recommend folic acid 0.4mg-0.8mg/d for primary prevention or 4mg/day if previous pregnancy with a neural tube defect (ideally 1 month before conception through first trimester)

ask about a history of genital/orolabial herpes in woman and partner

• women with no history of HSV should be counselled about avoiding exposure near term (if partner is HSV-positive:advise abstinence, condom use and/or antiviral suppression of partner. Avoidance of oral genital contact if partner has orolabial herpes)
• women with recurrent HSV should be counselled about the option of acyclovir at term, the role of C/S and avoiding transmission to the newborn postpartum.

ask about a prior infection with chickenpox (if no prior history, check immunity with varicella zoster IgG)

• if not immune and if not pregnant offer vaccine (delay conception 1 month after). If pregnant: counsel re avoiding exposure and reporting exposures immediately, vaccinate postpartum

consider early discussion/referral for prenatal diagnosis if ≥ 35 years at EDD or risk factors

consider early ultrasound (bleeding, uncertain dates, required for CVS)

complete history on prenatal form

screen for domestic violence:

• "Do you ever feel unsafe at home?"
• "Have you been hit, kicked, punched or otherwise hurt by someone within the past year?"

physical exam

regular prenatal visits every 4-6 weeks

earliest auscultation of fetal heart with doppler (10-12 weeks)

unsensitized Rh negative women should receive a dose of D Ig within 72 hours after elective abortion, amniocentesis, CVS, ectopic pregnancy termination, antepartum hemorrhage, miscarriage, abdominal trauma, external version procedures, stillbirth ± threatened abortion before 12 weeks (first trimester 50μg, after 12 weeks 300μg) - informed consent needed

offer influenza vaccine for women who will be in 2nd or 3rd trimester during flu season

quickening (18-20 weeks)

Rh negative women: administer dose (300μg) of D Ig if antibody negative at 28 weeks - informed consent needed (U.K. doses of 100μg at 28 and 34 weeks)

visits every 2-3 weeks after 30 weeks

visits every 1-2 weeks after 36 weeks

offer induction of labour between 41-42 weeks gestation (if declined recommend serial fetal surveillance)

Rh negative women: adminster dose of D Ig 120μg (300μg if test for fetomaternal hemorrhage not done) within 72 hours of delivery if a D positive infant is delivered (U.K. 100μg)

rubella and varicella vaccine(s) for all non-immune women

infants born to HBsAg positive mothers should receive HBIG 0.5mL IM within 12 hours of birth and Hepatitis B vaccine at birth, 1 and 6 months

ocular prophylaxis for newborn

newborn hip exam

recommend rooming-in and early, frequent contact

rubella serology

offer HIV testing (with informed consent and pretest counselling including risk factors, risk of transmission to fetus and availability of therapy to reduce risk of transmission to fetus)

offer hepatitis C antibody screening to women with risk factors (IDU, exposure to blood products - medical or occupational, HIV positive, elevated AST, prison inmates, multiple sex partners, tattoos)

Tay Sachs disease testing in Ashkenazi Jews by hexosaminidase-A in serum (men, nonpregnant women) or WBCs (pregnant women)

offer Canavan carrier screening for Ashkenazi Jews

screen for hemoglobinopathies (sickle cell disease, beta thalassemia) by MCV ± hemoglobin electrophoresis in high risk populations (Asian, African, Mediterranean, Hispanic, middle Eastern, East Indian)

consider cystic fibrosis carrier testing (recommended routinely in USA, not routinely available in Canada unless + family history)

HBsAg

syphilis serology

ABO and Rh blood type and antbody testing

test women at high risk for diabetes (50gGTT), if neg repeat 24-28 wks

PAP (if not done in previous 6-12 months)

screen women age <25 years or at high risk for chlamydia (consider screening all women)

screen women at high risk for gonorrhea

consider screening for bacterial vaginosis by gram stain or Amsel criteria in women at risk for preterm labour or symptomatic women

screen for asymptomatic bacteriuria by urine culture (12-16 weeks)

offer prenatal diagnosis to women with risk factors:

