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## Complete Summary

#### GUIDELINE TITLE

DoD/VA clinical practice guideline for management of uncomplicated
pregnancy.

#### BIBLIOGRAPHIC SOURCE(S)

U.S. Department of Veteran Affairs, Veterans Health Administration,
Veterans Health Administration. DoD/VA clinical practice guideline for
the management of uncomplicated pregnancy. Washington (DC): Department
of Veteran Affairs; 2002 Oct. Various p. \[533 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [September 11, 2007, Rocephin (ceftriaxone
    sodium)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Rocephin):
    Roche informed healthcare professionals about revisions made to the
    prescribing information for Rocephin to clarify the potential risk
    associated with concomitant use of Rocephin with calcium or
    calcium-containing solutions or products.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Uncomplicated pregnancy (*Evaluation; Screening; Risk
    Assessment/Prognosis; Management*)

-   Complications of pregnancy (*Screening; Prevention*)

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Obstetrics and Gynecology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To provide a scientific evidence-base for practice interventions and
    evaluations

-   To enhance patient education so that pregnant women and their
    providers will each be aware of the specific expectations for every
    visit, thus promoting a partnership with a common goal of a healthy
    infant and mother

-   To improve patient and provider satisfaction with antenatal care
    from initial encounter in the clinic through parturition by
    providing an overview of screening and monitoring options as well as
    discussion about general clinical approaches to uncomplicated
    pregnancy

-   To change the traditional interval-based visit template to a system
    with specific gestational age visits, each having a specific
    well-defined goal and objectives

#### TARGET POPULATION

Pregnant female patients eligible for care in the Department of
Defense/Veterans Administration (DoD/VA) health care delivery system

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Interventions at All Visits**

1.  Screening for hypertensive disorders of pregnancy

2.  Breastfeeding education

3.  Exercise during pregnancy

4.  Influenza vaccine (season-related)

5.  Referral to a specialist if client no longer meets criteria for
    uncomplicated pregnancy

**Interventions at First Visit (6-8 Weeks)**

1.  Self-questionnaire of prenatal risk factors

2.  Selected history taking

3.  Selected physical examination (thyroid disorders, hypertension,
    sexually transmitted disease, body mass index \[BMI\], vital signs,
    domestic violence, blood pressure, cardiac abnormality, vaginal
    bleeding, pelvic exam, dating criteria)

4.  Screening for tobacco use -- offer cessation

5.  Screening for alcohol use -- offer cessation

6.  Screening for drug abuse -- offer treatment

7.  Screening for domestic abuse

8.  Screening for Rh Status

9.  Screening for rubella

10. Screening for varicella

11. Screening for hepatitis B

12. Screening for syphilis rapid plasma regain (RPR)

13. Screening for asymptomatic bacteriuria (ASB)

14. Screening for human immunodeficiency virus (HIV) -- Counsel

15. Immunization -- tetanus diphtheria (Td) booster (first trimester)

16. Immunization -- hepatitis B (first trimester)

17. Laboratory testing as indicated (Glucola for gestational diabetes
    mellitus \[GDM\], cervical smear, complete blood count \[CBC\], ABO
    Rh blood typing, rapid plasma reagent \[RPR\], rubella test,
    hepatitis B surface antigen test, gonorrhea and Chlamydia test,
    urinalysis and culture, antibody screen

**Interventions at First Visit with Provider (10-12 Weeks)**

1.  Assessing inappropriate weight gain

2.  Auscultation fetal heart tones

3.  Screening fundal height

4.  Screening for gonorrhea

5.  Screening for chlamydia

6.  Screening for cervical cancer

7.  Counseling for cystic fibrosis screening

**Interventions (Weeks 16-27)**

1.  Maternal serum analyte screening

2.  Routine ultrasound

3.  Counseling for family planning

4.  Educate regarding preterm labor

**Interventions (Weeks 28-36)**

1.  Assess for preterm labor

2.  Daily fetal movement counts

3.  Screening for gestational diabetes

4.  Iron supplementation

5.  Anti-D prophylaxis for Rh-Negative pregnant women

6.  Screening for Group B Streptococcus (GBS)

7.  Assessment of fetal presentation

**Interventions (Weeks 38-41)**

1.  Weekly cervical check (stripping)

2.  Post-dates antenatal fetal testing

**Guideline Developer Recommendation *against* the Following
Interventions During Pregnancy**

1.  Screening with fetal fibronectin

2.  Cervical examination

3.  Antenatal pelvimetry

4.  Routine urine dipstick test

5.  Routine edema evaluation

6.  Screening for cytomegalovirus (CMV)

7.  Screening for parvovirus

8.  Screening for toxoplasmosis

9.  Screening for bacterial vaginosis

10. Vitamin supplementation

11. Immunization -- measles, mumps, rubella (MMR)

12. Immunization -- Varicella

13. Ultrasound (US) evaluation of cervical length at week 24

14. Repeat screening for anemia, syphilis, and isoimmunization

15. Screening for hypothyroidism

#### MAJOR OUTCOMES CONSIDERED

-   Maternal, fetal, and neonatal outcomes (morbidity, mortality,
    complications of pregnancy)

-   Patient and provider satisfaction

-   Identification of high-risk pregnancies

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Institute for Clinical Systems Improvement (ICSI) - *Health Care
Guideline: Routine Prenatal Care* (2000) was identified by the Working
Group as an appropriate seed guideline. It served as the starting point
for the development of questions and key terms.

Fifty-six researchable questions and associated key terms were developed
by the Working Group after orientation to the seed guideline and to
goals that had been identified by the Working Group. The questions
specified:

-   Population - characteristics of the target population

-   Intervention - diagnostic, screening, therapy, and assessment

-   Control - the type of control used for comparison

-   Outcome - the outcome measure for this intervention (morbidity,
    mortality, patient satisfaction, and cost)

A systematic search of the literature was conducted. It focused on the
best available evidence to address each key question, and ensured
maximum coverage of studies at the top of the hierarchy of study types:
evidence-based guidelines, meta-analyses, and systematic reviews
(Cochrane, EBM, and EPC reports). The Institute for Clinical Systems
Improvement (ICSI) Guideline evidence was carefully reviewed. The
Working Group agreed that ICSI, Cochrane, or other meta-analyses
addressed 32 of the questions. Three questions were not researched
because legal mandates preclude debate.

At this point, the focus shifted to the 21 remaining questions that
required further study. The search continued using well-known and widely
available databases that were appropriate for the clinical subject.
Limits on language (English), time (1990 through June 2001) and type of
research (randomized controlled trials \[RCT\]) were applied. The search
included MEDLINE and additional specialty databases, depending on the
topic.

The search strategy did not cast a wide net. Once definitive clinical
studies that provided valid relevant answers to the question were
identified, the search stopped. It was extended to studies/reports of
lower quality (observational studies) only if there were no high quality
studies.

The results of the search were organized and reported using reference
manager software. At this point, additional exclusion criteria were
applied. Typical exclusions were studies with physiological endpoints,
or studies of populations that were not comparable to the population of
interest (e.g., studies of practices in Third World counties).

Evidence Appraisal Reports for each of the 21 unanswered questions were
prepared by the Center for Evidence-based Practice at the State
University of New York, Upstate Medical University, Department of Family
Medicine (these reports are available by request). Each report covered:

-   Summary of findings

-   Methodology

-   Search terms

-   Resources searched

-   Articles critically appraised

-   Findings

The Working Group suggested some additional references. Copies of
specific articles were provided to participants on an as-needed basis.
This document includes references through June 2001.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Practicing clinicians thoroughly evaluated the evidence-based
recommendations. The clinical experts and research team evaluated the
evidence according to criteria proposed by the U.S. Preventive Services
Task Force (USPSTF) (2001). The experts themselves, after an orientation
and tutorial on the evidence grading process, formulated Quality of
Evidence ratings, a rating of Overall Quality, a rating of the Net
Effect of the Intervention, and an overall Recommendation.

