Professor Department of Obstetrics and Gynecology UCSF Prenatal Care Prenatal Care Visit Schedule

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Kate Frómeta, CNM Assistant Professor Department of Obstetrics and Gynecology UCSF

Re-examining Prenatal Care

Antepartum and Intrapartum Management Conference San Francisco, CA

No Disclosures Prenatal Care

  • A. Q 4 weeks until 28

Q 2 weeks until 36 weekly B. More Frequent Visits C. Less Frequent Visits

Presentation Title 3

Visit Schedule for Low-Risk Women

Q 4 w e e k s u n t i l 2 8 Q 2 w . . . M

  • r

e F r e q u e n t V i s i t s L e s s F r e q u e n t V i s i t s

74% 23% 4%

Prenatal Care

  • A. at every visit
  • B. at the first visit only
  • C. with elevated BPs only
  • D. No urine dips

Presentation Title 4

Urine Dips

a t e v e r y v i s i t a t t h e f i r s t v i s i t

  • n

l y w i t h e l e v a t e d B P s

  • n

l y N

  • u

r i n e d i p s

58% 9% 23% 9%

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Prenatal Care

  • A. Routinely have women see a provider

who is not an OB or Midwife or Family Practice MD/NP.

  • B. Only see another type of provider if

indicated

Presentation Title 5

Integration of Support Services

R

  • u

t i n e l y h a v e w

  • m

e n s e e . . . O n l y s e e a n

  • t

h e r t y p e

  • f

p r . . .

73% 27%

Presentation Title 6

History of Prenatal Care

  • Adolphe Pinard and midwife

Madame Bequet

  • Refuge de L'Avenue du Maine

1892

OB/Anesthesia Symposium 7

History of Prenatal Care

  • First models out of Europe in early 20th century
  • By 1930: UK ministry of health
  • PNV at 16, 24, 28, then q 2 w until 36 then weekly
  • Measure fundal height at 32 and 36 weeks
  • Fetal heart rate monitoring and urine testing q visit

Presentation Title 8

History of Prenatal Care: US

  • Children’s Bureau started in 1912
  • Focused on preventing infant mortality
  • Promotion of the idea of prenatal care

in the European model

  • “More Ritualistic than Rational”
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OB/Anesthesia Symposium 9

Reasons for PNC

  • Decrease LBW through nutrition/substance abuse intervention
  • Identifying infectious disease
  • Identify Rh negative mothers and give Rhogam as needed
  • Identification and rectification of breech presentation
  • Identification of preeclampsia to decrease eclampsia
  • Identification and treatment of severe anemia
  • Assure appropriate delivery setting
  • Anomalies, breech, preterm
  • Build trust, anticipatory guidance
  • ETC. ETC. ETC.

Presentation Title 10

Our Failures

  • US Obstetric care is the most expensive in the world
  • One of the highest rates of both infant and maternal mortality of

industrialized countries

  • Major opportunities for improvement

OB/Anesthesia Symposium 11

Difficulty of Assessing Prenatal Care

  • Never studied before implementation
  • Considered standard of care therefore RCT are not a Possibility
  • Relationship between care seeking and other positive health

behaviors

  • Measuring quantity vs quality
  • content, provider, setting

OB/Anesthesia Symposium 12

Quantity: Schedule of Visits

  • US standard:
  • First visit in 1st trimester
  • f/u q 4 weeks until 28 then q2 until 36 then weekly (13-14)
  • ACOG “frequency of obstetric visits should be individualized”
  • NICE guidelines:
  • First visit before 10 weeks
  • f/u at 16, 25 , 28, 31,34, 36,38,40,41
  • WHO (2016)
  • 8 visits = adequate prenatal care
  • first 12 weeks
  • f/u at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation.
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Presentation Title 13

UCSF Schedule Of Prenatal Care Visits

  • First visit in 1st trimester
  • Q 6 weeks until 28 weeks
  • Q 4 weeks until 36 weeks
  • Q 2 weeks
  • * Individualized to risk status*
  • Antenatal Testing
  • 9-10 visits

OB/Anesthesia Symposium 14

US Expert Panel on Prenatal Care (1989)

  • 8 visits for multip, 10 for primip
  • Including preconception visit
  • More integration of support services “team approach”
  • Eliminate “Visits that are not

meaningful are counterproductive”

OB/Anesthesia Symposium 15

Quantity Of Visits: Standard vs. Reduced Visit Schedule

  • McDuffie et al. (1996) JAMA
  • RCT N=2764
  • 9 for primips, multips 8 (+ 1 phone call at 12 weeks) vs. 14
  • No difference:
  • PTB
  • LBW
  • PreE
  • C/S
  • Satisfaction (reduced more likely to rate # of visits as “just right”)

Presentation Title 16

Quantity Of Visits: Standard vs. Reduced Visit Schedule

  • Binstock and Wolde-Tsadik (1995) and Walker and Koniak-Griffin

(1997)

  • Smaller sample sizes (n=549, 81), both in CA, homogenous populations
  • White, highly educated, women
  • Latina women on Medicaid attending a birth center
  • ~8 visits vs. 11-14
  • No change in perinatal outcomes
  • greater satisfaction with reduced visits
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Presentation Title 17

