What are the Department of Health (DOH) policies on maternal and fetal healthcare in the community setting, including prenatal visit recommendations, immunizations, and management of low-risk and high-risk pregnancies?

DOH Maternal and Fetal Healthcare Policies in the Community Setting

a. Leopold's Maneuvers I to IV

Leopold's maneuvers are systematic palpation techniques performed during the third trimester to determine fetal lie, presentation, position, and engagement, which are critical for planning delivery mode and anticipating potential complications.

Leopold's Maneuver I (Fundal Grip)

• Purpose: Determines which fetal part occupies the fundus (head vs. breech) 1
• Technique: Palpate the uterine fundus with both hands to assess the consistency and shape of the fetal part
• Clinical significance: Identifies fetal lie (longitudinal, transverse, or oblique) and helps estimate gestational age by fundal height 2

Leopold's Maneuver II (Umbilical Grip)

• Purpose: Locates the fetal back and small parts (limbs) 1
• Technique: Place hands on either side of the maternal abdomen and palpate to distinguish the smooth, firm fetal back from irregular small parts
• Clinical significance: Determines fetal position (right or left) and optimal location for auscultating fetal heart tones 2

Leopold's Maneuver III (Pawlik's Grip)

• Purpose: Identifies the presenting part and confirms findings from Maneuver I 1
• Technique: Grasp the lower portion of the maternal abdomen just above the symphysis pubis with thumb and fingers of one hand
• Clinical significance: Confirms cephalic vs. breech presentation and assesses mobility of the presenting part 2

Leopold's Maneuver IV (Pelvic Grip)

• Purpose: Determines the degree of fetal head descent and engagement into the pelvis 1
• Technique: Face the mother's feet and place hands on both sides of the lower abdomen, pressing deeply toward the pelvis
• Clinical significance: Assesses engagement (when the widest diameter of the presenting part passes through the pelvic inlet), which predicts likelihood of vaginal delivery and labor progression 2

Common pitfall: Leopold's maneuvers are less accurate in obese patients, with polyhydramnios, or with anterior placentation—ultrasound should be used for confirmation in these cases 2.

b. Complete Immunizations for Pregnant Mothers

All pregnant women should receive inactivated influenza vaccine in any trimester and Tdap vaccine between 27-36 weeks of gestation during each pregnancy, as these are the only two vaccines routinely recommended for all pregnant women. 3, 4

Routine Immunizations (All Pregnant Women)

• Inactivated Influenza Vaccine: Administer during any trimester of pregnancy to protect both mother and infant from influenza complications, which carry increased maternal morbidity and mortality risk during pregnancy 3, 4
• Tdap (Tetanus, Diphtheria, Acellular Pertussis): Administer between 27-36 weeks gestation (as early in this window as possible) during each pregnancy to provide optimal passive antibody protection to infants who face highest pertussis mortality risk in the first 3 months of life 3, 4, 5

Preconception/Postpartum Immunizations (NOT During Pregnancy)

• MMR (Measles, Mumps, Rubella): This is a live vaccine contraindicated during pregnancy; screen for rubella immunity preconceptionally and vaccinate postpartum if seronegative 1, 6
• Varicella: Live vaccine contraindicated during pregnancy; screen preconceptionally and vaccinate postpartum if non-immune 1

Special Circumstances Immunizations

• Hepatitis B: Administer if at risk (healthcare workers, multiple sexual partners, injection drug use) or if screening reveals susceptibility 1, 2
• Hepatitis A: Consider if traveling to endemic areas or at occupational risk 1
• Pneumococcal: Administer to high-risk pregnant women (chronic heart/lung disease, diabetes, immunocompromised) 1
• Meningococcal: Consider for high-risk patients (asplenia, complement deficiency, travel to endemic areas) 1

Critical safety principle: Inactivated vaccines, bacterial vaccines, and toxoids have no evidence of adverse fetal effects and growing safety data support their use in pregnancy, while live vaccines are contraindicated due to theoretical fetal risk 3, 4, 7.

c. Prenatal Visit Frequency

Normal/Low-Risk Pregnancy

Low-risk pregnant women should have approximately 13 prenatal visits following the traditional U.S. schedule, though international evidence suggests fewer visits (7-8) may be adequate. 8

Traditional U.S. Schedule (13 visits total):

• First trimester: Monthly visits (approximately 3 visits) 1, 8
• Second trimester: Every 4 weeks (approximately 3 visits) 1
• Third trimester: Every 2 weeks from 28-36 weeks (approximately 4 visits), then weekly from 36 weeks until delivery (approximately 3 visits) 1

Important context: The U.S. recommends significantly more visits (median 13) compared to peer countries like France and the Netherlands (7.5 visits), and this intensive schedule lacks strong evidence base 1, 8. Most countries recommend that low-risk women see only general practitioners or midwives rather than obstetrician-gynecologists 8.

