Re-examining Prenatal Care Antepartum and Intrapartum Management Conference San Francisco, CA Kate Frómeta, CNM Assistant Professor Department of Obstetrics and Gynecology UCSF Prenatal Care Visit Schedule for Low-Risk Women A. Q 4 weeks until 28 Q 2 weeks until 36 .MoreB. Frequentweekly Visits .LessC. Frequent Visits 3 No Disclosures Presentation Title 74% 1 Q 4 weeks until 28 Q 2 w... 4% 23% Prenatal Care Urine Dips More Frequent Visits A. at every visit Less Frequent Visits B. at the first visit only C. with elevated BPs only D. No urine dips 4 Presentation Title 58% 9% 23% at every visit at the first visit only 9% with elevated BPs only No urine dips Prenatal Care Integration of Support Services A. Routinely have women see a provider who is not an OB or Midwife or Family B. Only seePractice another MD/NP. type of provider if indicated 5 Presentation Title . First models out of Europe in early 20 . 73% By 1930: UK ministry of health 27% - PNV at 16, 24, 28, then q 2 w Historyuntil 36 then of weekly Prenatal Care - Measure fundal height at 32 and 36 weeks - History of Prenatal Care Fetal heart rate monitoring and urine testing q visit Routinely have women see ... Only see another type of pr... 7 OB/Anesthesia Symposium th century 2 6 Presentation Title . Adolphe Pinard and midwife Madame Bequet - Refuge de L'Avenue du Maine 1892 . Children’s Bureau started in 1912 - History of Prenatal Care: US Focused on preventing infant mortality - Promotion of the idea of prenatal care in the European model . “More Ritualistic than Rational” 8 Presentation Title Reasons for PNC Our Failures . Decrease LBW through nutrition/substance abuse intervention . Identifying infectious disease . US Obstetric care is the most expensive in the world . Identify Rh negative mothers and give Rhogam as needed . Identification and rectification of breech presentation . One of the highest rates of both infant and maternal mortality of . Identification of preeclampsia to decrease eclampsia industrialized countries . Identification and treatment of severe anemia . Assure appropriate delivery setting . Major opportunities for improvement - Anomalies, breech, preterm . Build trust, anticipatory guidance ETC. ETC. ETC. 9 OB/Anesthesia Symposium 10 Presentation Title Difficulty of Assessing Prenatal Care Quantity: Schedule of Visits . Never studied before implementation . Considered standard of care therefore RCT are not a Possibility . US standard: - First visit in 1st trimester . Relationship between care seeking and other positive health behaviors - f/u q 4 weeks until 28 then q2 until 36 then weekly (13-14) - ACOG “frequency of obstetric visits should be individualized” . Measuring quantity vs quality . NICE guidelines: - content, provider, setting - 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. 11 OB/Anesthesia Symposium 12 OB/Anesthesia Symposium 3 UCSF Schedule Of Prenatal Care Visits US Expert Panel on Prenatal Care (1989) . First visit in 1st trimester . 8 visits for multip, 10 for primip . Q 6 weeks until 28 weeks - Including preconception visit . Q 4 weeks until 36 weeks . More integration of support services “team approach” . Q 2 weeks . * Individualized to risk status* . Antenatal Testing . Eliminate “Visits that are not meaningful are counterproductive” . 9-10 visits 13 Presentation Title 14 OB/Anesthesia Symposium Quantity Of Visits: Quantity Of Visits: Standard vs. Reduced Visit Schedule Standard vs. Reduced Visit Schedule . McDuffie et al. (1996) JAMA . RCT N=2764 . Binstock and Wolde-Tsadik (1995) and Walker and Koniak-Griffin . 9 for primips, multips 8 (+ 1 phone call at 12 weeks) vs. 14 (1997) - No difference: - Smaller sample sizes (n=549, 81), both in CA, homogenous populations . PTB - White, highly educated, women . LBW - Latina women on Medicaid attending a birth center . PreE - ~8 visits vs. 11-14 . C/S - No change in perinatal outcomes . Satisfaction (reduced more likely to rate # of visits as “just right”) - greater satisfaction with reduced visits 15 OB/Anesthesia Symposium 16 Presentation Title 4 Quantity Of Visits: Quantity Of Visits: Standard vs. Reduced Visit Schedule Standard vs. Reduced Visit Schedule . Sikorski et al (1995) - n=2794 (reduced =6-7 vs 13) . 