Prenatal Care Self-Identify As Women, Some Gender-Diverse Clients Who Are Biologically Female Also Choose to Bear Children, and Many Are Cared for by Midwives

CHAPTER© Jones & Bartlett2 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Prenatal© Jones & Bartlett Learning, Care LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEPregnancy OR DISTRIBUTION is a transformative time in a woman’sNOT life, FOR and prenatalSALE OR care DISTRIBUTION provides an opportunity to deliver meaningful health care within the context of a continuing and nurturing relationship. While the majority of clients who present for prenatal care self-identify as women, some gender-diverse clients who are biologically female also choose to bear children, and many are cared for by midwives. All clients de- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC serve thoughtful and compassionate prenatal care that is adapted to fit their unique situation. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Midwives are privileged to witness and support the growth and development of mother and fetus during pregnancy. Prenatal care is a comprehensive ongoing program of care that addresses© Jones the & biophysical,Bartlett Learning, psychosocial, LLC and educational needs ©of Jonespregnant & clients Bartlett and Learning, LLC theirNOT families. FOR SALEThe purpose OR DISTRIBUTION of prenatal care is to provide primary preventiveNOT FOR health SALE care OR to DISTRIBUTION pregnant women and to facilitate women’s acquisition of knowledge regarding health behaviors that promote optimal pregnancy and birth outcomes. Additionally, risk assessment is done at each visit to identify deviations from the wide range of normal that can affect maternal and fetal well-being. For women with conditions that fall outside the midwife’s © Jones & Bartlettscope of Learning,practice, it is LLC important to consult, collaborate,© Jones or refer& Bartlett to an appropriate Learning, clini LLC- NOT FOR SALEcian. ORDuring DISTRIBUTION pregnancy, an obstetrician or perinatologistNOT FOR is the SALE most common OR DISTRIBUTION consultant needed. Pregnant women are also susceptible to all the same ills and injuries as anyone else, and so the services of other healthcare professionals, such as a dermatologist, endocri- nologist, psychologist, or physical therapist, may also be required. Provision of the© Jonesbasic components & Bartlett of prenatal Learning, care isLLC included in the core competencies© Jones & Bartlett Learning, LLC of midwifery practice.NOT For FOR further SALE information, OR DISTRIBUTION the midwife is encouraged to compareNOT the FOR SALE OR DISTRIBUTION standards for basic midwifery practice that have been developed by the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA), and the In- ternational Confederation of Midwives (ICM). By reviewing the core documents produced by these organizations (all available online at the respective organizations’ websites), one can© Jones gain an &understanding Bartlett Learning, of the expected LLC standards for midwifery© practiceJones in& theBartlett United Learning, LLC StatesNOT andFOR globally. SALE Additionally, OR DISTRIBUTION each midwife’s perinatal practiceNOT is shaped FOR by SALE state andOR DISTRIBUTION local regulations, resources, and standards of practice. Midwives are concerned with the intrinsic characteristics of the clients they serve, as well as the structure, process, and outcomes of prenatal care. All of these components are © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Blue Planet Studio/Shutterstock. 49

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important in developing a model of care and service The number and types of screening and diagnos- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC delivery approach that is responsive to women’s needs tic tests performed during pregnancy are determined NOT FORwhile SALE ensuring OR assessmentDISTRIBUTION of quality and continued NOTby indicationsFOR SALE for OR testing DISTRIBUTION or evaluation, current rec- improvement. The ongoing nature of providing pre- ommendations for practice, and discussion with the natal care lends itself to the development of a ther- woman regarding the benefits, potential harms, and apeutic working relationship between woman and alternatives to testing. Shared decision making is en- midwife, making it an ©ideal Jones opportunity & Bartlett to improve Learning, couraged, LLC which includes informed© Jones nonacceptance & Bartlett Learning, LLC health behaviors and lifestyleNOT FOR choices SALE during OR preg DISTRIBUTION- of testing and the associatedNOT evaluation FOR recommenSALE OR- DISTRIBUTION nancy and beyond through active listening, respect- dations for positive results. It is important to disclose ful dialogue, and tangible and emotional support. the potential costs of tests, procedures, and referrals The content and structure of prenatal care follow so clients are aware of expenses that may be incurred. a typical© Jonespattern of& Bartlettscheduled Learning, visits, health LLC educa- A standardized© formatJones to & clearly Bartlett document Learning, informa LLC- tion topics, and tests, which can be easily modified tion provided, discussions, and the client’s decision to NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to meet the needs and preferences of each individual accept, decline, or refuse an offered or recommended client. The traditional schedule of prenatal care ren- test, procedure, or referral is an essential mechanism dered by a provider or group of providers is struc- to have in place. tured as 12–14 visits scheduled every 4 weeks until Many pregnant women are unfamiliar with the © Jonesthe & 28th Bartlett week Learning,of pregnancy, LLC every 2 weeks until the © Jonesrange of & options Bartlett and Learning, expectations LLC of the healthcare NOT FOR36th SALE week ofOR pregnancy, DISTRIBUTION and then weekly until birth. NOTsystem FOR and SALE can benefit OR DISTRIBUTION from guidance in navigating A reduced visit schedule may also be well suited for the system and negotiating for care that is appropriate low-risk women (Krans & Davis, 2012). Prenatal to their needs. Midwives are responsible for outlin- care visit intervals, methods, and structure are neces- ing to their clients the scope of their practice and the sarily modified for client© Jones and provider & Bartlett safety Learning,during usual LLC parameters for prenatal,© laborJones and & birth,Bartlett and Learning, LLC the COVID-19 pandemic.NOT Another FOR SALEmodel proposedOR DISTRIBUTION postpartum care services. In addition,NOT FOR describing SALE how OR DISTRIBUTION is that of