**Quality of Evidence (QE)**

**I**: Evidence obtained from at least one properly randomized
controlled trial\
**II-1**: Evidence obtained from well-designed controlled trails without
randomization\
**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group\
**II-3**: Evidence obtained from multiple time series studies with or
without the intervention. Dramatic results in uncontrolled experiments
(such as the results of the introduction of penicillin treatment in the
1940s) could also be regarded as this type of evidence.\
**III**: Opinions of respected authorities, based on clinical
experience; descriptive studies and case reports; or reports of expert
committees

**Overall Quality**

**Good**: High grade evidence (I or II-1) directly linked to health
outcome\
**Fair**: High grade evidence (I or II-1 linked to intermediate outcome
or Moderate grade evidence (II-2 or II-3) directly linked to health
outcome\
**Poor**: Level III evidence or no linkage of evidence to health outcome

**Net Effect of Intervention**

**Substantial**:

-   More than a small relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A large impact on an infrequent condition with a significant impact
    on the individual patient level

**Moderate**:

-   A small relative impact on a frequent condition with a substantial
    burden of suffering, or

-   A moderate impact on an infrequent condition with a significant
    impact on the individual patient level

**Small**:

-   A negligible relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A small impact on an infrequent condition with a significant impact
    on the individual patient level

**Zero or Negative**:

-   Negative impact on patients, or

-   No relative impact on either a frequent condition with a substantial
    burden of suffering, or

-   An infrequent condition with a significant impact on the individual
    patient level

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Guideline for the Management of Uncomplicated Pregnancy is the
product of many months of diligent effort and consensus building among
knowledgeable individuals from the Veterans Administration (VA),
Department of Defense (DoD), academia, and guideline facilitators from
the private sector. An experienced moderator facilitated the
multidisciplinary Working Group that included obstetricians, midwives,
internists, family practitioners, physician´s assistants, nurses, and
pharmacists, as well as consultants in the field of guideline and
algorithm development.

The Working Group participated in two face-to-face sessions to reach a
consensus about the guideline recommendations and to prepare a draft
document. The draft was revised by the experts through numerous
conference calls and individual contributions to the document. The
guideline presents evidence-based recommendations that have been
thoroughly evaluated by practicing clinicians.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The following rating scheme is from the U.S. Preventive Services Task
Force (USPSTF) (2001).

**Grade of Recommendation**

**A**: A strong recommendation that the intervention is always indicated
and acceptable\
**B**: A recommendation that the intervention may be useful/effective\
**C**: A recommendation that the intervention be considered\
**D**: A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I**: Insufficient evidence to recommend for or against; clinical
judgment should be used

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The final draft of the guideline is distributed for review by an at
large audience across the Veterans Administration (VA) and Department of
Defense (DoD). Patient Care Services and the Network-appointed Guideline
Champions solicit feedback from a broader group of end users. Members of
related QUERI groups are also asked to comment. Network designated staff
will be asked to use the guideline in the direct care setting and
provide feedback to the Network Guideline Champions. This portion of the
field test is intended to provide feedback regarding the format and
usability. At this time, the peer review of the guideline is also being
completed by at least three VA /DoD staff, including primary care
clinicians, who have been trained and previously assigned to perform the
independent review. Within 3 weeks, the rating tool containing the
reviewer´s comments and recommendation will be forwarded to the Office
of Quality and Performance and the Vice Chairperson of the NCPG Council.
The Vice Chairperson of the NCPG Council will forward a summary of the
recommendations from the peer reviewers to the National Champions. Final
editing incorporates feedback as appropriate. The National Senior
Champions along with the Evidence Chaperone and the NCGPC Representative
will integrate comments and suggestions into the final document as
appropriate. Discussion of serious controversies regarding
interpretation of the evidence will be included in the introduction to
the guideline and may be the subject of discussion at the time of review
with the Council. Provider tools will also be finalized and submitted to
Employee Education System for final formatting. Prior to delivery to the
NCPG Council, the champions group will re-convene by conference call to
approve the final draft and tools.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations for the management of uncomplicated pregnancy in the
primary care setting are organized into 3 major algorithms. The
algorithms, the objectives, annotations, and recommendations that
accompany them, and the evidence supporting the recommendations are
presented below. The quality of evidence (I, II-1, II-2, II-3, III),
overall quality (good, fair, poor), net effect of intervention
(substantial, moderate, small, zero or negative), strength of
recommendation grading (A-D, I) are defined at the end of the \"Major
Recommendations\" field.

*Note: A list of abbreviations is provided at the end of the \"Major
Recommendations\" field.*

[Algorithm: Management of Uncomplicated
Pregnancy](http://www.oqp.med.va.gov/cpg/UCP/up_cpg/content/algorithms/algo_fr.htm)

A.  **Confirmed Pregnancy**

> Confirmation of pregnancy is established by a confirmed positive urine
> or serum pregnancy test.

B.  **First Visit with Nurse: 6 To 8 Weeks\
    Complete Self-Questionnaire\
    Assess For Risk Factors**

> *Annotation*
>
> After confirmation of the pregnancy, the goal of the first prenatal
> contact is to exchange information and identify existing risk factors
> that may impact the pregnancy. This initial contact may be
> accomplished in a group setting or during a one-on-one visit. Table 1
> in the original guideline document contains a checklist of the data
> collected during the first visit with the nurse and/or health care
> provider (Family Practitioner, Certified Nurse-Midwife or
> Obstetrician/Gynecologist \[OB/GYN\]). These data are required to
> assess the appropriateness of using the Uncomplicated Pregnancy
> Guideline follow-up. In addition, all active duty pregnant women are
> required to have an occupational health screening per AR40-501
> exception to policy.

C.  **Are There Any Contraindications To Continue With The Uncomplicated
    Pregnancy Guideline?**

> *Annotation*
>
> **Indications for Referral to Physician on First Visit**
>
> Past OB/GYN History:

-   Prior preterm delivery (\<37 weeks)

-   Intrauterine fetal demise (IUFD) -- 10 weeks after cardiac activity

-   Prior cervical/uterine surgery

-   Prior preterm labor requiring admission (e.g., early cervical
    change)

-   Fetal anatomic abnormality (e.g., open neural tube defects in prior
    child or first degree relative)

-   Past complicated pregnancy

> Medical History:

-   Pre-existing diabetes

-   Gestational diabetes

-   HIV

-   Chronic hypertension

-   Systemic disease that requires ongoing care (e.g., severe asthma,
    lupus, and inflammatory bowel disease)

-   Current mental illness requiring medical therapy

-   Cancer

-   Seizure disorders

-   Hematologic disorders

-   Recurrent urinary tract infections/stones

> Psycho-Social:

-   Substance use disorders

-   Eating disorders

-   Postpartum depression

> Conditions in Current Pregnancy:

-   Relative body mass index (BMI) \<16.5

-   Age (\<16 or \>40 years at delivery)

-   Vaginal bleeding

D.  **Are There Absolute Contraindications To Continue With The
    Uncomplicated Pregnancy Guideline?**

> *Annotation*
>
> ***Absolute Contraindications* to the Uncomplicated Pregnancy
> Guideline:**
>
> Pregnant women identified as having any of the following conditions
> should exit the Uncomplicated Pregnancy Guideline.

-   Pre-existing diabetes

-   Gestational diabetes mellitus (GDM)

-   Fetal anomaly or abnormal presentation ([\>]{.underline}36 weeks)

-   Multiple gestation

-   Placenta previa

-   Chronic hypertension

-   Systemic disease that requires ongoing care (e.g., severe asthma,
    lupus, and inflammatory bowel disease)

-   Drug abuse

-   Human immunodeficiency virus (HIV) (or abnormal screen)

> ***Relative Contraindications* to the Uncomplicated Pregnancy
> Guideline**:
>
> Pregnant women identified as having one or more of the following
> conditions should be evaluated by a healthcare provider (experienced
> in obstetrics) to determine the risk of continuing with the
> Uncomplicated Pregnancy Guideline.

