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U NITED STATES DEPARTM ENT OF LABOR F rances Perkins, Secretary CH ILD R E N ’S BUREAU K atharine F. L enroot, Chief T Standards of Prenatal Care An Outline fo r the Use o f Physicians Bureau Publication N o. 153 T United States Government Printing Office Washington : 1940 For sale by the Superintendent of Documents, Washington, D. C. 2 .n https://fraser.stlouisfed.org Be. Reserve Bank of St. Louis Federal Price 10 cents LETTER OF TR A N SM ITTAL U n it e d States D epartm ent of L abor, C h il d r e n ’ s B u r e a u , , Washington April 19, 1940. Transmitted herewith is the pamphlet, Standards of Prenatal Care, with a revised Maternity Record Form. The pamphlet, first published in 1925, was the work of a committee, headed by Robert L. DeNormandie, M . D., which was appointed at the suggestion of directors of State bureaus of child hygiene to draw up standards of prenatal care for the use of physicians. Both the revision of 1939 and the present revision were made by Edwin F. Daily, M . D., Director of the Maternal and Child Health Division of the Children’s Bureau, with the assistance of the Bureau’s advisory com mittee o f obstetricians: Fred L. Adair, M . D., Robert L. DeNormandie, M . D., and James R . McCord, M. D. Respectfully submitted. K a t h a r in e F. L e n r o o t , M adam : Chief. Hon. F r a n c e s P e r k in s , Secretary of Labor. ii https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Standards o f Prenatal Care Prenatal care is that part o f maternal care which has as its object the complete supervision o f the pregnant woman in order to preserve the life, health, and happiness o f the mother and child. All pregnant women should be under medical supervision during their entire pregnancy, at the time o f delivery, and during the puerperium. It is only by thorough pre natal care that diseases which may cause death or disability o f either the mother or the child may be avoided, arrested, or cured, and that the woman may maintain a physical condition that will enable her to with stand the unavoidable strain associated with labor and delivery. The physician at the first visit should obtain and record the facts con cerning the patient’s past history and present pregnancy. Past History Illnesses, particularly the following: Tuberculosis or exposure to tuberculosis. Scarlet fever. Tonsillitis or other focal infections. Rheumatic fever. Cardiovascular and renal disease (including hypertension). Venereal disease. Operations and accidents, especially those o f the abdomen and pelvis (date, attendant, and results). Menstrual history (cycle, amount o f flow, duration, and pain). Previous pregnancies and labors. Pertinent data regarding pregnancy should be recorded: D ate o f termination. Period o f gestation. each previous Complications during pregnancy (including abortion). Labor. Onset— normal or induced. Character. Duration. Termination o f labor. Normal or artificial. I f artificial, what method was used? Other complications. Puerperium. Infection* Hemorrhage. Other complications. Treatment or operations as a result o f these complications. Infant. Live born or stillborn. Weight. I f live born: Breast fed— yes or no. Alive now? 215821°—40 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis I f dead, give cause and age at death. I 2 STANDARDS OF PRENATAL CARE History o f Present Pregnancy D ate o f last normal menstruation. Estimated date o f delivery. Symptoms or complaints: Dizziness. Headaches. Persistent? Disturbed vision. Palpitation or dyspnea. Cough and sputum. Nausea and vomiting. Diarrhea or constipation. Vaginal discharge. Bleeding. Dysuria (frequency, amount). Edema (site). Cramps in extremities. Physical Examination The physician should then proceed to the physical examination and record the following: Systolic and diastolic blood pressure. Temperature. Pulse rate. W eight. Record whether dressed or undressed. Relation o f present weight to usual weight. Height. General appearance and nutrition o f patient. Skin. Ears and hearing. Eyes and vision. Nose and throat. M outh (teeth and gums). Neck (lym ph nodes and thyroid). Breasts. Heart (auscultation, percussion). Lungs (auscultation, percussion). Abdomen (inspection, palpation, fetal heart rate). Spine and posture. Extremities. Vaginal examination: T o determine the existence o f a pregnancy (and whether it is uterine or ectopic). T o determine the size and position o f the uterus. T o determine the size o f the birth canal and type o f pelvis— B y measuring the diagonal conjugate (distance from sacral promontory to lower margin o f symphysis pubic.) B y measuring the transverse diameter o f the outlet (the distance between the ischial tuberosities). T o discover any pelvic disease or tumor. T o find any evidence o f venereal disease, and if suspected to take smears. Speculum examination o f the cervix and vagina is essential in early pregnancy as a routine procedure. In case o f vaginal bleeding or im pending labor at any period o f ges tation only rectal or aseptic vaginal examination should be made. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY RECORD FORM .................................................................... ...................... ,________________________ N ame A ddress a n d tele ph on e n o . . __________ A o e Married □ . ............... Single Referred by □ .........................IU cB Date of first visit Date'of last period Estimated date of delivery _______ ________________________ Plans to be delivered by................................................. ....................Home .□ Hospital □ Previous illnesses and operations Now living No. born alive ■Now dead Under 7 mos. No. born dead ■7 mos. or more Previous pregnancies and deliveries (date, complications, results) Present pregnancy : Symptoms and complaints P H YS IC A L E X A M IN A T IO N : Date Examiner Height General appearance Skin Ears and hearing Eyes and vision Nose and throat Mouth (teeth, gums) Neck (lymph nodes and thyroid) Breasts Heart L u n g s ___________________________________ Abdomen (inspection, palpation, fetal heart rate) Spine and posture______________________________________ ____________________________ _________ Extremities Vaginal examination:___________________________ ________ -________________________________________________ Pelvic measurements: Outlet (bi-isch. tub.)___________________________Inlet (diag. con].)_______________________Type of pelvis I n it ia l E x a m in a t io n RETURN EXAMINATIONS Week of gestation. . . . Weight........................ Temperature................ Albumin.......... Date to return............. Examiner.................... L A B O R A T O R Y TESTS: Wassermann: Date______________ "___________ Result__________________________________ Hemoglobin____________________ Vaginal smear Other: 215821°— 40 (Pace p. 2 front) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis FO LLO W -U P H ISTO R Y —Prenatal and postpartum periods: Symptoms and complaints Date Findings and treatment (including diet instructions) D E L IV E R Y : Week of gestation Date Normal □ Oper, (specify) Doctor or midwife Complications Birth wt.______________Birth registered □ ______ Eye prophylaxis If stillbirth: Death ° (.during labor □ _________Abnormalities of child (specify) r Cause If neonatal death: Age______days_____ _______ If less than 1 day If maternal death : Date Place hr.________ min.______Cause Cause P O S T P A R T U M E X A M I N A T IO N ( A T A B O U T 6 W E EK S): Date_____________________________ Blood press............................................ Gen, cond. mother Perineum_______________________ _________ _____________________________ Cervix Uterus_________ ______________________________ _____________________ Adnexa Infant—Under care o f private M. D. □ Remarks: Other medical care □ .................... .......... .... ............................................ 215821°— 40 (Face p. 2 back) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis No medical care □ ........................... Examiner. _______ __________ Dead □ STANDARDS OR PRENATAL CARE 3 Laboratory Examination Taking o f blood: For Wassermann or other serologic test o f the blood for syphilis at the first visit during pregnancy. Repeat this test if the result is doubtful. For hemoglobin determination and erythrocyte and leukocyte count. Urinalysis (specific gravity, albumin, sugar). A microscopic examination o f the sediment is advisable as a matter o f routine. I f albumin is present a 24-hour specimen should be obtained. X -r a y : O f chest if pulmonary tuberculosis or cardiac disease is suspected. O f abdomen or pelvis if there is question o f multiple pregnancy, monstrosity, disproportion, or other complications. Hygiene o f Pregnancy If pregnancy is determined, minute instructions in the hygiene o f preg nancy should be given to the patient. Points covered should include: Diet, including fluids. Exercise, rest, sleep, and recreation. Clothing, including shoes. Baths and care o f the skin. Regulation o f bowel movements. Care o f the teeth. Care o f the breasts. Intercourse during pregnancy. Hygiene o f the home and preparation of home for delivery. M ental hygiene. NOTE:— Refer to publications of the United States Children’s Bureau, Wash ington, D . C .— Prenatal Care, Publication N o. 4, and W hat Builds Babies, Folder N o . 