increased visits in early pregnancy based the full range of perinatal services is accessed when on factors associated with increased risk, and specific needed demonstrates to clients the continuum of care disease states, thereby addressing issues and inter- available to meet their needs. As a member of the vening early to reduce potential adverse outcomes maternity care team, the midwife provides support, (Nicolaides,© Jones 2011). & OnlineBartlett resources Learning, and text-based LLC continuity of ©care, Jones and advocacy & Bartlett for the Learning, woman, pro LLC- communicationsNOT FOR are SALE also used OR inDISTRIBUTION providing limited viding a commonNOT threadFOR SALEand source OR of DISTRIBUTION comfort and prenatal care services within various models to ad- safety should specialty care become necessary. dress emerging clinical situations or client concerns Building a warm, caring, and professional rela- remotely (de Mooij et al., 2018). tionship allows for mutual trust to develop. Trust, in © Jones & TheBartlett Centering Learning, Pregnancy LLC model of group prena- © Jonesturn, fosters & Bartlett women’s Learning,active participation LLC in healthcare tal care has become popular in recent years. In this decisions. People who trust their care providers are NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION evidence-based model, groups of 8–12 women of more likely to accept recommendations when chal- similar gestational ages meet in 10 sessions through- lenges or complications arise. The ethical obligation, out pregnancy for health assessment, education, and then, is to behave in a trustworthy manner and pro- support. This format capitalizes on pregnant client’s vide care during pregnancy that is respectful of each need to share their concerns,© Jones reactions, & Bartlett and experi Learning,- client’s LLC individual desires and preferences.© Jones & Client Bartlett pref- Learning, LLC ences with others, and NOTon their FOR openness SALE to OR learning DISTRIBUTION erences can range from their preferredNOT FOR type SALE of health OR- DISTRIBUTION about childbirth. In the group prenatal care approach, care provider and approach to care, to the amount of the midwife’s role shifts from authority figure to group active participation in their own care, the planned and facilitator. The group members influence the topics preferred location for labor and birth, and the meth- addressed© Jones at each &visit, Bartlett participate Learning, in physical LLC assess- ods to access ©additional Jones services& Bartlett as needed. Learning, LLC ments,NOT share FORself-care SALE strategies, OR DISTRIBUTION and provide social MaternalNOT participation FOR SALE in prenatal OR DISTRIBUTION care encour- support to one another. Research has demonstrated ages self-determination and can enhance a woman’s improved perinatal health outcomes including re- confidence in her ability to labor and give birth in duced rates of preterm birth (PTB) and depression, the manner that helps her to feel safe and success- decreased stress, higher rates of breastfeeding, and ful. Increased levels of confidence about the ability © Jonesincreased & Bartlett satisfaction Learning, with LLCcare using this model of © Jonesto give birth& Bartlett are associated Learning, with improvedLLC perinatal NOT FORprenatal SALE care OR (Cunningham DISTRIBUTION et al., 2019; McDowell NOThealth FOR outcomes SALE ORand DISTRIBUTIONchildbirth satisfaction (Atta- et al., 2018). nasio et al., 2014). Thoughtful, deliberate attention

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during prenatal care to factors promoting birth confi- in this life stage. Early-gestation pregnancy can be dis- © Jones & Bartlett Learning, LLC © Jones & Bartlettdence can Learning, enhance the LLC quality of maternity care and covered by the clinician as an incidental finding during NOT FOR SALEimprove OR outcomes DISTRIBUTION for mothers and infants. MidwivesNOT FORalmost SALE any typeOR ofDISTRIBUTION healthcare visit. Depending on the can share information, openly acknowledge develop- clinician, the practice setting, and the client, care upon ing situations, review options that are possible during pregnancy diagnosis can be brief, with a referral to a childbirth, and encourage strength and flexibility. midwife or other specialty provider, or it can result a This practice benefits© Jones both &the Bartlett mother-to-be Learning, and the LLCcomplete first prenatal ©visit. Jones Women & Bartlettfrequently Learning, make LLC midwife when addressingNOT FOR whatever SALE ORcircumstances DISTRIBUTION the diagnosis of pregnancyNOT themselves FOR SALE with affordableOR DISTRIBUTION come their way and is an important part of prenatal and easy urine-based home pregnancy tests. care. The process of mutual participation and shared Pregnancy signs and symptoms are classified as decision making during prenatal care builds trust and presumptive, meaning those changes that the mother fosters© Jones resilience & Bartlett in the face Learning, of unexpected LLC or unfor- can perceive;© Jones probable, & Bartlett meaning Learning, those changes LLC that tunate events. can be detected by the examiner; and positive, mean- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Health disparities are preventable differences in ing those changes that can be directly attributed to the disease prevalence or the burden of disease, injury fetus (Engstrom & Cappiello, 2019). or violence, and lack of opportunities to achieve op- The diagnosis of pregnancy may be a welcome timal health experienced by socially marginalized event or devastating news. Many women have mixed © Jones & Bartlettpopulations Learning, (Centers forLLC Disease Control and Preven© Jones- feelings & Bartlett about theLearning, changes thatLLC pregnancy will bring NOT FOR SALEtion [CDC],OR DISTRIBUTION 2018). These disparities are entrenchedNOT FORto their SALE lives. OR Ambivalence DISTRIBUTION is common as the newly in longstanding inequities in healthcare access, rac- pregnant client adjusts her self-image to include a ism, education, income, and having safe and sanitary baby that is more of an abstraction than a reality in the home, work, and environmental conditions. These early weeks of pregnancy. The diagnosis of pregnancy multifaceted issues© Jonescan act &as Bartlettchronic stressors Learning, that LLCshould be shared and explored© Jones in a& private Bartlett setting Learning, in LLC influence health NOTrisk and FOR pregnancy SALE ORcourse DISTRIBUTION and out- a straightforward and kindNOT manner. FOR ThisSALE openness OR DISTRIBUTION al- come, and often have no easy or clear solution. Such lows clients to