What are the recommended guidelines for obstetric care?

Recommended Guidelines for Obstetric Care

The most comprehensive obstetric care requires a standardized, levels-based approach addressing maternal risk factors and optimizing outcomes through appropriate risk stratification, regular monitoring, and specialized care when needed. 1

Core Components of Obstetric Care

Risk Assessment and Care Levels

• Maternal cases should be categorized according to a four-level maternal care classification system: basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV) 1
• Risk assessment should include comprehensive evaluation of pre-existing medical conditions, obstetric history, and current pregnancy complications 1
• Demographic factors, medical history, and obstetric history should be thoroughly documented as they influence pregnancy outcomes 1

Prenatal Visit Structure

• Visit frequency should be based on risk stratification, with higher-risk patients requiring more frequent monitoring 1
• International guidelines recommend a range of 7.5-15 prenatal visits, with approximately 13 visits recommended for low-risk pregnancies in the U.S. 2
• Each visit should document maternal vital signs, weight, urine analysis results, fetal heart rate, and fundal height measurements 1

Preconception Care

Nutritional Recommendations

• All women of reproductive age should take daily folic acid supplementation of 400 micrograms to prevent neural tube defects 3, 4
• Women with previous neural tube defect-affected pregnancies should take 4000 micrograms (4 mg) of folic acid daily beginning at least one month before conception and continuing through the first trimester 3, 5
• A comprehensive nutritional assessment should evaluate anthropometric factors (e.g., BMI), biochemical factors (e.g., anemia), clinical factors, and dietary risks 2

Medication and Substance Use

• Review all current medications; avoid FDA pregnancy category X medications and most category D medications unless potential maternal benefits outweigh fetal risks 2
• Screen for tobacco, alcohol, and drug use; use validated questionnaires like CAGE or T-ACE to screen for alcohol and substance abuse 2
• Counsel patients about possible toxins and exposure to teratogenic agents at home and in the workplace 2

Infection Prevention and Immunizations

• Screen for periodontal, urogenital, and sexually transmitted infections as indicated 2
• Update immunizations with hepatitis B, rubella, varicella, Tdap, human papillomavirus, and influenza vaccines as needed 2
• Counsel patients about preventing TORCH infections (Toxoplasmosis, Other viruses, Rubella, Cytomegalovirus, Herpes simplex viruses) 2

Antenatal Care

Physical Activity Recommendations

• All pregnant women without contraindications should be physically active throughout pregnancy 2
• Previously inactive women should also begin appropriate physical activity during pregnancy 2
• Women diagnosed with gestational diabetes mellitus and those categorized as overweight or obese should engage in regular physical activity 2
• Regular physical activity during pregnancy reduces the risk of gestational diabetes mellitus (38%), pre-eclampsia (41%), gestational hypertension (39%), prenatal depression (67%), and macrosomia (39%) 2

Special Populations Management

• Women after bariatric surgery require specialized monitoring of nutrient levels, gestational weight gain, and potential surgical complications 2
• Women with obesity require additional monitoring and specialized care plans to address increased risks 2
• High-risk pregnancies should have documented multidisciplinary planning involving obstetrics, anesthesiology, and relevant subspecialties 1

Intrapartum Care

Labor Management

• For active phase arrest without evidence of cephalopelvic disproportion, oxytocin augmentation should be the first-line treatment 6
• When using oxytocin, accurate control of the rate of infusion flow is essential using an infusion pump with frequent monitoring of contractions and fetal heart rate 7
• Initial oxytocin dose should be no more than 1-2 mU/min, with gradual increases in increments of no more than 1-2 mU/min until a normal labor contraction pattern is established 7

Anesthetic Considerations

• Consider early insertion of a neuraxial catheter for anticipated difficult delivery 2, 6
• For cesarean delivery, neuraxial techniques are preferred over general anesthesia when possible 2, 6
• For postoperative analgesia after neuraxial anesthesia for cesarean delivery, consider selecting neuraxial opioids rather than intermittent injections of parenteral opioids 2

Cesarean Delivery Techniques

• Blunt expansion of a transverse uterine hysterotomy is recommended to reduce surgical blood loss 2
• Closure of the hysterotomy in 2 layers may be associated with a lower rate of uterine rupture 2
• The peritoneum does not need to be closed as closure is not associated with improved outcomes and increases operative times 2
• In women with 2 cm or more of subcutaneous tissue, reapproximation of that tissue layer should be performed 2
• The skin should be closed with subcuticular suture in most cases 2

Emergency Preparedness

• Basic and advanced life-support equipment should be immediately available in the operative area of labor and delivery units 2, 6
• If cardiac arrest occurs during labor, maintain uterine displacement (usually left displacement) and perform cesarean delivery if maternal circulation is not restored within 4 minutes 2, 6

Common Pitfalls to Avoid

• Failure to provide folic acid supplementation before conception and during early pregnancy significantly increases the risk of neural tube defects 8, 9
• Underestimating the importance of preconception care; approximately half of all pregnancies in the United States are unintended, making routine preconception counseling for all women of reproductive age essential 2
• Inadequate screening for substance use and mental health issues during pregnancy can lead to missed opportunities for intervention 2
• Failure to recognize the need for specialized equipment and personnel for difficult airway management during emergency situations 6