At the first prenatal visit, take a careful history, looking for factors that might increase the risk for the pregnant woman.
Many providers use a questionnaire, filled out by the patient, as a starting point for this evaluation. A sample Prenatal Registration and Obstetrical Questionnaire form can be used for this purpose.
Prenatal Registration and Obstetrical Questionnaire
Early in pregnancy, often at the first prenatal visit, a complete physical exam is performed. At that time, a Pap smear (when indicated) and cervical cultures (for STD screening) are obtained. In many practices, an ultrasound scan is done at or shortly after the first visit to:
- Confirm intrauterine pregnancy placement
- Confirm fetal viability
- Confirm the number of fetuses
- Provide a highly reliable estimate of gestational age
Document your findings in a structured flow-sheet. Many offices and hospitals have developed their own, but one is shown here:
In many areas, electronic medical records are used rather than paper charts. In those situations, there will likely be a pregnancy template that will be used. But the fields are the same and the content will be the same.
There are so many issues to cover during the first prenatal visit (history, physical, labs, patient education, paperwork), that some physicians schedule two “first prenatal visits.”
One important aspect of prenatal care is education of the pregnant woman about her pregnancy, danger signs, things she should do and things she should not do.
Many providers find it useful to give the woman printed material covering these issues that she can take with her. This allows her to read the material at a later time and to refer to it whenever she has questions. One example of a Prenatal Information form can be viewed here.