express a wide range of emotions and conditions are often uncovered during the course of describe their view of this pregnancy in the context of prenatal care and can act to heighten the midwife’s their lives. The midwife can then take cues for next vigilance for preventable complications. Individual- steps from the client’s response. ized© Jones humanistic & Bartlett care within Learning, a team-based LLC approach © Jones & Bartlett Learning, LLC canNOT best FOR assist SALE women OR to access DISTRIBUTION services and optimize NOT FOR SALE OR DISTRIBUTION perinatal health. Midwives can learn to identify their Chart Review and History to own implicit biases and institutional practices that perpetuate systemic racism, which can contribute to Consider ( Jordan et al., 2019) © Jones & Bartlettincreased Learning, rates of maternal LLC morbidity and mortality,© Jones & Bartlett Learning, LLC and work to correct them. Reproductive history NOT FOR SALE OR DISTRIBUTION NOT FOR• SALE OR DISTRIBUTION Every woman has unique, yet universal, needs • GP TPAL during pregnancy and will undergo many changes • Menstrual history and adjustments of a physical, psychological, and • Usual menstrual patterns social nature. Caring for a woman during this time • Last menstrual period (LMP) of transition can ©foster Jones feelings & Bartlettof autonomy Learning, and en- LLC • Known or suspected© Jones date & Bartlettof conception Learning, LLC hance self-care practices.NOT FOR As such,SALE prenatal OR DISTRIBUTION care has • Method of birthNOT control FOR SALE OR DISTRIBUTION the potential to nurture each client’s ability to care for • Planned or unintended pregnancy herself and her child, and to develop new strengths • Conception issues as a person and a mother and thereby improve family • Interconception interval health.© Jones & Bartlett Learning, LLC ©• JonesHistory & ofBartlett primary orLearning, secondary LLCinfertility • Assisted reproductive technologies or NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION treatments Diagnosis of Pregnancy • Early signs and symptoms of pregnancy • Breast tenderness Key Clinical Information • Fatigue © Jones & BartlettThe diagnosis Learning, of pregnancy LLC should be considered when© Jones & Bartlett• Fetal Learning, movement LLC NOT FOR SALEcaring OR for DISTRIBUTIONany woman of childbearing age. PregnancyNOT FOR SALE• ORNausea DISTRIBUTION and/or vomiting is the most common cause of secondary amenorrhea • Urinary frequency

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• Birth history Skin changes © Jones• & Bartlett Learning, LLC © Jones & Bartlett• Dates Learning, of prior births LLC • Hyperpigmentation NOT FOR SALE• ORPain DISTRIBUTIONrelief measures used during labor NOT FOR• SALEMelasma OR DISTRIBUTION and birth • Linea nigra • Routes and sites of prior births • Areolar darkening • Pregnancy, birth, or postpartum problems • Vascular spiders • Babies’ weights© Jones and health & Bartlett Learning, LLC• Palmar erythema © Jones & Bartlett Learning, LLC • Infant feedingNOT method FOR SALE OR DISTRIBUTION• Striae NOT FOR SALE OR DISTRIBUTION ■ Length of breastfeeding if chosen • Breast changes • Interval history since LMP • Enlargement • Pain or cramping • Increased vascularity ©• JonesVaginal & bleeding Bartlett Learning, LLC • Increased© Jones tenderness & Bartlett and sensitivity Learning, LLC • Illness or fever Abdominal examination and gestational age NOT FOR SALE OR DISTRIBUTION • NOT FOR SALE OR DISTRIBUTION • Occupational or environmental substance assessment exposures • Fetal heart tones • Use of herbs or supplements • Fundal height • Tobacco, vaping, marijuana, alcohol, and • Palpable fetal parts, position, and movement © Jones & Bartlettother Learning, substance LLCuse © Jones• Abdominal& Bartlett tenderness Learning, and LLC consistency NOT FOR SALE• ORSignificant DISTRIBUTION family, social, or lifestyle changes NOT• FORPelvic SALE evaluation OR and DISTRIBUTION gestational age assessment • Social and lifestyle history • Bimanual uterine sizing • The woman’s feelings and intentions regard- • Consistency and position of uterus and cervix ing pregnancy • Cervix • Living situation© Jones & Bartlett Learning, LLC • Color, size, appearance© Jones of os & Bartlett Learning, LLC • Housing NOT FOR SALE OR DISTRIBUTION• Length and dilatationNOT FOR SALE OR DISTRIBUTION • Personal and environmental safety concerns • Consistency and position • People sharing the space • Cervical motion tenderness • Transportation • Vaginal or cervical discharge • Partner situation • Adnexal tenderness, enlargement ©• JonesPartner & genderBartlett Learning, LLC • Other physical© Jones examination & Bartlett components Learning, as indi LLC- NOT• Marital FOR SALEor commitment OR DISTRIBUTION status cated by NOThistory FOR SALE OR DISTRIBUTION • Partner’s feelings regarding pregnancy • Partner’s intent to co-parent this child • Information about the father of the baby or Differential Diagnoses to © Jones & Bartlettsperm Learning,donor LLC © Jones & Bartlett Learning, LLC • History of emotional, physical, or sexual Consider NOT FOR SALE OR DISTRIBUTION NOT FORPregnancy, SALE intrauterine OR DISTRIBUTION trauma • Also consider the following: • Support systems • • Ectopic pregnancy • Employment status and occupational envi- • Problems related to unintended pregnancy ronment (see Unintended Pregnancy in Chapter 6) • Socioeconomic ©status Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Threatened abortion Relevant medical/surgicalNOT FORhistory SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • • Molar pregnancy • Allergies • Blighted ovum • Medications Secondary amenorrhea (see Amenorrhea in • Medical and mental health conditions • Chapter 7) • ©Surgeries Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • NOTSexually FOR transmitted SALE OR infections DISTRIBUTION (STIs) NOT FOR SALE OR DISTRIBUTION • Review of systems (ROS) Tests and Procedures to Consider Physical Examination to • Urine or serum qualitative or quantitative human © JonesConsider & Bartlett Learning, LLC © Joneschorionic & Bartlett gonadotropin Learning, (hCG) LLC NOT FOR• SALEVital signs, OR weight,DISTRIBUTION height, and body mass index NOT• FORAbdominal SALE or OR vaginal DISTRIBUTION ultrasound, depending on (BMI) estimated gestational age

