1. Patient identifying data
2. Confirmation of dates: A menstrual history should be taken to decide when the last period was and its regularity. Naegele's rule (add 1 week, subtract 3 months) can be used to predict the date of delivery, and can be confirmed with ultrasound.
3. Past Obstetrical History
- How many pregnancies has the woman had?
- What were the dates, gestational ages at delivery, and birthweight?
- What types of deliveries, or complications were there?
6. Visit log: It would be super to keep track of gestational age, symphysis-fundal height, wt, BP, FHR and stuff in a visit log.
7. Frequency of visits: The initial assessment should happen before 12 weeks. Thereafter, assessments should happen every 6 weeks to 28 weeks, then every two weeks to 36 weeks, then weekly until delivery. Other testing should be ordered as necessary. Women should also receive date-confirmation and anatomy ultrasounds, as well as screening for genetic anomalies and gestational diabetes.
The ultrasound is a useful tool for assessing shit in the pregnant woman. The following markers are useful:
- 11-14 wk: Used to assess nuchal translucency (NT) and expected dates.
- 16-20 wk: An anatomical survey is done of the intracranial contents, spine, face, limbs, 4 chamber heart, outflow tracts, 3 vessel umbilical cord, kidneys, bladder, and stomach. Also, the placental location is assessed.
- Third trimester: Done case by case, and used to follow growth and recheck any abnormalities spotted on earlier ultrasounds.