2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE
THE PHYSICIAN’S CLINICAL JUDGMENT MUST ULTIMATELY DETERMINE THE
APPROPRIATE TREATMENT FOR EACH INDIVIDUAL
IDENTIFICATION OF PREGNANCY
1. Preconception counseling is documented for all patients who make it known that they are planning
pregnancy.
2. Pregnancy is appropriately diagnosed prior to the end of the first trimester and the first prenatal visit occurs
during the first trimester (on or between 176 and 280 days prior to delivery or estimated date of delivery
[EDD*]).
*National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) definition
FIRST PRENATAL VISIT
Patient Information including:
1. Menstrual history
2. Comprehensive health history with information on
the current pregnancy
3. Family history
4. Obstetrical history including:
 Previous deliveries and/or operations on the
uterus/cervix
 Congenital abnormalities
 Therapeutic, spontaneous, or elective
abortions
 Previous infertility
 Risk for multiple gestation
 Previous fetal demise
 Premature onset of labor or prolonged
pregnancy
 History of pulmonary, cardiac, metabolic,
endocrine, neurological urinary tract,
hematological, or psychological disease
 History of sexually transmitted disease
 Neonatal mortality/morbidity
 Maternal age <15 or >35
 Nutritional disease or hyperemesis gravidarum
 HIV infection
5. Social history including:
 Social/economic stress factors
 Physical or sexual abuse
 Maternal use of drugs, alcohol or tobacco
 Nutrition
 Assessment of workplace risk factors
Physical
examination
including:
 Height and
weight
 Blood pressure
 Evaluation of
nutritional
status
 Pelvic exam
Laboratory tests as follows:
 Urinalysis
(including
microscopic
exam or culture)
 Antibody screen
 Pap smear
 Complete blood
count
 Rubella
antibody titer
measurement
 Screening for
Hepatitis B
surface antigen
 HIV counseling
and offer of
screening
 Blood type and
D (Rh) type
determination,
with notation of
any prior
RhoGAM
administration
 Serological test
for Syphilis
(VDRL or RPR)
Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US
Preventive Services Task Force (1996)
Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July
2004..
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2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE
FOLLOW-UP VISITS
Visit schedule:
 Every 4 weeks for the first 28 weeks of gestation
 Every 2 weeks until 36 weeks gestation
 Weekly after 36 weeks
The following should be performed and recorded at each visit:
 Weight
 Blood pressure
 Measured fundal height
 Fetal heart beat
The following should be performed and recorded within the following time ranges:
 Repeat hematocrit at 28 to 32 weeks
 Fetal presentation (>36 weeks)
 Repeat antibody test at approximately 26 weeks for unsensitized Rh negative women (if patient still
unsensitized, RhoGAM should be administered)
 Cervix check (≥ 28 weeks)
 Flu shots for women in 2nd and 3rd Trimester; except if contraindicated.

 Gestational Diabetes Mellitus at 28 weeks
Expected weight gain:
 First trimester  2 to 5 lbs. total
 After first trimester  ¾ to 1 lb. per week
 Average total weight gain  25 lbs. +/- 5 lbs
OPTIONAL TESTING FOR PATIENTS ASSESSED TO BE AT RISK
Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US
Preventive Services Task Force (1996)
Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July
2004..
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2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE
Maternal serum alpha-fetoprotein or multiple marker screen between 15 and 18 weeks gestation
Oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening or an initial
glucose challenge test (GCT) (serum level 1 hour post 50g glucose load) followed by an OGTT (for
those whose GCT exceeds glucose threshold value on GCT) at 24 to 28 weeks
Glucose tolerance test for abnormal glucose screen (>140mg/l)
Group B streptococcal screening at 35 to 37 weeks
Cytomegalovirus (CMV) titers
Screening for sickle cell and other inheritable diseases
Skin testing for tuberculosis
Gonorrhea culture
Chlamydia culture
Obstetrical ultrasound at 18 to 20 weeks
Toxoplasmosis antibody test
Hemoglobin electrophoresis if patient is clearly anemic (Hgb <10 or Hct <32; a Hgb between 10 and
11 may not be worrisome)
Offer chorionic villus sampling (CVS) (-12 weeks) or amniocentesis (15 to 18 weeks) for women age
>35, family history of chromosomal abnormalities, mental retardation or inborn errors of metabolism
Tests of fetal well-being
 Assessment of fetal movement (e.g., kick counts)  10 movements/2 hours
 Non-stress testing (≥28 weeks)
 Contraction stress Testing (≥26 weeks)
 Biophysical testing (≥26 weeks)
 Doppler ultrasound of umbilical arterial flow
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 Varicella Immunity Status
 Oral Health
 Genetic Risks: History of both parents should be reviewed for genetic disorders
Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US
Preventive Services Task Force (1996)
Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July
2004..
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2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE
DOCUMENTING COUNSELING AND EDUCATION IN THE MEDICAL RECORD
Documentation should include and address information about the pregnancy:
 Discussion of upcoming tests
 Safe exercise and physical activity in pregnancy
 Premature labor symptoms
 Nutrition during pregnancy, including adequate intake of calcium, iron, and folic acid
 Travel and pregnancy
 Genetic counseling, if appropriate
 Use of safety belts
 Sexuality during pregnancy (including STD prevention)
 Avoidance of alcohol, tobacco and drugs
 Childbirth classes
 Environmental/work hazards
 Warning signs of potential problems
 HIV screening, prenatal transmission of HIV, and antiretroviral treatment alternatives
Documentation should include and address information about the delivery:
 Signs of labor
 VBAC counseling
 Obstetrical anesthesia and analgesia
* Labor and delivery process
* Relaxation techniques
* Tubal sterilization
*
Documentation should include and address information about post delivery:
 Breast/bottle feeding
 Circumcision
 Newborn/infant safety car seats
 Psychosocial Services
POSTPARTUM CARE
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Postpartum visit on or between days 21 and 56 after delivery*
Pelvic exam
Evaluation of weight, blood pressure, breasts, and abdomen
Birth control counseling, if appropriate
Exercise and nutrition counseling, if appropriate
Postpartum vaccinations
*National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) definition
RESOURCES
American College of Obstetricians and Gynecologists
www.acog.org
Agency for Healthcare Quality and Research
www.ahrq.gov
Oxford Health Plans
www.oxfordhealth.com
Oxford Healthy Mother Healthy Baby® program
888-200-9234
Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US
Preventive Services Task Force (1996)
Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July
2004..
4
2004 OBSTETRICAL CARE CLINICAL PRACTICE GUIDELINE
Source: American College of Obstetricians and Gynecologists (1992-2002), Institute for Clinical Systems Improvement (ICSI) (2001), US
Preventive Services Task Force (1996)
Reviewed and approved by Oxford Health Plans Regional QM committees: February 1998, April 2000, July 2001, July 2002, July 2003, July
2004..
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