-   Age (\<16 or \>40 years at delivery)

-   Past complicated pregnancy

-   Prior preterm delivery (\<37 weeks)

-   Prior preterm labor requiring admission (e.g., early cervical
    change)

-   Intrauterine fetal demise (IUFD) -- 10 weeks after cardiac activity
    was first noted

-   Prior cervical/uterine surgery

-   Fetal anatomic abnormality (e.g., open neural tube defects in prior
    child or first degree relative)

-   Abnormal fetal growth

-   Preterm labor requiring admission (i.e., regular uterine
    contractions and cervical change)

-   Abnormal amniotic fluid

-   Second or third trimester bleeding

-   Relative BMI \<16.5

-   Hematologic disorders

-   Severe anemia (\<24 percent hematocrit)

-   Cancer

-   Seizure disorders

-   Recurrent urinary tract infection/stones

-   Substance use disorders (alcohol/tobacco)

-   Eating disorders

-   Surgery

-   Abnormal screen -- antibody, hepatitis, syphilis, and Papanicolaou
    (PAP)

-   Abnormal maternal serum analyte test (e.g., triple screen)

-   Current mental illness requiring medical therapy

E.  **Visit With Provider - Weeks 10-12**

> *Annotation*
>
> See *Prenatal Care Interventions and Interventions Summary Table in
> the original guideline document*.

F.  **Routine Visits - Weeks 16-27**

> *Annotation*
>
> Visits during this period should include the following:

-   Auscultation of fetal heart tones - if negative, elevate care

-   Screening fundal height

-   Screening for hypertensive disorders

-   Assessing inappropriate weight gain

-   Educate about symptoms of preterm labor (week 20)

-   Review for development of contraindications -- exit the
    Uncomplicated Pregnancy Guideline if absolute contraindications are
    identified

> For specific interventions see *Prenatal Care Interventions -- Weeks
> 16-27*.

G.  **Routine Visits - Weeks 28-41**

> *Annotation*
>
> Visits during this period should include the following:

-   Auscultation of fetal heart tones - if negative, elevate care

-   Screening fundal height

-   Screening for hypertensive disorders

-   Assessing inappropriate weight gain

-   Assess for symptoms of preterm labor (week 28)

-   Assessment of fetal kick counts

-   Review for development of contraindications - exit the Uncomplicated
    Pregnancy Guideline if absolute contraindications are identified

> For specific interventions see *Prenatal Care Interventions -- Weeks
> 28-41*.

H.  **Postpartum Visit**

> *Annotation*
>
> The postpartum visit provides the opportunity for providers to
> interact with the new mother and her infant through interview, exam,
> and testing. The timing and the content of the postpartum visit have
> often been topics for debate. Recent literature helps the provider to
> answer these questions based on the evidence.

-   The maternal postpartum visit should occur approximately 8 weeks
    after delivery. Eight weeks is the optimal time to decrease the rate
    of false positive cervical smears, though consideration of the
    mother´s schedule should also be taken into account. (Rarick &
    Tchabo, 1994) (***Quality of the Evidence \[QE\]*: I; *Overall
    Quality*: Good; *Recommendation* *\[R\]*: B**)

-   Tests that should be performed at this visit include the cervical
    smear, pelvic exam, and breast exam. (Londo et al., 1994; Weiss,
    Senf, & Udall, 1989) (***QE*: II; *Overall Quality*: Fair; *R*: B**)

-   Topics addressed at this exam should include contraception,
    postpartum depression, feeding method, sexual activity, weight,
    exercise and the woman´s assessment of her adaptation to motherhood.
    (***QE*: III; *Overall Quality*: Poor; *R*: C**)

**Prenatal Care Interventions**

To see a prenatal care intervention summary table, refer to the original
guideline document.

**Interventions at All Visits**

**I-1 Screening for Hypertensive Disorders of Pregnancy \-- Weeks: All**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend measuring blood pressure of all pregnant women at each
    prenatal visit, following the guidelines of the National High Blood
    Pressure Education Program and the Veterans
    Administration/Department of Defense (VA/DoD) Clinical Practice
    Guidelines for Hypertension. (National Institutes of Health (NIH)
    Working Group on High Blood Pressure in Pregnancy, 2000; United
    States Preventive Services Task Force (USPSTF), Guide to Clinical
    Preventive Services, 1996) (***QE*: III; *Overall Quality*: Good;
    *R*: B**)

2.  Women diagnosed with hypertension during pregnancy should exit the
    Uncomplicated Pregnancy Guideline. (NIH Working Group on High Blood
    Pressure in Pregnancy, 2000; Cunningham & Lindheimer, 1992) (***QE*:
    III; *Overall Quality*: Good; *R*: B**)

3.  Korotkoff 5 sound (disappearance of sound) will be used to determine
    the diastolic pressure.

**I-2 Breastfeeding Education \-- Weeks: All**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend offering breastfeeding education to all pregnant women at
    10 to 12 weeks or the first visit with the provider. (American
    Academy of Pediatrics \[AAP\], 1997; Hill & Humenick, 1993;
    Hill, 1991) (***QE*: III, II-3; *Overall Quality*: Fair; *R*: B**)

2.  Recommend asking pregnant women, \"What do you know about
    breastfeeding?\" rather than, \"Do you plan on breast or bottle
    feeding?\" to provide an open opportunity for education. (Hartley &
    O´Connor, 1996) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

3.  Recommend continuing education throughout pregnancy for those
    pregnant women who express a desire to breastfeed or for those who
    are still undecided on feeding method. (Berens, 2001) (***QE*: III;
    *Overall Quality*: Fair: *R*:C**)

4.  Recommend including family/significant others in breastfeeding
    education. (Berens, 2001; Humenick, Hill, & Wilhelm, 1997) (***QE*:
    III; II-1; *Overall Quality*: Fair; *R*: B**)

**I-3 Exercise During Pregnancy \-- Weeks: All**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Strongly recommend all healthy, pregnant women perform regular mild
    to moderate exercise sessions, three or more times per week.
    (Campbell & Mottola, 2001; Clapp, 2001; Clapp et al., 2000; Clapp,
    Lopez, & Harcar-Sevcik, 1999; Sternfeld et al., 1995; Sady et
    al., 1989) (***QE*: I; *Overall Quality*: Good; *R*: A**)

2.  Recommend individualized exercise programs for all pregnant women,
    based on their pre-pregnancy activity level. (Clapp, Lopez, &
    Harcar-Sevcik, 1999; Sternfeld et al., 1995) (***QE*: II-2; *Overall
    Quality*: Good; *R*: B**)

3.  Recommend against high-altitude (\>10,000 feet) activities, scuba
    diving. and contact sports during pregnancy. (Hammer, Perkins, &
    Parr, 2000; Camporsei, 1996; Alderman et al., 1995) (***QE*: II-2;
    *Overall Quality*: Good; *R*: D**)

**I-4 Influenza Vaccine (Season-Related) \-- Weeks: Any Week**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend immunizing for influenza all pregnant women who will be in
    the second or third trimester during the epidemic season.
    (\"Immunization during pregnancy,\" 1993; Englund, Glezen, &
    Piedra, 1998) (***QE*: III; *Overall Quality*: Poor: *R*: C**)

**Interventions First Visit with Nurse \[6-8 weeks\]**

**I-5 Screening for Tobacco Use - Offer Cessation \-- Week: 6-8**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Strongly recommend routine screening for tobacco use in pregnancy at
    the initial prenatal visit. For patients who smoke, recommend
    assessment of smoking status at each subsequent prenatal visit.
    (Lumley, Oliver, & Waters, 2001; Mullen et al., 1991) (***QE*: I;
    *Overall Quality*: Good; *R*: A**)

2.  If the screening is positive, cessation should be strongly
    recommended. (Wisborg et al., 2000; Panjari et al., 1999;
    Dolan-Mullen, Ramirez, & Groff, 1994) (***QE: I; Overall Quality:
    Good; R: A***)