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© Jones & BartlettTherapeutic Learning, Measures LLC to © Jones &• Bartlett As soon Learning, as possible when LLC >12 weeks’ gestation • Prenatal testing as indicated and desired NOT FOR SALEConsider OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Daily prenatal or other vitamin supplement • Folic acid—400 micrograms po Consultation, Collaboration, • Iron as indicated—27–60 mg po or Referral to Consider • Omega-3© fatty Jones acids & docosahexaenoicBartlett Learning, acid LLC• Maternity care services© Jones & Bartlett Learning, LLC (DHA) andNOT eicosapentaenoic FOR SALE OR acid DISTRIBUTION (EPA) • Genetic counselingNOT FOR SALE OR DISTRIBUTION —300 mg po • Genetic diagnostic testing • Treatment of any underlying condition as indicated • Adoption services • Abortion services © Jones & Bartlett Learning, LLC • ©Specialty Jones perinatal & Bartlett care Learning, LLC Integrative Therapies to • Nutritional services NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Consider • Medical services • High-folate and/or high-iron foods (see Appendix B) • Collaboration for care of medical problems during pregnancy © Jones & BartlettEducation Learning, and LLC Support © Jones• &Social Bartlett services Learning, LLC • Pregnancy verification statement for various NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Measures to Consider agencies: • Pregnancy options counseling as indicated • Women, infants, and children (WIC) • Preliminary nutrition, weight gain, and social program concerns counseling • Medicaid • Tobacco, vaping,© Jones marijuana, & Bartlett alcohol, Learning, and sub- LLC • Other programs© based Jones on history& Bartlett and prefer Learning,- LLC stance avoidanceNOT FOR SALE OR DISTRIBUTION ences, such as NOT FOR SALE OR DISTRIBUTION • Over-the-counter (OTC) or prescription medica- • Substance use treatment tion safety • Alcohol use treatment; smoking cessation • Review prenatal care options and expectations programs • Prenatal testing as indicated © Jones & Bartlett Learning, LLC ©• JonesCounseling & Bartlett or mental Learning, health services LLC • Family involvement • Women’s shelter/safe house NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Provide or suggest readings to increase knowl- • For diagnosis or treatment outside the midwife’s edge of pregnancy care and birth choices scope of practice • Practice information • Philosophy of care • Women’s rights and responsibilities © Jones & Bartlett Learning, LLC © JonesInitial & Bartlett Prenatal Learning, LLC NOT FOR SALE• ORPrenatal DISTRIBUTION and birth care providers NOT FOR SALE OR DISTRIBUTION • Consultation and collaboration practices Assessment • Birth site options • Medical and hospital affiliations Key Clinical Information • Billing arrangements The initial assessment of the pregnant woman pro- © Jones & Bartlett Learning, LLCvides the basis for ongoing© Jones prenatal & Bartlett care. This Learning, en- LLC NOT FOR SALE OR DISTRIBUTIONcounter builds on the NOTinformation FOR SALEobtained OR during DISTRIBUTION Follow-up Measures to Consider the office visit at which the pregnancy was diagnosed. • Discuss and document If the initial prenatal assessment visit is the first en- • Gestational age and expected due date (EDD) counter with the pregnant women (for example, the © Jonesor estimated & Bartlett date Learning, of birth (EDB) LLC client diagnosed© Jones her & pregnancyBartlett Learning,at home), the LLC reader is NOT• FORRelevant SALE reproductive, OR DISTRIBUTION medical, and social directedNOT to the FOR Diagnosis SALE of ORPregnancy DISTRIBUTION section in this history chapter for care elements to include at this initial visit. • Clinical findings Careful attention to behaviors and communica- • Woman’s preferences for pregnancy and care tion, the client’s personal health history, family history, • Midwifery plan of care and physical examination allows the midwife to de- © Jones & Bartlett• Return Learning, for continued LLC care © Jonesvelop & Bartlett a comprehensive, Learning, yet dynamic,LLC midwifery plan NOT FOR SALE• ORBetween DISTRIBUTION 6 and 12 weeks’ gestation for initialNOT FORof care SALE with OR the DISTRIBUTIONclient and alerts the midwife to sen- prenatal visit sitive concerns that may require further investigation

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or follow-up over time. Gentle touch, coupled with Prior pregnancy conditions or complications, © Jones• & Bartlett Learning, LLC © Jonesan & organized, Bartlett systematic,Learning, yet LLC unhurried, manner is such as NOT FORideal SALE during OR the DISTRIBUTIONfirst visit. Providing respectful care NOT FOR• Preterm/postterm SALE OR DISTRIBUTION birth that promotes a sense of safety and connection with • Bleeding the woman and her unique experience is particu- • Hypertensive disorder of pregnancy larly important during the pregnancy and birth (see • Gestational diabetes Appendix A). This first© Jonesprenatal &care Bartlett encounter Learning, is a LLC• Prior birth complications© Jones & Bartlett Learning, LLC time-intensive visit. It NOTis well FOR worth SALE the investment OR DISTRIBUTION • Pregnancy losses NOT FOR SALE OR DISTRIBUTION of time and energy to establish rapport with the preg- • Birth defects nant woman and her family and co-create an optimal, • Prior physical or psychological birth trauma individualized plan of care. • Prior birth history One© ofJones the important & Bartlett elements Learning, of prenatal LLC care • Reproductive© Jones health &history Bartlett Learning, LLC is the identification of health factors that can affect • Infertility NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pregnancy. Protective factors result in greater resiliency • Gynecologic disorders, problems, or treat- when physiologic or psychological stresses arise, ment, such as while negative factors can increase a woman’s risk of • STIs and pelvic inflammatory disease complications. Many negative factors can be modified (PID) © Jonesor & diminished Bartlett Learning,through timely LLC assessment, diagnosis, © Jones •& BartlettCervical cryotherapyLearning, LLC NOT FORand SALE intervention OR DISTRIBUTION or treatment. These factors can be NOT FOR• SALELoop ORelectrosurgical DISTRIBUTION excision procedure related to lifestyle, diet, substance use, social circum- • Contraceptive history stances, genetic heritage, environmental exposures, • Sexual history ability to access prenatal care, and cultural or ethnic • Interval history since LMP background and practices.