• CVS 10½-12 weeks (f/u AFP & 18 week scan)
• Amniocentesis 15 weeks (can be done later if necessary)

offer maternal serum triple screen to all women (15-20 weeks, optimal time between 15-17 weeks) Note: first trimester screening using nuchal translucency measurement ± serum markers may be available in some centers

detailed ultrasound at 16-20 weeks (dates, anomalies, twins, placenta placement) - optimal time is 18 weeks

consider glucose test between 24-28 weeks unless low risk with either 2 step: 1 hour, 50g load, not fasting - if >7.8mM do 3 hour GTT with 100g load (or 1 step: 2 hour, 75g GTT, fasting)

Rh negative women: repeat Rh antibody level at 24-28 weeks

consider repeat hemoglobin at 24-28 weeks

if high risk: repeat syphilis serology, HBsAg, HIV serology, screening for chlamydia and gonorrhea (repeat syphilis serology again at delivery)

± repeat urine culture

f/u ultrasound if high risk (IUGR, placenta previa, bleeding)

screen for group B strep (GBS) with vaginal-rectal culture (35-37 weeks) and offer treatment to all colonized women with intrapartum IV antibiotics at the time of labour or rupture of membranes. Also offer treatment to all women with previously documented GBS bacteriuria or previous infant with GBS and women with risk factors (preterm labour <37 weeks, PROM > 18 hours, maternal fever >38°C) whose culture results are not available at time of delivery

newborn screening for PKU, congenital hypothyroidism and galactosemia

Rh negative women who deliver Rh positive infant: test (Kleihauer-Betke or rosette) for fetomaternal hemorrhage in excess of amount covered by standard dose of D Ig

discuss prescription and over-the-counter medications

discuss prenatal vitamins (including folic acid, vitamin A toxicity)

counsel re potentially harmful effects of smoking on fetus and recommend smoking cessation

screen for evidence of risk-drinking (2 drinks per day or binge drinking), counsel re potentially harmful effects of alcohol on fetus, advise abstinence or limited drinking

discuss potential risks to fetus of illicit drug use and encourage abstinence

recommend reading material and Pregnancy Planning Guide (www.pregnancyplanningguide.com)

counsel re avoiding exposure to toxoplasmosis(1), listeria(2), and CMV(3)

• avoid raw/undercooked meat(1,2), unpasteurized milk or milk products(1,2), soft cheeses (feta, Brie, Camembert, blue-veined, Mexican queso fresco)(2), deli foods(2), pâté(2), refrigerated smoked seafood (2)
• reheat leftovers, coldcuts and hotdogs until steaming hot(2)
• frequent handwashing (1,2,3) especially after caring for child, changing diapers(3), wash fruits and vegetables (1,2)
• avoid cat litter(1), wear gloves for gardening(1)

avoid eating shark, swordfish, king mackerel, tilefish, tuna steaks due to high levels of mercury (other fish, including canned tuna can be eaten in moderation: about 1-2 meals per week)

discuss diet (including folate, calcium, iron, calories and caffeine)

discuss exercise (advantages, contraindications, maximum target heart rate)

give hospital registration form if required

give copy of Maternity Care Calendar, highlight relevant information

discuss prenatal classes

counsel re prenatal diagnosis by CVS or amniocentesis with women with identified risk factors (age > 35 years at EDD, previous affected pregnancy, known translocation

discuss maternal serum triple screening with all pregnant women (including limited sensitivity and specificity, psychological implications, risks associated with prenatal diagnosis and 2nd trimester abortion, delays inherent in process)

discuss and recommend breastfeeding

discuss circumcision

discuss labour and delivery (pain relief, monitoring, episiotomy, labour support, when to call)

discuss community resources for infants & parents

recommend infant car seat

discuss signs that your baby is breastfeeding well (by day 4: breastfeeding at least 8 times, has at least 6 wet diapers and 3-4 soft, yellow stools in 24 hours)

breastfeeding information and support (early frequent contact, positioning and latching, hand expression, support groups, collection, storage and freezing)

recommend vitamin D supplementation (200-400 IU/day)

recommend infants be placed on back to sleep, avoid exposure to second-hand smoke, avoid overheating and soft, loose bedding, to decrease risk of SIDS

watch for signs of postpartum depression