3.  There is insufficient data to recommend for or against pharmacologic
    therapy for tobacco cessation in pregnancy.

**I-6 Screening for Alcohol Use - Offer Cessation \-- Week: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend routine screening for alcohol consumption using a
    standardized tool (refer to the VHA/DoD Clinical Practice Guideline
    for the Management of Substance Use Disorders -- Appendix A-1 for
    screening tools). (Handmaker, Miller, & Manicke, 1999; Chang et al.,
    1999; Reynolds et al., 1995) (***QE*: I; *Overall Quality*: Fair;
    *R*: B**)

2.  If the screening is positive, cessation should be strongly
    recommended. (Handmaker, Miller, & Manicke, 1999; Chang et al.,
    1999; Reynolds et al., 1995) (***QE*: I; *Overall Quality*: Fair;
    *R*: B**)

3.  There is insufficient evidence regarding which cessation
    intervention tool is the most effective.

4.  A positive screening does not exclude the pregnant women from the
    Uncomplicated Pregnancy Guideline.

**I-7 Screening for Drug Abuse - Offer Treatment \-- Weeks: 6-8**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend routine screening for illicit drug use using a self-report
    method. (Horrigan, Piazza, & Weinstein, 1996) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

2.  Recommend pregnant women identified as abusing drugs be offered
    treatment, as per the VHA/DoD Clinical Practice Guideline for the
    Management of Substance Use Disorders. (Howell, Heiser, &
    Harrington, 1999) (***QE*: II-3; *Overall Quality*: Fair; *R*: B**)

3.  Pregnant women identified as abusing drugs are excluded from the
    Uncomplicated Pregnancy Guideline.

**I-8 Screening for Domestic Abuse \-- Weeks: 8, 24, 32**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend routine screening for domestic abuse (Gazmararian et
    al., 1996) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**) at
    weeks 8, 24, and 32, using the following three simple/direct
    questions. (McFarlane et al., 1992) (***QE*: II-2; *Overall
    Quality*: Fair; *R*: B**):

    -   Within the last year, have you been hit, slapped, kicked, or
        otherwise physically hurt by someone?

    -   Since you\'ve been pregnant, have you been hit, slapped, kicked,
        or otherwise physically hurt by someone?

    -   Within the last year, has anyone forced you to have sexual
        activities?

2.  There is insufficient evidence to recommend for or against specific
    interventions for identifying domestic abuse in pregnancy.
    (McFarlane, Soeken, & Wiist, 2000; Parker et al., 1999) (***QE*:
    III; *Overall Quality*: Poor; *R*: I**)

3.  If the screening is positive, follow appropriate medical/legal
    mandates for reporting requirements for state/branch of service.

**I-9 Screening for Rh Status \-- Weeks: 6-8**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend routine antibody screening for Rh status at the initial
    prenatal visit via indirect-antiglobulin (Coombs\') testing. (Howard
    et al., 1998; Bowell, Allen, & Entwistle, 1986) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: C**)

2.  Pregnant women with positive screens should be referred for
    consultation to assist with further management.

3.  There is insufficient evidence to recommend for or against routine
    repeat testing at 28 weeks´ gestation. (***QE*: III; *Overall
    Quality*: Poor; *R*: D**)

**I-10 Screening for Rubella \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend all pregnant women have a serum screen for rubella status
    at the initial prenatal visit. (McElhaney et al., 1999) (***QE*:
    II-2; *Overall Quality*: Fair; *R*: B**)

2.  Recommend seronegative pregnant women be counseled to avoid
    exposure. (***QE*: III; *Overall Quality*: Poor; *R*: B**)

3.  Recommend seronegative pregnant women be vaccinated in the immediate
    postpartum period. Postpartum vaccination demonstrates \>90 percent
    protection against clinical rubella infection and seropositivity is
    long lasting. Vaccinating healthy women of childbearing age provides
    protection for the women from adult onset rubella and for their
    future children from Congenital Rubella Syndrome (CRS). (Horstman et
    al., 1985) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

**I-11Screening for Varicella Weeks: 6-8**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend routine screening for varicella through history. (Smith et
    al., 1998) (***QE*: I; *Overall Quality*: Good; *R*: B**)

2.  If negative/unsure history, obtain a varicella titer.

3.  Recommend offering vaccination postpartum, if varicella is
    non-immune. (Centers for Disease Control \[CDC\] guideline for
    screening for varicella) (***QE*: I; *Overall Quality*: Good; *R*:
    B**)

**I-12 Screening for Hepatitis B \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend routine screening for hepatitis B surface antigen at the
    initial prenatal visit. (\"Immunization during pregnancy,\" 1993)
    (***QE*: III; *Overall Quality*: Fair; *R*: B**)

2.  Consider rescreening all pregnant women with hepatitis risk factors
    identified during the pregnancy (e.g., intravenous \[IV\] drug use,
    exposure to hepatitis, sexually transmitted diseases \[STDs\], new
    tattoos, and blood transfusion). (Duff, 1998) (***QE*: III; *Overall
    Quality*: Fair; *R*: C**)

**I-13 Screening for Syphilis Rapid Plasma Reagin (RPR) \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend routine screening for syphilis using serologic testing
    (i.e., Rapid Plasma Reagin \[RPR\] or Venereal Disease Research
    Laboratory \[VDRL\]) at the initial prenatal visit. (Donders et al.,
    1993; Dorfman & Glaser, 1990) (***QE*: II-3; *Overall Quality*:
    Fair; *R*: B**)

2.  Recommend confirmatory test using a more specific treponemal assay
    (Fluorescent treponemal antibody absorption \[FTA-ABS\],
    microhemagglutination Treponema pallidum \[MHA-TP\],
    hemagglutination treponemal test for syphilis \[HATTS\]) for
    pregnant women who test positive. (Hart, 1986) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

3.  Strongly recommend therapy with penicillin G antibiotic for pregnant
    women who have confirmed syphilis, as recommended by other sexually
    transmitted disease (STD) guidelines. (***QE*: II-2; *Overall
    Quality*: Fair; *R*: A**)

4.  Recommend appropriate medical/legal mandates follow-up and
    state/service branch reporting requirements for pregnant women
    screening positive.

**I-14 Screening for Asymptomatic Bacteriuria (ASB) \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Strongly recommend screening for asymptomatic bacteriuria \[ASB\] at
    initial obstetrical visit via urine culture and sensitivity.
    (Smaill, \"Antibiotics for asymptomatic bacteriuria,\" 2001; USPSTF,
    1996; Romero et al., 1989) (***QE*: I; *Overall Quality*: Good; *R*:
    A**)

2.  There is insufficient evidence to recommend for or against repeat
    screening throughout the remainder of pregnancy. (***QE*: III;
    *Overall Quality*: Poor; *R*: I**)

3.  Strongly recommend a three to seven day course of appropriate
    antibiotics based on positive culture and sensitivity and woman´s
    history of medication allergies. (Smaill, \"Antibiotics for
    asymptomatic bacteriuria,\" 2001) (***QE*: I; *Overall Quality*:
    Good; *R*: A**)

4.  There is insufficient evidence to recommend for or against a test of
    cure (TOC) after completion of antibiotic therapy, except in
    pregnant women with ASB-Group B Strep. (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

**I-15 Screening for Human Immunodeficiency Virus (HIV) -- Counsel \--
Weeks: 6-8**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Strongly recommend routine testing at the initial prenatal visit.
    (American Academy of Pediatrics/American College of Obstetricians
    and Gynecologists \[AAP/ACOG\], 1995) (***QE*: I; *Overall Quality*:
    Good; *R*: A**)

2.  Pregnant women who test positive for HIV should be referred for
    treatment and counseling.

3.  Recommend retesting all high risk pregnant women during the early
    third trimester and offer repeat testing for patients who refused
    the first test. (Tookey et al., 1998; Higgins, et al., 1991)
    (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

