Infant Care, Child and Adolescent Care, and Prenatal Care

Table of Contents

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

Introduction

Mother and infant care start before the time of delivery. Prenatal care revolves around screening maneuvers, counseling, education and intervention, and immunization and chemoprophylaxis. Based on the guidelines, a minimum of 13 visits to the gynecologists is scheduled for prenatal care, including the preconception and postpartum visit. The first examination visit for ensuring the health of an infant is scheduled after 3—5 days of birth. Other visits are scheduled as follows:

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

Prenatal Care

Schedule for Routine prenatal care

Monthly through 28 weeks EGA
Bimonthly 28—36 weeks EGA
Weekly until delivery

This schedule is for a normal healthy woman. Those with a history of diabetes and complicated pregnancy may require more care and various appointments.

Landmarks for visits

Each visit consists of all or at least 1 of the following:

Screening maneuvers
Counseling, Education, and Intervention
Immunization and Chemoprophylaxis

Following are the landmarks of visits to a gynecologist before and during pregnancy:

Preconception Visit

A. Screening maneuvers

1. Profile assessment is completed to check for the following preconception risks

Infectious disease risk
Genetic risk
The potential for vaginal birth after Caesarean (VBAC)
Workplace and lifestyle hazard assessment
Preterm labor risk

2. Other screening maneuvers include

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

B. Counseling, Education, and Intervention: Information and counseling on following are conveyed to the expecting 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

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

Visit 1 (6–8 weeks)

A. Screening maneuvers

Profile assessment is completed to check for the following risks:

Blood pressure
History and physical
Rubella
Varicella
Cervical cancer screening
Domestic violence
Depression
GC/Chlamydia
CBC
ABO/Rh/Ab
Urine culture
Viral hepatitis
Syphilis
Blood lead screening
HIV

B. Counseling, Education, and Intervention

Preterm labor and VBAC
Discuss 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

Tetanus booster
Varicella/VZIG
Influenza
Pertussis
Nutritional supplements

Visit 2 (10–12 weeks)

A. Screening maneuvers

Blood pressure
Weight
Auscultation of fetal heart tones
Fetal aneuploidy screening

B. Counseling, Education, and Intervention

Preterm labor education
Prenatal and lifestyle education
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

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

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

Weight and blood pressure
Fundal height
Fetal heart tones
Cervical assessment

B. Counseling, Education, and Intervention

Preterm labor education
Prenatal and lifestyle education
Follow-up of modifiable risk factors
Family issues
Classes
Length of stay
GDM
Preterm labor prevention

C. Immunization and Chemoprophylaxis

Rho D Immune Globulin

Visit 5 (28 weeks)

A. Screening maneuvers

Preterm labor risk
Weight and Blood Pressure
Fundal height
Fetal heart tones
Gestational diabetes mellitus
Domestic violence
Depression
[Rh antibody status]
[GC/Chlamydia]
[Hepatitis B surface Ag]

B. Counseling, Education, Intervention

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

ABO/Rh/Ab
Rho D Immune Globulin
Hepatitis B Ag

Visit 6 (32 weeks)

A. Screening maneuvers

Weight and Blood Pressure
Fetal heart tones
Fundal height

B. Counseling, Education, Intervention

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

Weight and Blood Pressure
Fundal height
Fetal heart tones
Confirm fetal position
Cervix exam
Culture for group B strep

B. Counseling, Education, Intervention

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

Weight and Blood Pressure
Fundal height
Fetal heart tones
Cervix exam

B. Counseling, Education, Intervention

Prenatal and lifestyle education

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

Cervical cancer screening
GC/Chlamydia
Height and weight
History and physical
Gestational diabetes mellitus
Domestic violence
Depression

B. Counseling, Education, Intervention

Contraception
Postpartum depression discussion
Breastfeeding concerns and support

C. Immunization and Chemoprophylaxis

Tetanus/Pertussis

Diet in Pregnancy

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

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

Weight gain goals in pregnancy:

Normal: 25-35 lbs.
Overweight: 15-25 lbs.
Obese: 11-20 lbs.