Quantity Of Visits: Standard vs. Reduced Visit Schedule

  • Sikorski et al (1995)
  • n=2794 (reduced =6-7 vs 13)
  • Fewer ultrasounds and antenatal admissions
  • Less suspicion of IUGR (no difference in diagnosis of IUGR)
  • No change in perinatal outcomes (PreE, IOL, C/S, SGA, PPH etc)
  • Less satisfaction

OB/Anesthesia Symposium 18

Quantity Of Visits: Standard vs. Reduced Visit Schedule

  • 2015 Cochrane Review randomized/cluster-randomized
  • 7 trials, n=60,000 Reduced vs Standard PNC
  • High, medium and low-income countries
  • High Income
  • Reduced = 8-12 visits (13-14 in regular schedule ~ 3 less)
  • Low and middle income
  • Reduced = 4-5 visits (regular schedule about 7 ~2-4 less)

Dowswell et al. (2015)

OB/Anesthesia Symposium 19

Quantity of Visits: Standard vs. Reduced Visit Schedule

  • No difference between groups
  • Maternal mortality
  • Hypertensive d/o
  • PTB
  • SGA
  • Perinatal mortality
  • Associated with reduced visits in low and middle income countries
  • No difference in high income countries
  • Satisfaction

OB/Anesthesia Symposium 20

Quality Of Visits: Components of Prenatal Care

  • BP
  • Fundal Height
  • FHR auscultation
  • Urine Dip
  • Warning signs
  • Questions/Anticipatory

Guidance

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OB/Anesthesia Symposium 21

Fundal Heights

  • Vasilly Sutugin St. Petersberg 1875
  • Fundal height to determine gestational age/length
  • Alfred Baker Spalding, Stanford 1904

“Measure….the height of the fundus above the symphysis in cm….and add two to measurements between 22 and 26 cm, three to measurements between 26 and 30, four to measurements between 30 and 32 and five to measurements above 32, which sum will equal the probable week of pregnancy”

OB/Anesthesia Symposium 22

Fundal Heights

  • Sparks et al, 2011
  • Retrospect cohort
  • N=3627, u/s for abnormal fundal height = 448
  • Sensitivity LGA (>90%) 16.6% SGA (<10%) 17.3%
  • Lower for overweight/obese women
  • Higher for multips
  • Specificity 94.9-95.4% LGA and SGA 92.4-93.1%
  • Outcomes occurred about 10% of the time

OB/Anesthesia Symposium 23

Fundal Height WHO 2016

  • Replacing abdominal palpation with

symphysis-fundal height (SFH) measurement for the assessment of fetal growth is not recommended to improve perinatal outcomes. A change from what is usually practiced (abdominal palpation

  • r SFH measurement) in a particular

setting is not recommended

OB/Anesthesia Symposium 24

Assessing Fetal Growth

  • ? 3rd trimester u/s
  • Sensitivity 46-93% for SGA and 6.7-89% for LGA
  • NICE says no 3rd trimester u/s for LGA in “low-risk” population.
  • Customized growth charts
  • (GROW software – UK, endorsed by RCOG)
  • Ethnic/racial and gender differences (NICHD, WHO)
  • Deter-Rossavik model
  • Base 3rd tri growth on 2nd tri growth (u/s)
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OB/Anesthesia Symposium 25

Fetal Heart Rate Auscultation

  • In the US is standard of care at every visit (appropriate to

gestational age)

  • NICE (UK) recommends against fhr auscultation at routine visits
  • “Auscultation of the fetal heart may confirm that the fetus is alive but is

unlikely to have any predictive value and routine listening is therefore not recommended.”

OB/Anesthesia Symposium 26

Urine Dips

  • Protein
  • Proteinuria common in pregnancy 10-40% (≥+1)
  • Protein dipstick has ppv of PreE of 2-11%
  • High false positive when compared to 24 hr urines
  • New Guidelines place less emphasis on proteinuria
  • Glucose
  • False positive 11: 1
  • Glucose loading test much better

Alto, W (2005)

Urine Dips

  • “The time-honored inclusion of routine urine dipstick assessment for all

pregnant women can be modified…In the absence of risk factors….there has not been shown to be a benefit in routine urine dip- stick testing”

  • ACOG GUIDELINES FOR PERINATAL CARE, 2017

OB/Anesthesia Symposium 28

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OB/Anesthesia Symposium 29

Innovations

  • Centering Pregnancy
  • CHI
  • Expect with me
  • United Health
  • BabyScripts
  • Home weight and BP monitoring
  • OB Nest
  • Mayo Clinic

OB/Anesthesia Symposium 30

Innovations

OB Nest (HCD)

http://centerforinnovation.mayo.edu/files/2016/05/ob-nest-experiment-report.pdf

  • Butler Tobah et al, (2016)
  • RCT, N=150
  • 8 office and 6 RN phone visits vs. 12 office visits
  • RN moderated online community
  • Nest = greater satisfaction,

less pregnancy-related stress

  • No difference:
  • Maternal/fetal outcomes
  • Unplanned visits
  • Perceived quality of care

Presentation Title 31

Innovations

OB Nest

  • Self-Monitoring (home and drop-in)
  • Telemedicine
  • Text-based communication
  • Online community

“The intent behind the design is (to)...anticipate (patients’) needs and provide access to reassurance in a way that fits patients’ lives. The place of care becomes home based instead of clinic based, and the pregnant woman is no longer a passive recipient of care but instead an engaged partner”

Presentation Title 32

Thank You

Now Go Innovate!

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