Infant Care, Child and Adolescent Care, and Prenatal Care

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Image: “A human male baby, crying.” by Evan-Amos – Own work. License: Public Domain

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Introduction

Mother and infant care begin before the actual delivery. Prenatal care revolves around screening maneuvers, counseling, education, and intervention, as well as immunization and chemoprophylaxis. Based on these guidelines, at least 13 visits to the gynecologist are scheduled for prenatal care, including preconception and postpartum visits. The first visit involves an examination to assess the health of the newborn and is scheduled three to five days after birth. Other visits are scheduled at the following time points:

• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months

Prenatal Care

Schedule for routine prenatal care is as follows:

• Monthly, until 28 weeks estimated gestational age (EGA)
• Bimonthly, from 28—36 weeks EGA
• Weekly until delivery

This schedule is for a normal, healthy woman. Those with a history of diabetes and complicated pregnancies may require customized care and several appointments.

Milestones for visits

Each visit consists of all or at least one of the following:

• Screening maneuvers
• Counseling, education, and intervention
• Immunization and chemoprophylaxis

The recommended visits to a gynecologist before and during pregnancy are discussed in the subsequent sections.

Preconception Visit

A. Screening maneuvers

1. Profile assessment to check for the following preconception risks:

• Infectious diseases
• Genetic diseases
• Potential for vaginal birth after Cesarean (VBAC)
• Workplace and lifestyle hazard assessment
• Preterm labor

2. Screening maneuvers may also include the following assessments:

• Blood pressure
• History and physical examination
• Rubella
• Varicella
• Cervical cancer
• Domestic violence
• Depression

B. Counseling, education, and intervention

Counseling on the following topics are undertaken to further educate the expectant mother:

• Preterm labor
• Substance use/abuse
• Domestic violence
• Nutrition and weight
• Need for recording menstrual dates
• Medications, herbal supplements, and vitamins

C. Immunization and chemoprophylaxis

Education regarding the use of the following:

• Tetanus booster
• Varicella/VZIG
• Influenza
• Pertussis
• Nutritional supplements

Details of each visit are outlined in the subsequent sections.

Visit 1 (6–8 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Blood pressure
• History and physical examination
• Rubella
• Varicella
• Cervical cancer
• Domestic violence
• Depression
• Gonorrhea/chlamydia
• Complete blood count (CBC)
• ABO/Rh testing
• Urine culture
• Viral hepatitis
• Syphilis
• Blood lead levels
• HIV

B. Counseling, education, and intervention:

The following aspects are addressed:

• Preterm labor and VBAC
• Fetal aneuploidy screening
• Prenatal and lifestyle education
• Physical activity
• Follow-up of modifiable risk factors
• Warning signs
• Nutrition
• Nausea and vomiting
• Course of care
• Pregnancy physiology

C. Immunization and chemoprophylaxis

Education regarding the use of the following:

• Tetanus booster
• Varicella/VZIG
• Influenza
• Pertussis
• Nutritional supplements

Visit 2 (10–12 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Blood pressure
• Weight
• Auscultation of fetal heart tones
• Fetal aneuploidy screening

B. Counseling, education, and intervention

The following aspects are addressed:

• Preterm labor
• Prenatal and lifestyle habits
• Fetal growth
• Breastfeeding
• Review lab results from visit 1
• Pregnancy physiology
• Nausea and vomiting
• Follow-up of modifiable risk factors

Visit 3 (16–18 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Weight and blood pressure
• Fetal aneuploidy screening
• Auscultation of fetal heart tones
• OB ultrasound (optional)
• Depression
• Cervical assessment
• Fundal height

B. Counseling, education, and intervention

The following topics should be addressed:

• Preterm labor education
• Preterm labor prevention
• Prenatal and lifestyle education
• Follow-up of modifiable risk factors
• Physiology of pregnancy
• Second-trimester growth
• Quickening

C. Immunization and chemoprophylaxis

Progesterone is recommended for women at high-risk for preterm delivery

Visit 4 (22 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Weight and blood pressure
• Fundal height
• Fetal heart tones
• Cervical assessment

B. Counseling, education, and intervention

The following aspects are addressed:

• Preterm labor education
• Prenatal and lifestyle education
• Follow-up of modifiable risk factors
• Family issues
• Classes
• Length of stay
• Gestational diabetes mellitus
• Preterm labor prevention

