Prenatal care

Rationale

Optimal prenatal care has the potential to reduce perinatal morbidity and mortality by identifying and reducing potential risks, treating medical conditions, providing psychosocial support, and promoting healthier lifestyles.

Key Objectives

Given a patient presenting for prenatal care, the candidate will integrate the best available evidence into a model of shared decision-making, enabling patients to make informed decisions based on their needs in all aspects of preconception, pregnancy and fetal health.

Enabling Objectives

(list not exhaustive)

Given a patient who requires prenatal care, the candidate will

1. understand and apply the principles of informed decision-making and patient-centred care, including culturally sensitive care,
2. provide care for preconception counselling (e.g., folic acid supplementation, weight management, smoking cessation),
3. establish the desirability of the pregnancy in a patient with suspected or confirmed pregnancy and construct an appropriate initial management plan,
4. provide initial and subsequent prenatal care that includes an appropriate history, physical examination, exploration of socioeconomic determinants of pregnancy outcome, counselling, and laboratory investigations, and
5. identify risk factors and common prenatal complications (e.g., hypertension, maternal age, intrauterine growth restriction) and construct a plan for both the screening and initial management of these conditions.

The candidate will also

1. list and interpret relevant clinical findings, including
   1. factors that contribute to the estimation of the date of confinement (e.g., last menstrual period, date of positive pregnancy test),
   2. results of a thorough history, including family, social, maternal health, and obstetrical aspects,
   3. results of systematic screening for tobacco, alcohol, and substance use or exposure,
   4. indications warranting referral for therapeutic abortion and counselling,
   5. use of medications and supplements and the need for appropriate counselling,
   6. findings necessitating timely counselling regarding prenatal genetic screening, including options, risks, benefits, and possible outcomes,
   7. risk factors and signs of antenatal and postpartum depression,
   8. signs of intimate partner violence,
   9. physiological changes characteristic of pregnancy and determination of whether pregnancy is progressing in an uncomplicated manner (e.g., normal pregnancy symptoms), or if complications are present (e.g., hyperemesis, pain, bleeding),
   10. monitoring aspects in the second and third trimesters, including
       1. fetal and maternal progress (e.g., weight gain, blood pressure, fetal heart rate and movement)
       2. signs and symptoms of preterm labour
       3. determination of fetal lie and presentation in the third trimester
       4. signs and symptoms consistent with the onset of labour;
2. list relevant investigations and interpret the results of the investigations, including
   1. appropriate initial diagnostic and screening tests (e.g., complete blood count, blood type, rubella status),
   2. prenatal genetic screening options (e.g., serum integrated prenatal screen, nuchal translucency),
   3. current recommendations for ultrasonography in an uncomplicated pregnancy,
   4. indications and options for additional prenatal fetal surveillance (e.g., fetal movement counting, nonstress test, biophysical profile),
   5. current recommendations regarding screening for prenatal complications and risk factors, including but not limited to
      1. hemolytic disease of the newborn (e.g., Rh isoimmunization)
      2. gestational diabetes
      3. sexually transmitted infections
      4. group B Streptococcus,
3. construct an effective initial management plan, including
   1. discussing the patient’s adjustment to pregnancy (e.g., mood, work, stress, family),
   2. counselling and referral to community resources, including
      1. prenatal and parenting classes
      2. nutrition, including micronutrients and vitamins
      3. substance use or substance use disorder
      4. lifestyle (e.g., physical activity, sexual activity, travel)
      5. breastfeeding,
   3. managing common prenatal presentations and complications (e.g., nausea and vomiting, bleeding, intrauterine growth restriction),
   4. discussing an appropriate follow-up plan for patients with a positive genetic screening result (e.g., amniocentesis, specialist referral),
   5. managing post-term pregnancy, and
   6. referring for additional or specialized care if necessary (e.g., preeclampsia, psychiatric disorders, substance use disorder).