4.  Pregnant women identified with HIV are excluded from the
    Uncomplicated Pregnancy Guideline.

**I-16 Immunization -- Tetanus and Diphtheria (Td) Booster (First
Trimester) \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Strongly recommend routine screening for Td booster status at the
    initial prenatal visit. (USPSTF, 1996; \"Immunization during
    pregnancy,\" 1993) (***QE*: II-1; *Overall Quality*: Good; *R*: A**)

2.  If there is no documentation of Td booster within the last ten
    years, Td booster should be provided. There are no contraindications
    other than a previous severe reaction to Td vaccination, such as
    anaphylaxis, generalized urticaria, or angioedema. (Institute for
    Clinical Systems Improvement \[ICSI\], 2001; Fingar & Francis.,
    1998; USPSTF, 1996) (***QE*: II-1; *Overall Quality*: Good; *R*:
    A**)

3.  If the pregnant woman is an immigrant and it is unclear that she
    ever received the primary vaccination series, she should be given a
    primary series with an initial dose, a second dose a month later and
    a third dose 12 months later. (ICSI, 2001; Fingar & Francis, 1998;
    USPSTF, 1996) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

**I-17 Immunization - Hepatitis B (First Trimester) \-- Weeks: 6-8**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend immunizing for hepatitis B all pregnant women with
    high-risk factors predicting positive hepatitis B during pregnancy.
    (CDC guideline for Hepatitis B immunization; AAP/ACOG, 1995)
    (***QE*: II-3; *Overall Quality*: Fair; *R*: B**)

**Interventions First Visit with Provider \[10-12 weeks\]**

**I-18 Assessing Weight Gain (Inappropriate) \-- Weeks: All**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend assessing and documenting body mass index (BMI) of all
    pregnant women at the initial visit. (Sebire et al., 2001) (***QE*:
    II-2; *Overall Quality*: Fair; *R*: B**) (Institute of Medicine
    \[IOM\], 1990) (***QE*: III; *Overall Quality*: Fair; *R*: C**)

2.  Pregnant women found to have a BMI \<20 should be referred for
    nutrition counseling and considered at increased risk for fetal
    growth restriction. (Kramer \"High protein supplementation,\" 2000;
    Sebire et al., 2001) (***QE*: II-2; *Overall Quality*: Fair; *R*:
    B**)

3.  Recommend screening for inappropriate weight gain for all women at
    every visit during pregnancy. (\"A WHO collaborative study,\" 1997)
    (***QE*: III; *Overall Quality*: Fair; *R*: C**)

4.  Pregnant women with inadequate weight gain at 28 weeks who are
    unresponsive to nutritional treatment exit the Uncomplicated
    Pregnancy Guideline. (Kelly et al., 1997) (***QE*: II-2: *Overall
    Quality*: Fair; *R*: B**)

**I-19 Auscultation Fetal Heart Tones \-- Weeks: 10-12**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend assessing fetal heart tones at each prenatal visit,
    starting at 10 to 12 weeks. (Engstrom, 1985; Jimenez, Tyson, &
    Reisch,1983) (***QE*: III; *Overall Quality*: Poor; *R*: C**)

**I-20 Screening Fundal Height \-- Weeks: All**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend measuring fundal height in all pregnant women at each
    visit during the second and third trimesters. (Engstrom & Work,
    1992; Lindhard, et al., 1990; Mathai, Jairaj, & Muthurathnam, 1987;
    Pearce & Campbell, 1987; Wise & Engstrom, 1985; Jimenez, Tyson, &
    Reisch, 1983; Calvert et al., 1982; Quaranta et al., 1981) (***QE*:
    I; *Overall Quality*: Good; *R*: B**)

2.  There is insufficient evidence to recommend for or against measuring
    fundal height after 36 weeks´ gestation. (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

**I-21 Screening for Gonorrhea \-- Weeks: 10-12**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend screening for gonorrhea in all pregnant women. (***QE*:
    II-2; *Overall Quality*: Fair; *R*: B**)

2.  Pregnant women with positive cultures should be treated with
    ceftriaxone, per CDC guidelines.

3.  Pregnant women with positive screens for gonorrhea should be
    screened for other STDs.

4.  Recommend performing a TOC during pregnancy after completing
    antibiotic therapy. TOC in pregnant women, unlike non-pregnant
    women, is recommended due to risk of complications resulting from
    persistent or recurrent infections.

5.  Recommend counseling to decrease rate of reinfection.

6.  Recommend referring partner for testing and treatment, as
    appropriate. Pregnant women must abstain from intercourse pending
    TOC.

**I-22 Screening for Chlamydia \-- Weeks: 10-12**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend screening all pregnant women for chlamydia trachomatis at
    the initial physical examination. (Hammerschlag et al., 1979)
    (***QE*: II-2; Overall *Quality*: Fair; *R*: B**)

2.  Pregnant women with positive cultures should be treated with
    azithromycin or erythromycin, per CDC guidelines. (Blackwell et
    al., 1993) (***QE*: II-2; *Overall Quality*: Fair; *R*: A**)

3.  Pregnant women with positive screens for chlamydia should be
    screened for other STDs. (Vuylsteke et al., 1993) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

4.  Recommend performing a TOC during pregnancy after completing
    antibiotic therapy. TOC in pregnant women, unlike non-pregnant
    women, is recommended due to risk of complications resulting from
    persistent or recurrent infections. (***QE*: III; *Overall Quality*:
    Poor; *R*: C**)

5.  Recommend counseling to decrease rate of reinfection. (Vuylsteke et
    al., 1993) (***QE*: II-2; *Overall Quality*: Fair; *R*: C**)

6.  Recommend referring partner for testing and treatment, as
    appropriate. Pregnant women must abstain from intercourse pending
    TOC. (***QE*: III; *Overall Quality*: Poor; *R*: C**)

**I-23 Screening for Cervical Cancer \-- Weeks: 10-12**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend screening all pregnant women for cervical cancer at the
    first prenatal visit, or as early in pregnancy as possible. (Lurain
    & Gallop, 1979) (***QE*: II-2; *Overall Quality*: Good; *R*: B**)

2.  Recommend performing cervical screening in pregnancy with a brush
    sampler and spatula. (Hoffman et al., 1991; Koonings et al., 1992)
    (***QE*: I; *Overall Quality*: Good; *R*: A**)

3.  Recommend women with abnormal cervical smears during pregnancy be
    managed based on local algorithms, which may include repeat testing,
    observation, or colposcopy. (LaPolla, O´Neil, & Wetrich, 1988)
    (***QE*: III; *Overall Quality*: Fair; *R*: C**)

**I-24 Counseling for Cystic Fibrosis (CF) Screening \-- Weeks: 10-12**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend educating all pregnant women using a CF carrier-screening
    brochure about a possible risk of CF. (ACOG and American College of
    Medical Geneticists \[ACMG\], 2001) (***QE*: III; *Overall Quality*:
    Poor; *R*: I**)

2.  Recommend offering CF screening to all pregnant women who desire it.
    (ACOG & ACMG, 2001) (***QE*: III; *Overall Quality: Poor*; *R*: I**)

3.  Recommend referring all pregnant women with a family history of CF
    for genetic counseling. (ACOG & ACMG, 2001) (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

4.  For couples who desire screening at \<18 weeks´ gestation, only one
    partner should be initially screened; if the screening is positive
    then the other partner should be screened.

5.  For couples who desire screening at \>18 weeks´ gestation, both
    partners should be screened simultaneously. This reduces the
    increased time frame of sequential screenings and provides couples
    wishing to terminate the pregnancy faster access to the screening
    results.