C. Immunization and chemoprophylaxis

• Rho(D) immune globulin

Visit 5 (28 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Preterm labor risk
• Weight and blood pressure
• Fundal height
• Fetal heart tones
• Gestational diabetes mellitus
• Domestic violence
• Depression
• Rh antibody status
• Gonorrhea/chlamydia
• Hepatitis B surface antigen

B. Counseling, education, and intervention

The following aspects are addressed:

• Psychosocial risk factors
• Preterm labor education
• Awareness of fetal movement
• Preterm labor prevention
• Prenatal and lifestyle education
• Follow-up of modifiable risk factors
• Work
• Pregnancy physiology
• Preregistration
• Fetal growth

C. Immunization and chemoprophylaxis

Education regarding the following aspects:

• ABO/Rh/Ab
• Rho(D) immune globulin
• Hepatitis B surface antigen

Visit 6 (32 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Weight and blood pressure
• Fetal heart tones
• Fundal height

B. Counseling, education, and intervention

The following aspects are addressed:

• Preterm labor education
• Prenatal and lifestyle education
• Follow-up of modifiable risk factors
• Travel
• Sexuality
• Contraception
• Episiotomy
• Pediatric care
• Labor and delivery issues (preterm labor prevention)
• Warning signs of pregnancy-induced hypertension
• VBAC

Visit 7 (36 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Weight and blood pressure
• Fundal height
• Fetal heart tones
• Fetal position
• Cervix exam
• Culture for group B strep

B. Counseling, education, and intervention

The following aspects are addressed:

• Prenatal and lifestyle education
• Follow-up of modifiable risk factors
• Postpartum care
• Management of late pregnancy symptoms
• Contraception
• When to call provider
• Discussion of postpartum depression

Visit 8–11 (38–41 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Weight and blood pressure
• Fundal height
• Fetal heart tones
• Cervix exam

B. Counseling, education, and intervention

Prenatal and lifestyle education includes the following:

• Follow-up of modifiable risk factors
• Infant CPR
• Postpartum vaccinations
• Post-term management
• Labor and delivery update
• Breastfeeding

Visit Post-Partum (4–6 Weeks)

A. Screening maneuvers

Profile assessment to check for the following aspects:

• Cervical cancer screening
• Gonorrhea/chlamydia
• Height and weight
• History and physical examination
• Gestational diabetes mellitus
• Domestic violence
• Depression

B. Counseling, education, and intervention

The following aspects are addressed:

• Contraception
• Postpartum depression
• Breastfeeding concerns and support

C. Immunization and chemoprophylaxis

• Tetanus/Pertussis

Diet in Pregnancy

Foods are broadly categorized based on their safety profiles as follows:

Safe: Moderate caffeine intake, artificial sweeteners, fish maximum 12 oz per week

Unsafe: Saccharine, unpasteurized foods, swordfish, shark, or raw fish.

Weight gain goals in pregnancy are as follows:

• Normal: 25–35 lbs.
• Overweight: 15–25 lbs.
• Obese: 11–20 lbs.

Other counseling during pregnancy may include the following instructions/topics:

• Air travel is safe for the fetus for up to 36 weeks EGA
• Moderate exercise for 30 minutes on most days of the week
• Avoid hair treatment
• Avoid hot tubs and saunas during the first trimester of pregnancy
• Acetaminophen is the safest drug for pain relief
• Inclusion of vitamin B6 and change in dietary patterns are recommended for moderate nausea and vomiting

Examination of the Healthy Infant

Schedule for examination is as follows:

• 3–5 days after birth
• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months

Breastfeeding

Recommended as exclusive feeding for 6 months, with continuation through one year of age

Benefits for the infant

Decreased risk of the following conditions:

• Asthma
• Obesity
• Diabetes
• Infections
• SIDS

Benefits for the mother

Breastfeeding offers the following benefits to the mother:

• Decreased risk of ovarian and breast cancer
• Improved bonding

 

Screening for neonatal jaundice

The following aspects should be kept in mind:

• Preterm infants at high-risk for jaundice should be monitored every 8–12 hours
• Nanograms based on hours since birth should be used for risk stratifications and to initiate phototherapy
• Coombs test should be performed to check for rising bilirubin levels

Infants with glucose-6-phosphate dehydrogenase (G6PD) deficiency are at high risk of developing hyperbilirubinemia. Infants who are deficient in G6PD require intervention at lower bilirubin concentration.