© Jones Prenatal & Bartlettassessment Learning, and LLC• Medications (OTC or ©prescription), Jones & Bartlettsupple- Learning, LLC identification of healthNOT risks FORoffer the SALE opportunity OR DISTRIBUTION to ments, or herbs takenNOT FOR SALE OR DISTRIBUTION diagnose or treat actual or potential conditions or to • Illness or fever provide parents with information and support to help • Occupational or environmental substance them cope with unexpected outcomes. exposures Many pregnancy risk factors are associated with • Significant family, social, or lifestyle changes habitual© orJones addictive & Bartlettbehaviors, Learning, such as dietary LLC hab- • Medical, ©surgical, Jones and & mentalBartlett health Learning, history LLC its, sedentaryNOT FORlifestyles, SALE and smoking.OR DISTRIBUTION The midwife can • VaccinationNOT FOR history SALE (CDC, OR 2017) DISTRIBUTION begin to address these modifiable behaviors by assess- • Prior uterine surgery ing the client’s readiness to change using motivational • Diseases or health disorders, such as: interviewing principles (Magill et al., 2018). For those • Hypertension © Jonesindividuals & Bartlett who Learning, report or test LLC positive for recreational © Jones •& BartlettDiabetes Learning, LLC substance use, or with other lifestyle behaviors associ- • Autoimmune disease NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ated with negative health effects, using a direct coun- • Thyroid disease seling style and demonstrating empathy and reflective • Asthma listening can significantly modify behavior (Copeland • Epilepsy et al., 2015). • Mental health conditions © Jones & Bartlett Learning,• LLC Family health history © Jones & Bartlett Learning, LLC Chart Review andNOT HistoryFOR SALE OR DISTRIBUTION• Ethnic heritage NOT FOR SALE OR DISTRIBUTION to Consider • Chronic illnesses • Hereditary or genetic health conditions (Jordan et al., 2019) • Social and lifestyle history Age, cultural and demographic information • © Jones & Bartlett Learning, LLC • Emotional,© Jones physical, & Bartlett sexual abuse Learning, screening LLC • NOT Self-described FOR SALE ethnic/racial OR DISTRIBUTION identity • EconomicNOT situationFOR SALE and financial OR DISTRIBUTION resources • Employment status and type • Housing situation • Sexual orientation, gender identification, • Transportation options pronouns • Food purchase and storage resources • Present pregnancy information • Tobacco, vaping, marijuana, alcohol, and © Jones & •Bartlett LMP, interval, Learning, and flow LLC © Jones other& Bartlett substance Learning, use LLC NOT FOR SALE• Pregnancy OR DISTRIBUTION signs and symptoms, onset and NOT FOR• Presence SALE ORof caringDISTRIBUTION partner or supportive intensity others

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• Number and relationship of others in the home • Fetal lie and position © Jones & Bartlett Learning, LLC © Jones & Bartlett• Barriers Learning, to prenatal LLC care • Gastrointestinal system NOT FOR SALE OR DISTRIBUTION NOT FOR SALE• Nutritional OR DISTRIBUTION history • Genitourinary system • 24-hour food recall or multiday food journal • External genitalia • Identify consumption of: • Vulvar varicosities • Caffeine • Scars, lesions, piercings • Fish ©with Jones high mercury & Bartlett levels Learning, LLC • Discharge © Jones & Bartlett Learning, LLC ■ Shark,NOT FORswordfish, SALE king OR mackerel, DISTRIBUTION tile • Speculum examinationNOT FOR SALE OR DISTRIBUTION fish, tuna • Vagina • Soft, unpasteurized cheeses • Cervix • Raw eggs, meat, or fish • Collection of laboratory specimens © Jones• &Unpasteurized Bartlett Learning, milk or juices LLC • ©Bimanual Jones examination& Bartlett andLearning, assessment LLC of ges- • Smoked meat, processed meats (such as tational age NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION hot dogs), deli meat • Uterine size, contour, position • Review of environmental exposures • Cervical length, dilation, consistency • Cats in household • Tenderness • Lead in paint and pipes in older homes or in • Clinical pelvimetry assessment © Jones & Bartlett waterLearning, system LLC © Jones &• Bartlett Rectal examinationLearning, asLLC indicated NOT FOR SALE• ORHousehold DISTRIBUTION or garden pesticides and cleaningNOT FOR SALE• ORPresence DISTRIBUTION of hemorrhoids chemicals • Musculoskeletal system • Occupational exposures • Symmetry and ease of movement • Depression screening • Olfactory evidence of • Review of systems© Jones & Bartlett Learning, LLC • Tobacco, vaping,© Jonesmarijuana, & Bartlett alcohol, Learning, and LLC NOT FOR SALE OR DISTRIBUTION other substanceNOT use FOR SALE OR DISTRIBUTION Physical Examination to • Ketosis: fruity breath odor, popcorn urine odor Consider • Vital signs Differential Diagnoses to • Height, weight, BMI determination © JonesObservation & Bartlett of general Learning, appearance LLC and affect Consider© Jones & Bartlett Learning, LLC • Pregnancy, normal NOTHead, FOR eyes, SALE ears, OR nose, DISTRIBUTION oral cavity, and throat • NOT FOR SALE OR DISTRIBUTION • Pregnancy at risk, secondary to (HEENOT) • • Health habits, specify Brief examination of the mouth and teeth. Refer to • • Genetic disorders Chapter 6 and Promoting Oral Health • Maternal age • Gingivitis © Jones & Bartlett Learning, LLC © Jones &• Bartlett Fetal conditions, Learning, specify LLC • General dentition NOT FOR SALE OR DISTRIBUTION NOT FOR SALE• Maternal OR DISTRIBUTION health conditions, specify • Condition of mucus membranes • Prior uterine or cervical surgery Skin examination • • Infection • Integrity and turgor • Abuse: physical, sexual, emotional • Scars • Substance use or substance use disorder • Lesions © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Insufficient social support or at-risk living • VaricositiesNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION situation • Needle track marks • Occupational hazards • Signs of infestations Secondary diagnoses related to other findings as • Bruising • indicated by • Striae © Jones & Bartlett Learning, LLC • ©History Jones & Bartlett Learning, LLC • Body art, piercings, or tattoos (Farley et al., NOT FOR SALE OR DISTRIBUTION • NOTPhysical FOR examination SALE OR DISTRIBUTION 2019) • Diagnostic testing • Cardiopulmonary system • Breasts and axilla • Abdominal examination and assessment of gesta- Tests and Procedures to © Jones & Bartletttional Learning, age LLC © JonesConsider & Bartlett Learning, LLC NOT FOR SALE• ORFundal DISTRIBUTION height NOT FOR(American SALE CollegeOR DISTRIBUTION of Obstetricians & Gynecologists • Fetal heart rate (FHR) [ACOG], 2017a; Jordan et al., 2019)