**Interventions Weeks: 16-27**

**I-25 Maternal Serum Analyte Screening \-- Weeks: 15-20**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend offering multiple marker maternal serum analyte screening
    to all pregnant women at gestational ages between 15 and 20 weeks.
    The ideal screening period is 15 to 18 weeks in order to maximize
    test accuracy and allow time for adequate follow-up counseling and
    testing. (ACOG & American College of Medical Geneticists \[ACMG\],
    2001; Haddow et al., 1992) (***QE*: II-1; *Overall Quality*: Good;
    *R*: B**)

2.  Recommend providing pre-test patient education and counseling to
    ensure that women understand screening test limitations and
    false-positive rates, as well as the need for subsequent diagnostic
    tests for screen-positive women. (Nadel et al., 1990) (***QE*: II-2;
    *Overall Quality*: Good; *R*: B**)

3.  If the screening is positive, targeted ultrasound examinations can
    be used for risk modification and counseling prior to making the
    decision for invasive testing. (Smith-Bindman et al., 2001) (***QE*:
    II-1; *Overall Quality*: Good; *R*: B**)

4.  Pregnant women with persistent unexplained elevations of maternal
    serum alpha-fetoprotein (MSAFP) are at increased risk for adverse
    perinatal outcome and should exit the Uncomplicated Pregnancy
    Guideline. (ACOG & ACMG, 2001) (***QE*: II-1; *Overall Quality*:
    Good; *R*: B**)

5.  Women at high risk for fetal aneuploidy (age [\>]{.underline} 35 at
    delivery or prior first child or fetus with aneuploidy) require
    genetic counseling. (Haddow et al.,1994) (***QE*: II-1; *Overall
    Quality*: Good; *R*: B**)

**I-26 Routine Ultrasound \-- Weeks: 16-20**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend counseling and educating all pregnant women prior to
    scheduling sonographic study. Education will include information on
    potential benefits, limitations, and safety of prenatal ultrasound.
    Documentation of education and counseling is recommended; however,
    written informed consent is not deemed necessary. (Chervenak &
    McCullough, 1992) (***QE*: III; *Overall Quality*: Fair; *R*: B**)

2.  Recommend offering a complete obstetric sonographic examination
    between 16 and 20 weeks´ gestation to all low-risk consenting
    pregnant women (see Appendix A-2 titled \"Standard for Performance
    of Antepartum Obstetrical Ultrasound Examination\" in the original
    guideline document). (Society of Obstetricians and Gynaecologists of
    Canada \[SOGC\], 1999) (***QE*: III; *Overall Quality*: Fair; *R*:
    B**)

3.  Strongly recommend all complete obstetric sonographic studies be
    performed and interpreted by qualified healthcare providers (see
    Appendix A-2 titled \"Standard for Performance of Antepartum
    Obstetrical Ultrasound Examination\" in the original guideline
    document). (Crane et al., 1994; American Institute of Ultrasound in
    Medicine \[AIUM\], 2003) (***QE*: I; *Overall Quality*: Good; *R*:
    A**)

**I-27 Counseling for Family Planning \-- Weeks: Start at Week 20**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend antepartum counseling and educating all pregnant women
    regarding family planning, to include various temporary
    contraceptive means and/or permanent sterilization. (Pati &
    Cullins, 2000) (***QE*: III; *Overall Quality*: Poor; *R*: C**)

**I-28 Educate Regarding Preterm Labor \-- Week: 20**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Pregnant women will be screened for factors that would result in a
    10 percent or greater risk of preterm delivery and, if present, will
    be excluded from further care in the Uncomplicated Pregnancy
    Guideline. (Lockwood & Kuczynski, 1999; Knox et al., 1993; Holbrook,
    Laros, & Creasy, 1989; Ross et al., 1986) (***QE*: II-2; *Overall
    Quality*: Fair; *R*: B**) Risk factors that would place a patient at
    a \>10 percent risk of preterm delivery include the following:

    -   Prior spontaneous preterm delivery (following preterm labor or
        preterm premature rupture of membranes)

    -   History of cervical incompetence

    -   Tobacco abuse and poor nutrition (i.e., BMI \<18)

2.  Pregnant women will be educated about the most common symptoms of
    preterm labor. (Katz, Goodyear, & Creasy, 1990; Morrison, 1990; Ross
    et al., 1986; Herron, Katz, & Creasy, 1982) (***QE*: II-2; *Overall
    Quality*: Good; *R*: A**):

    -   Low, dull backache

    -   Four or more uterine contractions per hour. Uterine contractions
        may be perceived by the patient as:

        -   Menstrual-like cramps

        -   Sensation of the \"baby rolling up in a ball\"

        -   Abdominal cramping (may be associated with diarrhea)

        -   Increased uterine activity compared to previous patterns.

    -   Increased pelvic pressure (may be associated with thigh cramps)

    -   Change in vaginal discharge such as change in color of mucus,
        leaking of clear fluid, spotting, or bleeding

    -   Vaginal discharge associated with itching or fish-like odor
        immediately after intercourse

    -   General sensation that \"something feels different\" (e.g.,
        agitation, flu-like syndrome, and sensation that baby has
        \"dropped\")

3.  If the pregnant woman experiences any of the above symptoms or is
    unsure about the presence of any of the above, she should lie down
    on her side with one of her hands on her lower abdomen to palpate
    for uterine contractions an additional hour; if symptoms persist
    and/or she palpates four or more uterine contractions in the hour,
    she should seek immediate medical care. The exception to this is the
    pregnant woman who notes the presence of vaginal bleeding, leaking
    of clear fluid from the vagina, or a vaginal discharge with a
    fish-like odor immediately after intercourse, all of which should
    prompt immediate medical attention. (***QE*: III; *Overall Quality*:
    Poor; *R*: I**)

4.  Educate the pregnant woman that she is the most important link in
    the early diagnosis of preterm labor, and that early diagnosis and
    treatment of preterm labor increases the chances for successful
    prolongation of the pregnancy and the probability of a healthy
    infant. (Katz, Goodyear, & Creasy, 1990; Herron, Katz, &
    Creasy, 1982) (***QE*: II-2; *Overall Quality*: Good; *R*: B**)

*See Table 2 titled \"Risk Factors for Preterm Delivery\" in the
original guideline document.*

**Reinforce Education of Patient about Preterm Labor Risk \-- Week: 24**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Pregnant women will be educated about the most common symptoms of
    preterm labor (Katz, Goodyear, & Creasy, 1990; Morrison, 1990; Ross
    et al., 1986; Herron, Katz, & Creasy, 1982) (***QE*: II-2; *Overall
    Quality*: Good; *R*: A**):

    -   Low, dull backache

    -   Four or more uterine contractions per hour. Uterine contractions
        may be perceived by the patient as:

        -   Menstrual-like cramps

        -   Sensation of the \"baby rolling up in a ball\"

        -   Abdominal cramping (may be associated with diarrhea)

        -   Increased uterine activity compared to previous patterns

    -   Increased pelvic pressure (may be associated with thigh cramps)

    -   Change in vaginal discharge, such as change in color of mucus,
        leaking of clear fluid, spotting or bleeding

    -   Vaginal discharge associated with itching or fish-like odor
        immediately after intercourse

    -   General sensation that \"something feels different\" (e.g.,
        agitation, flu-like syndrome, and sensation that baby has
        \"dropped\")

2.  If the pregnant woman experiences any of the above symptoms or is
    unsure about the presence of any of the above, she should lie down
    on her side with one of her hands on her lower abdomen to palpate
    for uterine contractions for an additional hour. If symptoms persist
    and/or she palpates 4 or more uterine contractions in the hour, she
    should seek immediate medical care. The exception to this is the
    pregnant woman who notes the presence of vaginal bleeding, leaking
    of clear fluid from the vagina, or a vaginal discharge with a
    fish-like odor immediately after intercourse, all of which should
    prompt immediate medical attention. (Working Group Consensus)
    (***QE*: III; *Overall Quality*: Poor; *R*: I**)

3.  Reemphasize to the pregnant woman that she is the most important
    link in the early diagnosis of preterm labor, and that early
    diagnosis and treatment of preterm labor increases the chances for a
    healthy infant. (Katz, Goodyear, & Creasy, 1990; Herron, Katz, &
    Creasy, 1982) (***QE*: II-2; *Overall Quality*: Good; *R*: B**)