4— to publications o f State departments o f health, and to other publications on this subject. Return Visits The patient should be examined by a physician at least once a month during the first 6 months, then every 2 weeks or oftener as indicated, pref erably every week in the last 4 weeks. A properly qualified public-health nurse can be of assistance to the physician by stressing to the patient the value o f medical care early in pregnancy; by interpreting the physician’s findings; and by giving nursing supervision, care, and instruction to the patient throughout pregnancy. At each visit to the physician the patient’s general condition must be investigated, blood pressure taken and recorded, urinalysis done, pulse and temperature recorded, and weight taken. The symptoms and complaints should be discussed in detail with the patient. If the result o f the test for syphilis is positive, treatment should be started immediately and continued without interruption throughout pregnancy. The diet o f the patient should be discussed at each visit, and sudden in creases in weight should be watched for. The total gain in weight during pregnancy averages between 20 and 25 pounds, but this gain o f weight should be gradual from the third to the ninth month. External pelvimetry is only suggestive and by itself does not determine https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 STANDARDS OF PRENATAL CARE whether any disproportion is present. Abdominal examination should be made as indicated. Abdominal palpation in the eighth and ninth months will show whether there is any obvious disproportion between the size of the fetal head and the pelvis. The fetal heart rate should be noted. The fetal position can be determined and sometimes malpositions may be corrected. Further information regarding descent and fixation can be obtained by rectal examination. In a primigrávida, if the presenting part is not engaged in the pelvis 2 weeks before the estimated date of delivery, the physician in charge should determine, so far as possible, whether any disproportion or malposition exists. If a disproportion is diagnosed, special care must be taken to avoid unsterile, and definitely to limit sterile, vaginal examinations immediately prior to or after the onset of labor. This precaution must be observed because of the danger o f serious infection should operative procedures later become necessary. The place of delivery must be planned. If the prospective labor offers a probable chance of being a difficult one, the patient should be sent to a well-equipped hospital for delivery. Early and competent consultation should be obtained for complicated cases. Pregnancy is a physiologic condition, but there is no condition which so quickly may become pathologic. It is therefore necessary to instruct each patient at her first visit to report at once to the physician anything that may affect her well-being, especially the following symptoms: 1. Obstinate constipation. 2. Shortness o f breath. 3. Acute illnesses, especially colds, sore throat, and persistent cough. 4. Persistent or recurring headache. 5. Recurring nausea or vomiting. 6. Visual disturbances. 7. Dizziness. 8. Pain in the epigastrium. 9. Edema, especially o f the face, hands, and ankles. 10. Changes in frequency o f urination, oliguria, dysuria, and so forth. 11. Severe pain in the lower abdomen. 12. Vaginal bleeding, even the slightest (spotting). In case of vaginal bleeding or low abdominal pain the patient must be instructed to go to bed at once and to send for her physician. When bleed ing from the vagina occurs, its source must be determined by examination, and the patient, if possible, should be removed to a hospital. Vaginal examinations must be made under aseptic technique, and whether they are made in the home or in a hospital means must be at hand to control possible severe bleeding. If the patient develops toxemia in the course of her pregnancy, it is only by careful medical supervision and treatment that an eclamptic condition may be prevented. Eclampsia (convulsions) can in the majority of cases https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis STANDARDS OF PRENATAL CARE 5 be prevented but only by constant vigilance combined with cooperation between the patient and the physician. If the patient is to be delivered by a licensed midwife, she should have a complete physical examination and laboratory tests made by a physician as early in pregnancy as possible. If there is any doubt whether the patient will have a normal pregnancy and delivery, arrangements should be made for regular supervision and delivery by a physician. Only by careful study of each case is it possible to determine whether the patient should be delivered at home or in a hospital. Medical, social, and economic factors should be taken into consideration in making the decision. It is only by the early and repeated examination and treatment of pros pective mothers that premature termination of pregnancies, stillbirths, and many diseases and deaths of newborn infants can be prevented. By the same methods the mothers can be spared much distress and disease and many lives can be saved which would otherwise be lost from toxemia, accidents o f pregnancy and labor, and infection. The accompanying form is suggested for use by the physician in his own practice as well as at prenatal clinics. For his convenience space has been given for entries in regard to the delivery and the postpartum period. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
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