2015 Cochrane Review randomized/cluster-randomized - Fewer ultrasounds and antenatal admissions . 7 trials, n=60,000 Reduced vs Standard PNC - Less suspicion of IUGR (no difference in diagnosis of IUGR) . High, medium and low-income countries - No change in perinatal outcomes (PreE, IOL, C/S, SGA, PPH etc) . High Income - Less satisfaction - 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) 17 Presentation Title 18 OB/Anesthesia Symposium Quantity of Visits: Quality Of Visits: Standard vs. Reduced Visit Schedule Components of Prenatal Care . No difference between groups . BP - Maternal mortality . Fundal Height - Hypertensive d/o . FHR auscultation - PTB . Urine Dip - SGA . Warning signs . Perinatal mortality . Questions/Anticipatory - Associated with reduced visits in low and middle income countries Guidance - No difference in high income countries . Satisfaction 19 OB/Anesthesia Symposium 20 OB/Anesthesia Symposium 5 Fundal Heights Fundal Heights . Vasilly Sutugin St. Petersberg 1875 . Sparks et al, 2011 - Fundal height to determine gestational age/length - Retrospect cohort - N=3627, u/s for abnormal fundal height = 448 . Alfred Baker Spalding, Stanford 1904 “Measure….the height of the fundus above the symphysis in . Sensitivity LGA (>90%) 16.6% SGA (<10%) 17.3% cm….and add two to measurements between 22 and 26 cm, - Lower for overweight/obese women three to measurements between 26 and 30, four to measurements between 30 and 32 and five to measurements - Higher for multips above 32, which sum will equal the probable week of . Specificity 94.9-95.4% LGA and SGA 92.4-93.1% pregnancy” - Outcomes occurred about 10% of the time 21 OB/Anesthesia Symposium 22 OB/Anesthesia Symposium Assessing Fetal Growth Fundal Height WHO 2016 . ? 3rd trimester u/s - Sensitivity 46-93% for SGA and 6.7-89% for LGA . Replacing abdominal palpation with . NICE says no 3rd trimester u/s for LGA in “low-risk” population. symphysis-fundal height (SFH) . Customized growth charts measurement for the assessment of fetal growth is not recommended to improve - (GROW software – UK, endorsed by RCOG) perinatal outcomes. A change from what - Ethnic/racial and gender differences (NICHD, WHO) is usually practiced (abdominal palpation . Deter-Rossavik model or SFH measurement) in a particular rd nd setting is not recommended - Base 3 tri growth on 2 tri growth (u/s) 23 OB/Anesthesia Symposium 24 OB/Anesthesia Symposium 6 Fetal Heart Rate Auscultation Urine Dips . Protein . In the US is standard of care at every visit (appropriate to - Proteinuria common in pregnancy 10-40% (≥+1) gestational age) - Protein dipstick has ppv of PreE of 2-11% - High false positive when compared to 24 hr urines . NICE (UK) recommends against fhr auscultation at routine visits . New Guidelines place less emphasis on proteinuria - “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.” . Glucose - False positive 11: 1 - Glucose loading test much better Alto, W (2005) 25 OB/Anesthesia Symposium 26 OB/Anesthesia Symposium 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 28 OB/Anesthesia Symposium 7 Innovations Innovations OB Nest (HCD) . Centering Pregnancy http://centerforinnovation.mayo.edu/files/2016/05/ob-nest-experiment-report.pdf - CHI . Butler Tobah et al, (2016) . Expect with me - RCT, N=150 - United Health . 8 office and 6 RN phone visits vs. 12 office visits . BabyScripts - RN moderated online community - Home weight and BP monitoring . Nest = greater satisfaction, . OB Nest less pregnancy-related stress - Mayo Clinic . No difference: - Maternal/fetal outcomes - Unplanned visits - Perceived quality of care 29 OB/Anesthesia Symposium 30 OB/Anesthesia Symposium Innovations Thank You OB Nest Now Go Innovate! . 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” 31 Presentation Title 32 Presentation Title 8 9.