4.  Educate the pregnant woman that she can safely continue moderate
    exercise and activity during her pregnancy as long she does not
    notice any of the symptoms of preterm labor. The exception to this
    is that she may notice some increase in uterine cramping with
    moderate exercise or activity. This is of no consequence so long as
    the cramping ceases when she stops her activity. She should be told
    to limit her activity to no more than two hours per session. (See
    Intervention I-3 \"Exercise During Pregnancy\") (***QE*: II-1;
    *Overall Quality*: Good; *R*: B**)

5.  Women with uncomplicated pregnancies may continue a standard work
    schedule throughout their pregnancy. If their work is strenuous or
    they spend long periods of time on their feet, such as a nurse, they
    should limit their work week to 40 hours and workday to 8 hours
    during the last trimester (beginning at 28 weeks) or sooner if they
    frequently experience symptoms of preterm labor while at work.
    Pregnant women should attempt to limit periods of time on their feet
    to 3 hours. (Mozurkewich et al., 2000; Gabbe & Turner, 1997; Luke et
    al., 1995; Teitelman et al., 1990) (***QE*: II-2; *Overall Quality*:
    Good; *R*: B**)

6.  There is no evidence that sexual intercourse increases the
    probability of preterm labor in women with uncomplicated pregnancy.
    They may experience some uterine contractions following orgasm;
    however, this is a normal response and she only needs to seek
    medical attention if they persist at four or more per hour for at
    least three hours, or if vaginal bleeding or spotting is noted.
    (Read & Klebanoff, 1993) (***QE*: II-2; *Overall Quality*: Good;
    *R*: A**)

**Interventions Weeks: 38-37**

**I-29 Assess for Preterm Labor \-- Weeks: 28-34**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  All pregnant women at risk for preterm labor at week 28 will be
    asked if they have experienced any of the following symptoms since
    the previous visit:

    -   Low, dull backache

    -   Menstrual-like cramps or sensation the \"baby is rolling up in a
        ball\"

    -   Increased pelvic pressure (may be with thigh cramps)

    -   Abdominal cramping (may be associated with diarrhea)

    -   Increased uterine activity compared to previous patterns (more
        than 4 contractions per hour)

    -   Change in vaginal discharge such as change in color of mucus,
        leaking of clear fluid, spotting or bleeding

    -   Sensation that \"something feels different\" (e.g., agitation,
        flu-like syndrome, and sensation that baby has \"dropped\")

> Educate the pregnant woman that she is a vital link in the early
> detection and treatment of preterm labor. (Katz, Goodyear, & Creasy,
> 1990; Herron, Katz, & Creasy, 1982) (***QE*: II-2; *Overall Quality*:
> Good; *R*: B**)

2.  If the pregnant woman experiences any of the above symptoms or is
    unsure about the presence of any of the above, she should lie down
    on her side with one of her hands on her lower abdomen to palpate
    for uterine contractions for an additional hour. If symptoms persist
    and/or she palpates 4 or more uterine contractions in the hour, she
    should seek immediate medical care. The exception to this is the
    pregnant woman who notes the presence of vaginal bleeding, leaking
    of clear fluid from the vagina or a vaginal discharge with a
    fish-like odor immediately after intercourse, all of which should
    prompt immediate medical attention. (***QE*: III; *Overall Quality*:
    Poor; *R*: I**)

3.  If no diagnosis of preterm labor is established, continuation in the
    guideline is appropriate.

**I-30 Daily Fetal Movement Counts \-- Weeks: 28-37**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend instructing all pregnant women about the importance of
    assessing fetal movement on a daily basis beginning in the third
    trimester. (Moore & Piacquadio, 1989; Neldam, 1980) (***QE*: II-1;
    *Overall Quality*: Good; *R*: B**)

2.  Recommend instructing all pregnant women as to the course of action
    they should take if they do not perceive the minimum fetal movement
    counts within the time frame specific to their health care facility.
    (Moore & Piacquadio, 1989; Neldam, 1980; Pearson & Weaver, 1976;
    Sadovsky & Yaffe, 1973) (***QE*: II-1; *Overall Quality*: Good; *R*:
    B**)

**I-31 Screening for Gestational Diabetes \-- Week: 28**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend screening all pregnant women for gestational diabetes
    mellitus (GDM) at 24 to 28 weeks´ gestation. (Griffen et al., 2000;
    Danilenko-Dixon et al., 1999; Williams et al., 1999 (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

2.  Screening for GDM should be performed by randomly administering a 50
    gram oral glucose tolerance test (GTT) followed by a blood draw one
    hour later. (ACOG & ACMG, 2001; Naylor et al., 1997) (***QE*: II-1,
    II-3; *Overall Quality*: Good; *R*: A**) Generally accepted
    threshold values of the 1-hour screen are between 130 mg/dL and 140
    mg/dL. Pregnant women who are positive require the diagnostic 3-hour
    GTT. (AGOG & ACMG, 2001) (***QE*: III; *Overall Quality*: Fair; *R*:
    B**)

3.  In the 3-hour GTT a 100 gram-glucose load is administered to a woman
    who has fasted overnight (minimum 8 hours). Blood draws are
    performed fasting and at 1, 2 and 3 hours after the oral glucose
    load.

4.  Two acceptable sets of threshold values for the 3-hour 100 gram GTT
    that can be used to diagnose gestational diabetes: the National
    Diabetes Data Group (NDDG) criteria and the Carpenter/Coustan
    conversion criteria. Institutions should adopt one of these two
    criteria sets based upon their population demographics. There should
    NOT be variance within the facility itself, though variance may
    occur between facilities. Pregnant women diagnosed with gestational
    diabetes using these criteria will exit the Uncomplicated Pregnancy
    Guideline. . (ACOG & ACMG, 2001; Report from Expert Committee on the
    Diagnosis and Classification of Diabetes Mellitus, 2000) (***QE*:
    II-3; *Overall Quality*: Fair; *R*: B**)

5.  As impairment of glucose metabolism is a spectrum, pregnant women
    with just one abnormal value on the 3-hour GTT should exit the
    Uncomplicated Pregnancy Guideline (***QE*: III; *Overall Quality*:
    Poor; *R*: C**) and be managed using one of the following methods:

    -   Undergo a repeat 3-hour 100 gram glucose challenge test
        approximately one month following the initial test.

    -   Have dietary management and intermittent postprandial glucose
        testing performed in a manner similar to women with gestational
        diabetes. (ACOG & ACMG, 2001; Lindsay, Graves, & Klein, 1989;
        Langer et al., 1987) (***QE*: III, II- 2; *Overall Quality*:
        Fair; *R*: C**)

    -   Pregnant women with a repeat GTT test that shows normal value
        may reenter the Uncomplicated Pregnancy Guideline.

**I-32 Iron Supplementation \-- Week: 28**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  There is insufficient evidence to recommend for or against routinely
    supplementing iron for all pregnant women who are not anemic.
    (***QE*: II-3; *Overall Quality*: Fair; *R*: I**) Women exhibiting
    signs or symptoms of anemia at any time during their pregnancy
    should be evaluated upon presentation. (Hemminki & Rimpela, 1991)
    (***QE*: I; *Overall Quality*: Good; *R*: B**)

2.  Recommend supplementing with at least 50 mg elemental iron (325 mg
    ferrous sulfate) twice-a-day (bid) in all pregnant women diagnosed
    with anemia (hematocrit \<30). Diagnosis of anemia may vary with
    smoking status and altitude. Clinical correlation with local
    laboratory is advised.

**I-33 Anti-D Prophylaxis for Rh-Negative Pregnant Women \-- Week: 28**

*The Working Group´s Recommendations for Women In Low Risk Pregnancy*:

1.  Recommend administering anti-D prophylaxis to all unsensitized
    D-negative pregnant women. (Crowther & Keirse, 2001; Urbaniak, 1998)
    (***QE*: I; *Overall Quality*: Fair; *R*: B**)

2.  Recommend using either 300 micrograms of anti-D immunoglobulin at 28
    weeks or 100 micrograms of anti-D-immunoglobulin at 28 and 34 weeks´
    gestation.