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Pregnancy testing if needed ■ Done as early as 10 weeks’ gestation, © Jones• & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Urine or serum β-human chorionic gonado- and can be done through term NOT FOR SALE OR DISTRIBUTION NOT FOR SALEtropin OR (β DISTRIBUTION-hCG) ■ Offered to women with genetic high- • Routine prenatal STI testing (universal approach) risk indications (ACOG, 2016) • Chlamydia infection ■ May be offered to low-risk women • Syphilis with counseling on higher false pos- • Human immunodeficiency© Jones & virusBartlett (HIV) Learning, using LLC itive rate © Jones & Bartlett Learning, LLC opt-out approachNOT FOR SALE OR DISTRIBUTION ■ Detects trisomyNOT 21, trisomy FOR SALE18, trisomy OR DISTRIBUTION • Hepatitis B surface antigen 13, and sex chromosome aneuploidy • Gonorrhea testing if age <25 years or if risk ■ Detects fetal sex and blood type factors present ■ Does not detect NTDs • Cervical© Jones cytologic & Bartlett testing and/or Learning, human LLC papillo- • Second-trimester© Jones & screening Bartlett options Learning, LLC mavirus (HPV) testing if due • Quad serum screen NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Hematology evaluation and titers ■ Done between 15 and 22 weeks’ • Complete blood count (CBC) with platelet gestation count ■ Measures four specific substances: • Blood type, Rh factor, and antibody screen α-fetoprotein (AFP), hCG, estriol, © Jones & •Bartlett Rubella Learning, titer LLC © Jones & Bartlettand inhibin-ALearning, LLC NOT FOR SALE• Varicella OR DISTRIBUTION antibody screen NOT FOR SALE■ Screens OR DISTRIBUTION for Down syndrome and NTDs • Urinalysis with culture • Integrated two-stage screen • Fetal and genetic screening and testing discussed ■ First stage is nuchal translucency and and offered via nondirective approach first-trimester serum screen between • All genetic screening© Jones is offered & Bartlett with full Learning, in- LLC 11 and 13 6/7© weeks’ Jones gestation & Bartlett Learning, LLC ■ formed consentNOT FOR SALE OR DISTRIBUTION Second stageNOT is FORsecond-trimester SALE OR DISTRIBUTION • The option of no genetic screening is offered as serum screen between 15 and 22 an equal consideration weeks’ gestation • Carrier screening ■ Detects Down syndrome and NTDs • Can be done preconceptually or anytime ■ Highest serum screening sensitivity © Jonesduring & pregnancy Bartlett Learning, LLC © Jones(95%) with & Bartlett acceptable Learning, false positive LLC NOT• Cystic FOR fibrosisSALE ORand DISTRIBUTIONspinal muscular dys- NOTrate FOR (5%) SALE OR DISTRIBUTION trophy screening offered to all clients re- • Ultrasound examination, transvaginal, or gardless of ethnicity abdominal • Specific carrier genetic screening for • Establish or confirm dates ■ © Jones & Bartlettselect Learning, populations LLC © Jones & BartlettOptimal Learning, pregnancy LLC dating is between ■ Tay–Sachs disease—Ashkenazi Jew- 9 and 13 6/7 weeks’ gestation (ACOG, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ish, Cajun, and French Canadian 2016a) ■ Sickle cell screen or hemoglobin • Pregnancy location and fetal viability electrophoresis—African American • Fetal anatomical survey, with informed and African descent consent ■ Thalassemia—Southeast© Jones & Bartlett Asian, Learning,Med- LLC ■ First trimester© for Jones nuchal translucency& Bartlett Learning, LLC iterranean,NOT and FOR Hispanic SALE OR DISTRIBUTION ■ Second trimesterNOT with FOR optimal SALE timing OR DISTRIBUTION • First-trimester screening options between 18 and 20 weeks’ gestation • Serum screen done between 9 and 13 6/7 • Benefits, risks, and limitations of ultra- weeks’ gestation sonography should be discussed with all ©• Jones Nuchal & translucencyBartlett Learning, (NT) scan LLC done at clients© Jones (ACOG, & Bartlett 2016a) Learning, LLC NOT11–13 FOR 6/7SALE weeks’ OR gestation DISTRIBUTION • For selectedNOT high-risk FOR SALEpopulations OR DISTRIBUTIONor individuals, ■ Screens for Down syndrome, other consider aneuploidy, and certain cardiac • Amniocentesis or chorionic villus sampling defects • Specialized ultrasound screen ■ Does not detect neural tube defects • Drug screen © Jones & Bartlett Learning,(NTDs) LLC © Jones• Cytomegalovirus& Bartlett Learning, (CMV) test LLC NOT FOR SALE• ORNoninvasive DISTRIBUTION prenatal testing (NIPT) NOT FOR• Hepatitis SALE BOR and DISTRIBUTION C serologic tests ■ Analyzes cell-free fetal DNA • Thyroid-stimulating hormone (TSH)

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• Zika virus testing (see Zika Virus in Chapter 3) follow-up visit) provider counseling interven- © Jones & Bartlett Learning, LLC © Jones & Bartlett• Learning, Recent travel LLC to areas at risk for Zika virus tions effectively increase the rate of smoking NOT FOR SALE OR DISTRIBUTIONduring pregnancy or preconception periodNOT FOR SALEcessation OR DISTRIBUTION and abstinence for at least 6 months • Sex during pregnancy with partner who (Patnode et al., 2015) was in an area at risk for Zika virus • “Five As” of smoking cessation: Ask, Ad- • Symptoms such as fever, rash, muscle vise, Assess, Assist, Arrange and joint© Jones pain, conjunctivitis, & Bartlett Learning, headache LLC • “Five Rs” of© smoking Jones reduction& Bartlett for Learning,those LLC • Blood leadNOT screening FOR SALE OR DISTRIBUTION who continueNOT smoking: FOR SALERelevance, OR Risk,DISTRIBUTION • 1-hour glucose challenge test or other diabe- Rewards, Roadblocks, Repetition (see tes screening Smoking Cessation in Chapter 8 • For symptoms of bacterial vaginosis, candidi- • Nicotine replacement therapies © Jonesasis, & or Bartlett trichomoniasis Learning, LLC ©• JonesLimited & dataBartlett on use Learning, during pregnancy LLC • Wet prep provider performed micro- and reports of adverse fetal effects NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION scopic examination • Adequate omega-3 fatty acids DHA and EPA • Point-of-care commercial testing • Continue or modify treatment of existing condi- • Tuberculosis testing: purified protein deriva- tions in light of pregnancy diagnosis as indicated tive (PPD) © Jones & Bartlett •Learning, History ofLLC positive PPD or bacillus© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCalmette-Guérin (BCG) vaccine, considerNOT FORIntegrative SALE OR DISTRIBUTION Therapies to chest x-ray study Consider • Consider probiotic supplement for women with Therapeutic Measures to allergies © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Consider • Reduces incidence of certain atopic diseases NOT FOR SALE OR DISTRIBUTION in offspring (Cuello-GarciaNOT FOR et SALE al., 2015) OR DISTRIBUTION Pharmacotherapy • Acupuncture • Prenatal vitamins with folic acid, iron, and • Aromatherapy omega-3 fatty acids DHA and EPA • Childbirth education classes • Seasonal influenza vaccination in the fall or • Meditation and relaxation therapies © Joneswinter & Bartlettmonths (CDC, Learning, 2019a) LLC • © Jones & Bartlett Learning, LLC Prenatal exercise classes NOTEncourage FOR SALE appropriate OR DISTRIBUTION weight gain for BMI (Insti- • NOT FOR SALE OR DISTRIBUTION • Pregnancy massage tute of Medicine [IOM], 2009) • Prenatal yoga • BMI <18.5: gain 