Prevention and treatment of neonatal jaundice

The following aspects should be kept in mind:

• Maintain 8—12 breastfeeds per day
• Do not reduce breastfeeding in the case of mild jaundice

Treatment in the case of neonatal jaundice

Recommendations for the treatment of neonatal jaundice are as follows:

• Infants with severe hyperbilirubinemia or high risk of developing severe hyperbilirubinemia should undergo intensive phototherapy
• Most cases do not require admission to a neonatal intensive care unit (NICU) admission; however, careful monitoring is a must

Addressing Concerns During Infancy

The following precautions should be taken regarding sleep:

• Always on back to prevent sudden infant death syndrome (SIDS)
• Avoid blankets, toys, and bumpers
• Ensure 14–17 hours of sleep daily (newborns)
• Ensure 12–15 hours of sleep daily (infants)
• Mindful of infants with inadequate night waking by the age of six months
• Watch out for parental anxiety and burnout
• Emphasize bedtime routine

Pacifier use is associated with the following:

• Improvement in the risk of SIDS through six months
• Increased risk of otitis media and wheezing
• Dental malocclusion

Start weaning off the use of pacifiers at six months.

Vaccinations

The following should be borne in mind regarding vaccines:

• Infants and children are most vulnerable to potentially life-threatening diseases.
• Recommended vaccination schedules are aimed at the prevention of diseases
• The previous connection between autism and vaccination has been disproved
• Maintain adherence to CDC/ACIP recommendations

Failure to thrive (FTT)

If a child’s weight is less than that of other children of similar age and gender, it indicates that the child is failing to thrive. Measurements for FTT include both the current weight and rate of weight gain. Social issues are responsible for over 80% of cases of FTT.

FFT can be due to medical causes, which include the following:

• Genetic diseases such as Down syndrome
• Endocrine problems
• Organ problems
• Blood disorders
• Heart or lung problems affecting blood circulation and oxygenation
• Damage to the brain or CNS resulting in feeding difficulties
• Gastrointestinal problems such as lack of digestive enzymes
• Chronic infections
• Metabolic problems
• Low birth weight

FTT could be a result of the following factors in a child’s environment:

• Lack of emotional bond between the parent and child
• Child-caregiver-related problems
• Poverty
• Exposure to infections, toxins, and parasites
• Lack of the parents’ understanding regarding the child’s nutritional needs
• Poor and erratic eating habits

Often times, the cause cannot be determined. Laboratory tests for FTT include CBC, CMP, UA, urine culture, TSH, and ESR. Laboratory tests identify the cause of FTT in only 1% of cases.

Examination of Healthy Children and Adults

Important parameters during early childhood include screening for the following:

• Birth history
• Development
• Home environment
• School readiness
• Diet
• Physical activity
• Sleep

Head to toe examination include the following:

• BMI
• Cardiac exam
• Hips (through age 2 years)
• Genitalia

Recommended screening exams for children are as follows:

• Hgb at one year (often done annually through the age of five years)
• Consider fluoride varnish at the of age six months to five years
• Hearing and vision tests by the age of four years
• Lipid screening between the ages of nine and eleven years and during late adolescence
• Lead levels
• Tuberculosis

Vaccinations

The first dose of the meningococcal vaccine should be given between the ages of 11 and 12 years, followed by a booster dose at 16 years. For other vaccinations, the CDC/ACIP recommendations should be adhered to.

Autism spectrum screening

USPSTF does not recommend screening for autism. AAP recommends the validated tool between 18 and 24 months of age.

Early invasive behavioral therapy (> 25 hours/week) results in an improvement in the following aspects:

• Language ability
• Cognitive ability
• Adaptability

The following screening exams are recommended in adolescents:

• BMI at every general exam
• Chlamydia and gonorrhea screening in sexually active women
• Drugs
• Alcohol
• Home and environment
• Education and employment
• Depression
• Monitoring daily activities

Risky behavior among adolescents consists of the following:

• Alcohol use
• Drug use
• Sexual activity