Other counseling in pregnancy:

Air travel is safe for the fetus for up to 36 weeks
Moderate exercise for 30 minutes on most days of the week
Avoid hair treatment
Hot tubs and saunas are to be avoided during the first trimester of pregnancy
Acetaminophen is the safest drug for pain relief
Vitamin B6 and change in dietary pattern is recommended for moderate nausea and vomiting.

Examination of the Healthy Infant

Schedule

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 age 1 year.

Benefits for the infant

Decreased risk of:

Asthma
Obesity
Diabetes
Infections
SIDS

Benefits for the mother

Decreased risk of ovarian and breast cancer
Improved bonding

Screening for neonatal jaundice

Preterm infants at high-risk monitor for jaundice in hospital every 8-12 hours

Use nanograms based on hours since birth for risk stratifications and choice to initiate phototherapy.

Do blood group and Coombs testing to check for rising bilirubin.

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

Prevention and treatment of neonatal jaundice

8—12 breast feeds per day

Do not reduce breastfeeding in the case of mild jaundice

The recommendation for treatment in the case of neonatal jaundice

Infants with severe hyperbilirubinemia or a high risk of developing severe hyperbilirubinemia should undergo intensive phototherapy.

Most cases do not require a neonatal intensive care unit (NICU) admission, but careful monitoring is a must.

Addressing concerns during infancy

Sleep

Always on back to prevent Sudden infant death syndrome
Avoid blankets, toys, bumpers
14-17 hours per day (newborns)
12-15 hours per day (infants)
Most infants with inadequate night waking by age 6 months
Watch out for parental anxiety and burnout.
Emphasize bedtime routine

Pacifier use

Improves risk of SIDS through 6 months
May increase the risk of otitis media and wheezing
Dental malocclusion is more common with pacifiers than thumb sucking
Start weaning off pacifier at 6 months

Vaccinations

Baby receiving scheduled vaccine injection on thigh muscle.

Infants and children are most vulnerable to potentially life-threatening diseases. Recommended vaccination schedules are aimed at the prevention of such 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 other children of similar age and gender, it means the child is failing to thrive. Measurements for FTT include both the current weight and the rate of weight gain.

Causes

Social issues are responsible for over 80 % of cases of FTT.

FFT can be due to medical causes. These include:

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

FTT could be a result of child’s environment:

Lack of emotional bond between parent and child
Child-caregiver related problems
Poverty
Exposure to infections, toxins, and parasites.
Lack of understanding on parents behalf regarding child’s nutritional needs
Poor eating habits such as not having formal meal timings

Many times, the cause cannot be determined.

Lab testing for FTT: CBC, CMP, UA and culture, TSH, ESR

Lab testing identifies the cause of FTT in only 1 % of routine cases.

Examination of healthy children and adults

Important screening during early childhood

Birth history
Development
Home environment
School readiness
Diet
Physical activity
Sleep

Head to toe examination

BMI
Cardiac exam
Hips (through age 2 years)
Genitalia

Recommended screening exams among children

Hgb at one year (often done annually through age 5 years)
Consider Fluoride varnish at age 6 months to 5 years
Hearing and vision tests by 4 years
Lipid screening – 9—11 years of age and again in late adolescence
Lead, T.B screening in at-risk children

Vaccinations

The first dose of Meningococcal vaccines is given at age 11 through 12 years, followed by a booster dose at 16 years of age.

For other vaccinations, maintain adherence to CDC/ACIP recommendations.

Autism spectrum screening

USPSTF does not recommend screening for Autism.

AAP recommends validated tool at age 18 and 24 months

Early invasive behavioral therapy (> 25 hours/week) results in better:

Language ability
Cognitive ability
Adaptability

Recommended screening exams among adolescents

BMI at every general exam
Chlamydia and gonorrhea screening among sexually active females
Drugs
Alcohol use
Home and Environment
Education and employment
Depression
Activities

Risky behavior among adolescents

Alcohol
Drugs
Sexual activity