28–40 lb • • BMI = 18.5–24.9: gain 25–35 lb • BMI 25–29.9: gain 15–25 lb © Jones & Bartlett Learning,= LLC © Jones & Bartlett Learning, LLC • BMI ≥30: gain 11–20 lb Education and Support NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Lifestyle recommendations Measures to Consider • Regular exercise • Discuss the following topics: • At least 20–30 minutes moderate inten- • Prenatal nutrition and diet safety (see Appen- sity exercise (walking, swimming) most dix B) days ©of theJones week & Bartlett Learning, LLC • Exercise recommendations© Jones & Bartlett Learning, LLC • AerobicNOT and FOR strength SALE training OR areDISTRIBUTION safe for • Avoidance of NOTalcohol, FOR nicotine, SALE marijuana OR DISTRIBUTION most pregnant women and environmental exposures to harmful sub- • Adequate rest and sleep stances • Continuous disturbed sleep is associated • Social or personal lifestyle modification © Jones &with Bartlett adverse Learning, perinatal outcomes LLC (War- ©recommendations Jones & Bartlett Learning, LLC NOT FORland SALE et al., OR 2018) DISTRIBUTION • NOTRelief FOR measures SALE for commonOR DISTRIBUTION discomforts • Stress management techniques • Danger signs and when to call • Social support networks • Inform provider before taking new medications • Smoking or vaping cessation counseling as • How to access care providers needed (see Smoking Cessation in Chapter 8 for • Review prenatal care visit schedule © Jones & Bartlettmore Learning, detail on counseling) LLC © Jones &• Bartlett Traditional Learning, schedule LLC for prenatal visits NOT FOR SALE• ORBoth DISTRIBUTION minimal (<20 minutes in one visit) NOTand FOR SALE• Group OR prenatal DISTRIBUTION care such as Centering Preg- intensive (≥20 minutes plus more than one nancy starting in second trimester

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• More or less frequent visits based on risk Provide information about © Jones• & Bartlett Learning, LLC © Jones & Bartlettassessment Learning, LLC • Interdisciplinary healthcare team and NOT FOR SALE OR DISTRIBUTION NOT FOR• SALERecommended OR DISTRIBUTION pregnancy, childbirth, and parent- providers ing classes and information sources • Identified concerns, risks, and health • Recommended and optional prenatal testing conditions • Birth options • Risks and/or benefits • Location of birth© (seeJones Box 2-1& )Bartlett Learning, LLC • Current lifestyle behaviors© Jones & Bartlett Learning, LLC • Water birth/hydrotherapyNOT FOR SALEavailability OR DISTRIBUTION(see • Treatment options NOT FOR SALE OR DISTRIBUTION Hydrotherapy in Labor and Birth in • Review drug and alcohol screening policy Chapter 4) • Allow private time to encourage disclosure • Vaginal birth after cesarean (VBAC) counsel- • Develop plan for safety as indicated by history ©ing Jones as needed & Bartlett (see Chapter Learning, 4) LLC • Diagnosis-related© Jones information & Bartlett and Learning, support groups LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

BOX 2-1 Birth At Home Or In A Freestanding Birth Center © Jones Community& Bartlett birth—either Learning, in LLCthe home or in a freestanding© birth Jones center & setting—is Bartlett a Learning,safe option for LLC women who NOT FORmeet SALE and maintainOR DISTRIBUTION the criteria of low risk during pregnancyNOT and FORwho arrange SALE care OR with DISTRIBUTION a skilled provider (Cheyney et al., 2014; Elder, 2014; Olsen & Clausen, 2012; Zielinski et al., 2015). The prevalence of community births in the United States has increased by 72% from 2004 to 2014, and this trend is expected to continue (MacDorman & Declercq, 2016). Interest in community birth has been accelerated during the COVID-19 pandemic (Gildner & Thayer, 2020). There are no universally endorsed selection criteria for home birth candidates in the United States, although guidelines for© maternal Jones transfer & Bartlett from home Learning, to the hospital LLC have been jointly developed© Jones by several & Bartlettexpert Learning, LLC groups (Vedam et al., 2014). The Commission for the Accreditation of Birth Centers (CABC) provides support, education, and accreditationNOT toFOR developing SALE and OR existing DISTRIBUTION freestanding birth centers and AlongsideNOT Maternity FOR SALE OR DISTRIBUTION Centers. The information presented here is a brief overview of considerations for labor and birth when choosing to participate in community birth. The woman should have a strong preference for birth in a community setting and demonstrate the following characteristics: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■ Presence of protective factors for normal birth and healthy baby • NOTLow riskFOR for SALEperinatal OR complications DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Commitment to healthy pregnancy and physiologic birth • Flexible approach to addressing issues that arise ■ Strong sense of self-determination for life choices • Maintenance of positive health habits and prenatal care © Jones & Bartlett• Preparation Learning, of birthing LLC environment and supportive© others Jones & Bartlett Learning, LLC NOT FOR SALE• Willingness OR DISTRIBUTION to transfer during labor or postpartumNOT period FOR when indicatedSALE OR DISTRIBUTION ■ Plans in place for urgent or emergency transfer of care to a hospital setting ■ Spontaneous progressive labor The woman should also have the following psychosocial attributes: ■ Understand and acknowledge© Jones the & sharedBartlett responsibility Learning, for careLLC and outcome © Jones & Bartlett Learning, LLC ■ Have adequate socialNOT support FOR for SALEher choice OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■ Have a strong commitment to labor and birth without medications ■ Agree to assessment using screening criteria for the specific out-of-hospital practice ■ Have open and clear communication with the midwife The interested reader is encouraged to access American College of Nurse-Midwives (ACNM), Midwives Alliance© Jones of North &America Bartlett (MANA), Learning, the National LLC Association of Certified Professional© Jones Midwives & Bartlett (NACPM), Learning, and LLC AmericanNOT Association FOR SALE of Birth OR Centers DISTRIBUTION (AABC) documents regarding the safeNOT provision FOR of SALE pregnancy, OR labor, DISTRIBUTION birth, postpartum care, and newborn care in the community setting: ■ AABC: http://www.birthcenters.org ■ ACNM: http://www.midwife.org ■ © Jones & BartlettMANA: http://www.mana.org Learning, LLC © Jones & Bartlett Learning, LLC ■ NACPM: https//www.nacpm.org NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Note: Citations in this box can be found in the references listed at the end of this chapter.

