What are the recommendations for the first pregnancy visit?

First Prenatal Visit Recommendations

The first prenatal visit should occur as soon as pregnancy is confirmed, ideally before 10 weeks gestation, and must include comprehensive laboratory screening, medical/obstetric history, physical examination, risk assessment, and initiation of prenatal vitamins with folic acid. 1, 2

Timing of First Visit

• The first prenatal visit should be scheduled immediately upon pregnancy confirmation, ideally in the first trimester before 10 weeks gestation 1, 3
• Women should not wait until 8-10 weeks for their first appointment, as this represents an office-based delay that can compromise early pregnancy care 3
• Early initiation in the first trimester is crucial for achieving adequate total prenatal visits throughout pregnancy 4

Common Pitfall: Many obstetric offices inappropriately delay the first prenatal visit to 8+ weeks gestation even for fully insured women, missing critical opportunities for early intervention 3

Essential Laboratory Testing

Comprehensive first-trimester laboratory panel must include: 1, 2

• Complete blood count (CBC)
• Blood type and antibody screen (Rh status)
• Hepatitis B surface antigen
• Rubella immunity status
• Syphilis screening
• HIV testing
• Urinalysis and urine culture
• Thyroid-stimulating hormone (TSH), particularly in women with risk factors 2
• Fasting blood glucose to screen for pre-existing diabetes 2
• Cervical cytology (Pap smear) if due 5
• Gonorrhea and chlamydia screening 1

Medical History Components

A complete medical history must address: 1

• Reproductive history: previous pregnancies, complications, pregnancy losses, interval between pregnancies
• Chronic medical conditions: diabetes, hypertension, thyroid disease, autoimmune disorders
• Current medications and potential teratogenic exposures
• Family history for genetic conditions and chromosomal disorders
• Ethnic background to guide genetic screening recommendations
• Surgical history, particularly gynecologic or abdominal procedures

Physical Examination

The initial physical examination should focus on: 1

• Periodontal examination (dental health assessment)
• Thyroid examination for enlargement or nodules
• Cardiovascular examination including blood pressure baseline
• Breast examination
• Complete pelvic examination including cervical assessment and uterine size confirmation

Psychosocial Risk Screening

Mandatory screening must include: 6, 1

• Tobacco use - current and past exposure
• Alcohol consumption - quantity and frequency
• Substance use - illicit drugs and prescription medication misuse
• Intimate partner violence and domestic abuse
• Mental health disorders - depression, anxiety, prior psychiatric history
• Housing insecurity and social support assessment
• Nutritional needs and food insecurity

Critical Note: International guidelines consistently recommend screening for 7/7 psychosocial risk factors, yet many U.S. practices fail to adequately address these during the first visit 6, 5

Prenatal Education and Counseling

Essential topics to cover at the first visit: 6, 1

• Nutrition: "five-a-day" recommendation (2 servings fruit, 3 servings vegetables), balanced diet, adequate hydration 1
• Weight gain expectations based on pre-pregnancy BMI
• Exercise recommendations - regular moderate activity appropriate for pregnancy 1
• Teratogen avoidance: alcohol, tobacco, recreational drugs, certain medications 1
• Food safety: safe preparation techniques, foods to avoid (raw fish, unpasteurized products, deli meats)
• Avoidance of hyperthermia (hot tubs, saunas) 1
• Breastfeeding benefits for mother and infant 6

Prenatal Vitamin Supplementation

Immediate initiation required: 1

• Folic acid 400-800 mcg daily - critical for neural tube defect prevention, ideally started preconception 1
• Potassium iodide 150 mcg daily for fetal thyroid development 1
• Comprehensive prenatal vitamin containing iron, calcium, and other essential nutrients

Immunization Assessment

Review and update immunization status: 1

• Influenza vaccine - administer if pregnant during flu season and not previously vaccinated 6
• Tdap vaccine - ideally between 27-36 weeks, but can discuss timing at first visit 6
• Hepatitis B, rubella, and varicella - assess immunity; vaccinate postpartum if seronegative (live vaccines contraindicated during pregnancy) 1, 2

High-Risk Condition Identification

Special considerations requiring immediate intervention: 1

Pre-existing Diabetes

• Target hemoglobin A1C <6.5% to reduce congenital anomalies, preeclampsia, and preterm birth 1
• Establish multidisciplinary care team (endocrinologist, maternal-fetal medicine, dietitian, diabetes educator) 1
• Initiate fasting and postprandial glucose monitoring with specific targets 1
• Schedule dilated eye examination in first trimester 1

Chronic Hypertension

• Obtain baseline labs: CBC, liver enzymes, renal function, uric acid 2
• Initiate low-dose aspirin 81-150 mg daily starting at 12-16 weeks for preeclampsia prevention 1

Systemic Lupus Erythematosus

• Order antiphospholipid antibody panel and anti-Ro/SSA, anti-La/SSB antibodies early 2

Establishing Ongoing Care Schedule

For low-risk pregnancies, schedule visits: 4

• Monthly until 28 weeks gestation 4
• Every 2 weeks from 28-36 weeks 4
• Weekly from 36 weeks until delivery 4

Alternative evidence-based approach: 8-10 visits produce equivalent maternal and neonatal outcomes for low-risk women, though this may reduce patient satisfaction in some populations 4

Critical Pitfalls to Avoid

• Failure to provide preconception counseling for women with chronic conditions who present already pregnant 1
• Inadequate psychosocial screening - studies show <5% of clinics ask about smoking, alcohol, or medical conditions during scheduling calls 3
• Omitting vitamin counseling - 88% of clinics fail to mention prenatal vitamins when scheduling first appointments 3
• Delayed screening in high-risk women - women with BMI ≥30 or prior gestational diabetes require early glucose testing at 12-14 weeks, not just at 24-28 weeks 4
• Incomplete adherence to guidelines - research shows many first visits omit components of physical examination, pregnancy education, and prenatal screening despite guideline recommendations 5

Documentation Requirements

Establish and document: 6

• Medical home for ongoing prenatal care
• Emergency contact instructions and after-hours care access
• Plan for subsequent visit schedule based on risk stratification
• Referrals to specialists if high-risk conditions identified