High-Risk Pregnancy

High-risk pregnancies require more frequent visits with intervals determined by the specific maternal or fetal condition, often involving weekly or twice-weekly visits in the third trimester. 1, 8

• Frequency: Individualized based on condition severity, typically every 1-2 weeks in second trimester and weekly or more frequently in third trimester 1, 5
• Additional monitoring: May require non-stress tests, biophysical profiles, or ultrasounds for fetal surveillance starting at 32-34 weeks 1, 5
• Specialist involvement: Should involve maternal-fetal medicine specialists or appropriate subspecialists depending on the condition 8, 5

d. Low-Risk vs. High-Risk Pregnancy Definition and Management

Low-Risk Pregnancy Definition

A low-risk pregnancy is one without pre-existing maternal medical conditions, obstetric complications, or fetal abnormalities that increase the likelihood of adverse maternal or perinatal outcomes. 8

Characteristics of Low-Risk Pregnancy:

• No chronic medical conditions (hypertension, diabetes, heart disease, autoimmune disorders, thyroid disease) 1
• No previous adverse pregnancy outcomes (preterm birth, fetal loss, birth defects, low birth weight) 1
• Normal BMI (19.8-26.0 kg/m²) 1
• No substance abuse (tobacco, alcohol, drugs) 1
• No high-risk genetic or ethnic factors 1
• Normal fetal growth and anatomy on ultrasound 2

High-Risk Pregnancy Definition

A high-risk pregnancy involves maternal medical conditions, obstetric complications, or fetal abnormalities that significantly increase the risk of maternal morbidity, fetal morbidity, or perinatal mortality. 1, 8

Conditions Defining High-Risk Pregnancy:

• Pre-existing medical conditions: Diabetes (type 1 or 2), chronic hypertension, cardiovascular disease, autoimmune disorders, thyroid disease, renal disease 1, 5
• Pregnancy-related complications: Gestational diabetes, preeclampsia, placenta previa, placental abruption, preterm labor 1, 5
• Previous adverse outcomes: Prior preterm birth, fetal loss, birth defects, intrauterine fetal demise 1
• Fetal abnormalities: Growth restriction, congenital anomalies, multiple gestation 2, 5
• Maternal factors: Age >35 years, obesity (BMI ≥30), underweight (BMI <18.5), substance abuse 1

Management of Low-Risk Pregnancy

Low-risk pregnancies should follow routine prenatal care with standard visit schedules, basic screening tests, and can be managed by midwives, general practitioners, or obstetrician-gynecologists. 8

Management Components:

• Visit schedule: Follow traditional schedule or consider reduced visit model (7-8 visits) based on international evidence 1, 8
• Initial screening: Complete blood count, blood type/Rh, urinalysis/culture, rubella immunity, syphilis, hepatitis B, HIV, cervical cytology 1, 2
• Glucose screening: Screen for gestational diabetes at 24-28 weeks using one-step or two-step approach 1, 2, 5
• Ultrasound: Dating ultrasound in first trimester and anatomic survey at 18-22 weeks 2, 5
• Immunizations: Influenza vaccine any trimester, Tdap at 27-36 weeks 3, 4, 5
• Folic acid: 400-800 mcg daily starting preconceptionally 1
• Provider type: Can be managed by midwives or general practitioners in most countries; U.S. offers option of obstetrician-gynecologist 8

Management of High-Risk Pregnancy

High-risk pregnancies require intensive monitoring with condition-specific protocols, frequent visits, specialized testing, and involvement of maternal-fetal medicine specialists or appropriate subspecialists. 1, 8, 5

Management Components:

For Pre-existing Diabetes:

• Preconception: Achieve A1C <7% before conception to minimize risk of congenital anomalies and spontaneous abortion 1
• Glycemic targets: Premeal 60-99 mg/dL, peak postprandial 100-129 mg/dL, A1C <6% if achievable without significant hypoglycemia 1
• Monitoring: Pre- and postprandial glucose monitoring, ophthalmology exam each trimester 1
• Medications: Insulin is preferred; metformin and glyburide have safety data but most oral agents lack long-term data 1
• Fetal surveillance: Third trimester non-stress tests and ultrasounds for growth 1, 5

For Chronic Hypertension:

• Medication review: Discontinue ACE inhibitors and ARBs (teratogenic); use methyldopa, labetalol, or nifedipine 1
• Blood pressure targets: Maintain <140/90 mmHg to reduce preeclampsia risk 1
• Aspirin prophylaxis: 60-150 mg daily starting at 12-16 weeks for preeclampsia prevention 5
• Monitoring: Frequent blood pressure checks, urine protein assessment, fetal growth surveillance 2, 5

For Previous Adverse Outcomes:

• Interconception care: Intensive interventions to address modifiable risk factors before next pregnancy 1
• Progesterone: Consider for history of spontaneous preterm birth 5
• Cervical length screening: Transvaginal ultrasound at 18-24 weeks if prior preterm birth 5
• Enhanced surveillance: More frequent visits and fetal monitoring 5

For Obesity (BMI ≥30):

• Preconception counseling: Weight loss before pregnancy to reduce complications 1
• Glucose screening: Early screening in first trimester plus routine screening at 24-28 weeks 1, 2
• Ultrasound limitations: Acknowledge reduced accuracy of Leopold's maneuvers and ultrasound visualization 2
• Thromboprophylaxis: Consider for BMI ≥40 or additional risk factors 5

Critical principle: Women with high-risk conditions require delivery planning specific to their conditions, often involving induction before 41 weeks based on relative risks and benefits of continued pregnancy 8, 5.