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© Jones & BartlettFollow-up Learning, Measures LLC to Consider© JonesOngoing & Bartlett Learning, Prenatal LLC Care NOT FOR SALE• OR Discuss DISTRIBUTION and document NOT FOR SALE OR DISTRIBUTION • Pregnancy status Key Clinical Information • Woman’s expressed preferences The “routine” prenatal visit is anything but routine for • Risk assessment with plan for care most pregnant women. This visit is their opportunity • Client concerns© Jones and &information Bartlett providedLearning, LLCto have concerns addressed© Jones while & the Bartlett well-being Learning, of LLC • InformedNOT consent FOR for careSALE OR DISTRIBUTIONthemselves and their fetusNOT is evaluated.FOR SALE Prenatal OR DISTRIBUTIONcare • VBAC or planned repeat cesarean birth provides an opportunity to look for subtle signs or • Obtain and review operative notes to verify symptoms that can indicate development of a devia- type of uterine incision tion from normal. Time spent during prenatal care also • Coordinate surgical and anesthesia consulta- facilitates the creation of a caring, respectful, and ther- © Jonestions & and Bartlett provide Learning, for family-centered LLC cesar- apeutic ©relationship Jones & conduciveBartlett Learning,to optimal pregnancy LLC NOT FORean birth SALE options OR (SchornDISTRIBUTION et al., 2015) care andNOT outcomes FOR (Sandall SALE etOR al., DISTRIBUTION2013). • Schedule return prenatal visit Prenatal care began in the early 1900s as a method to screen for signs and symptoms of preeclampsia. Over time, it has evolved into a platform for providing Consultation, Collaboration, © Jones & Bartlett Learning, LLC © Jonesinformation & Bartlett to Learning,promote healthy LLC pregnancy and birth, NOT FOR SALEor Referral OR DISTRIBUTION vto Consider NOT FORand SALErisk screening OR DISTRIBUTION and testing. Follow-up examina- • Specialty maternity care services tions and discussions by the midwife allow clients to • Genetic counseling, screening and testing fully realize the benefits of prenatal care and foster an • Nutritional services ongoing interaction that builds a trusting therapeutic • Obstetric or perinatal services relationship. • Other perinatal© Jonesor medical & Bartlettspecialty asLearning, indicated LLC Follow-up on laboratory© Jones and test& Bartlett results, behav Learning,- LLC by secondaryNOT diagnoses FOR or SALE findings OR DISTRIBUTIONioral changes, and teachingNOT highlights FOR SALE the value OR placed DISTRIBUTION • Social services as indicated by lifestyle and social on these measures. The group prenatal care model indicators capitalizes on the social support, information, and • WIC program and Medicaid compassion provided by a cohort of peers—women © Jones• Inpatient & Bartlett or outpatient Learning, substance LLC use treat- from diverse© Jones backgrounds & Bartlett meeting Learning, on the LLCcommon NOT FORment SALEprogram OR DISTRIBUTION groundNOT of the FORpregnancy SALE and OR childbearing DISTRIBUTION experience. • Counseling or therapy The overarching goal of prenatal care is a safe and • Women’s shelter/safe house emotionally satisfying pregnancy, increased empow- • Participation in collaborative interdisciplinary erment and self-efficacy regarding the woman’s own care enhances health outcomes and experiences health behaviors, and optimal outcomes given the © Jones & Bartlett• For diagnosisLearning, or treatmentLLC outside the midwife’s© Jones unique & Bartlett circumstances Learning, of the LLC mother’s life and health NOT FOR SALEscope OR DISTRIBUTIONof practice NOT FORduring SALE her pregnancy.OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CHANGES TONOT PRENATAL FOR SALE CARE OR DUE DISTRIBUTION TO COVID-19 NOT FOR SALE OR DISTRIBUTION Prenatal care practices have been rapidly adjusting owing to the concerns brought about by the COVID-19 pandemic. To reduce the risk of potential exposure to COVID-19 a variety of new prenatal visit strategies have been instituted. They include reduced numbers of routine in-office visits, use of telehealth modalities, and drive-through ©clinics Jones where & Bartlettpregnant women Learning, are assessed LLC while remaining in their© cars Jones (Poon & et Bartlett al., 2020). InLearning, some large LLC NOTpractice FOR setting, SALE healthcare OR DISTRIBUTION members are divided into cohorts of eitherNOT inpatient FOR orSALE outpatient OR teams DISTRIBUTION to reduce COVID-19 exposure. A common revised prenatal care model limits in-person prenatal visits to the initial prenatal exam, an anatomy ultrasound scan if desired or indicated, and subsequent visits at 28, 36, and 39 or 40 weeks. Components of care such as screenings and laboratory testing are grouped together and performed during the in-person visit to © Jones & Bartlettreduce Learning,client exposure. LLC For example, gestational diabetes© Jones screening & Bartlett and tetanus, Learning, diphtheria, LLC and pertussis (Tdap) NOT FOR SALEvaccine OR can DISTRIBUTION be performed at the same time rather NOTthan in FOR separate SALE visits. OR Additional DISTRIBUTION prenatal visits are conducted through telehealth platforms or telephone calls, both of which are often reimbursable. When feasible, clients are

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