**I-34 Screening for Group B Streptococcus (GBS) \-- Week: 36**

*The Working Group´s Recommendations For Women In Low Risk Pregnancy*:

1.  Recommend screening all pregnant women for GBS at 35 to 37 weeks´
    gestation, using a rectovaginal culture and selective broth media to
    identify colonized women. (Main & Slagle, 2000; Yancey et al., 1996)
    (***QE*: II-1; *Overall Quality*: Good; *R*: B**)

2.  Pregnant women with positive rectovaginal cultures should be treated
    with intrapartum IV chemoprophylaxis with either penicillin or
    ampicillin (if no contraindications)\* (Smaill, \"Intrapartum
    antibiotics,\" 2001; Main & Slagle, 2000; Boyer & Gotoff, 1986)
    (***QE*: I; *Overall Quality*: Good; *R*: A**)

3.  Pregnant women who have had a previous child with early-onset GBS
    infection or have GBS bacteriuria in the current pregnancy should
    receive intrapartum antibiotics, without screening cultures.
    (***QE*: II-1; *Overall Quality*: Good; *R*: A**)

4.  Pregnant woman presenting in labor \<37 weeks´ gestation should
    receive intrapartum intravenous (IV) chemoprophylaxis. (Boyer &
    Gotoff, 1986) (***QE*: II-1; *Overall Quality*: Good; *R*: A**)

5.  For women in labor at term with unknown culture status, administer
    intrapartum antibiotics (IAP) if the duration of membrane rupture
    [\>]{.underline}18 hours or maternal temperature
    [\>]{.underline}100.4 degrees F (38 degrees C). (***QE*: II-1;
    *Overall Quality*: Fair; *R*: B**)

6.  Prophylactic antibiotics should be administered at least two hours
    prior to delivery, when possible\*\*. (Lin et al., 2001; de Cueto et
    al., 1998) (***QE*: II-2; *Overall Quality*: Good; *R*: B**)

7.  Women undergoing scheduled cesarean delivery prior to the onset of
    labor with intact membranes do not require prophylactic antibiotics,
    unless they have had a previous child with early-onset GBS
    infection. (Hager et al., 2000) (***QE*: III; *Overall Quality*:
    Fair; *R*: C**)

*\*Management of the GBS-colonized parturient with a history of an
allergic reaction to penicillin agents: Due to emerging resistance to
previous second-line antimicrobial agents, clindamycin and erythromycin
(10 to 15 percent resistant strains in most centers), alternative
second-line agents for women with a history of allergic reactions to
penicillin or ampicillin are listed below:*

-   *Administer vancomycin 2 gm IV load, followed by 1 gm IV every 12
    hours, for immediate hypersensitivity reaction (anaphylaxis,
    dyspnea, rapid onset of urticarial rash).*

-   *Administer cefazolin 2 gm IV load, followed by 1 gm IV every 8
    hours, for allergic reaction other than immediate hypersensitivity.*

*\*\*Management of the parturient anticipated to deliver imminently
following admission: As it is difficult to anticipate accurately when a
woman will deliver, women identified as candidates for intrapartum
antibiotics for prophylaxis (IAP) should receive prophylactic
antibiotics regardless of the interval between admission and delivery as
vertical transmission rates have been shown to have a clinically and
statistically significant decrease within 2 hours of maternal
administration. Thus, withholding of IAP from women solely on the basis
of anticipated admission-delivery interval should be discouraged.*

**I-35 Assessment of Fetal Presentation \-- Week: 36**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend screening for non-cephalic presentation for all patients
    at 36 weeks´ gestation. (Hofmeyr & Kulier, \"Cephalic
    version,\" 2001) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

2.  There is insufficient evidence to recommend for or against Leopold´s
    versus cervical exam as the best screening method to determine fetal
    presentation (Lydon-Rochelle et al., 1993; Thorp, Jenkins, &
    Watson, 1991) (***QE*: II-2; *Overall Quality*: Fair; *R*: I**)

3.  Recommend ultrasound for confirmation, if non-cephalic presentation
    is suspected. (Thorp, Jenkins, & Watson, 1991) (***QE*: II-2;
    *Overall Quality*: Good; *R*: B**)

4.  Recommend offering external cephalic version at 37 weeks or beyond,
    if non-cephalic presentation is confirmed and there are no
    contraindications. Exit the Uncomplicated Pregnancy Guideline.
    (Hofmeyr & Kulier, \"Cephalic version,\" 2001; Hofmeyr & Kulier,
    \"External cephalic version,\" 2001) (***QE*: I; *Overall Quality*:
    Good; *R*: B**)

**Interventions Weeks: 38-41**

**I-36 Weekly Cervical Check (Stripping/sweeping) \-- Weeks: 38-41**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend offering routine membrane stripping to all pregnant women
    every visit beginning at 38 weeks. (Boulvain et al., 1999) (***QE*:
    I; *Overall Quality*: Good; *R*: A**)

**I-37 Post-Dates Antenatal Fetal Testing \-- Week: 41**

*The Working Group´s recommendations for women in low risk pregnancy*:

1.  Strongly recommend antepartum fetal testing beginning at 41 weeks.
    (Rosen et al. 1995; Guidetti, Divon, & Langer, 1989) (***QE*: I;
    *Overall Quality*: Good; *R*: A**)

2.  Testing should consist of weekly amniotic fluid index (AFI) and
    twice weekly non-stress testing (NST). (***QE*: III; *Overall
    Quality*: Fair; *R*: B**)

3.  An AFI of less than 5 or a non-reactive NST should prompt further
    evaluation to determine the need for delivery. These women should
    exit the Uncomplicated Pregnancy Guideline. (Manning et al., 1993;
    Rutherford et al., 1987; Chamberlain et al., 1984) (***QE*: II-2,
    III; *Overall Quality*: Fair; *R*: B**)

**Interventions *[Not]{.underline}* Recommended in Prenatal Care**

**I-38 Screening with Fetal Fibronectin**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine screening for preterm birth with fetal
    fibronectin test. (Revah, Hannah, & Sue-A-Quan, 1998; Goldenberg et
    al., 1996; Greenhagen et al., 1996; Hellemans, Gerris, & Verdonk,
    1995; Lockwood et al., 1993; Leitech et al., 1999; Faron et
    al., 1998) (***QE*: I, II-2; *Overall Quality*: Good, Fair; *R*:
    D**)

**I-39 Cervical Examination**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against performing cervical examination to screen for
    preterm birth prevention in low risk asymptomatic pregnant women.
    (Buekens et al., 1994) (***QE*: I; *Overall Quality*: Good; *R*:
    D**)

**I-40 Antenatal Pelvimetry**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against the use of antenatal pelvimetry (clinical or
    radiographic) in routine prenatal care. (Pattinson, 2001) (***QE*:
    I; *Overall Quality*: Fair; *R*: D**)

2.  There is fair evidence that clinical pelvimetry is not effective in
    predicting the actual occurrence of cephalopelvic disproportion
    (CPD), and its performance is associated with significant increase
    in cesarean section rates. (Pattinson, 2001) (***QE*: I; *Overall
    Quality*: Fair; *R*: D**)

**I-41 Routine Urine Dipstick Test**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against the use of urine dipstick testing for protein and
    glucose during prenatal visits (the appropriate screening test for
    gestational diabetes is the one-hour glucola). (Kuo, Koumantakis, &
    Gallery, 1992) (***QE*: II-2; *Overall Quality*: Fair; *R*: D**)

2.  Recommend the use of selective laboratory urinalysis for pregnant
    women with signs or symptoms of preeclampsia.

**I-42 Routine Edema Evaluation**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine evaluation for edema in pregnancy .(Young
    & Jewell, 2000; Kent et al., 1999) (***QE*: II-1; *Overall Quality*:
    Fair; *R*: D**)

**I-43 Screening for Cytomegalovirus (CMV)**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  The evidence is insufficient to recommend for or against routine
    screening for CMV. (***QE*: III; *Overall Quality*: Poor; *R*: I**)

2.  Recommend counseling pregnant women about methods to prevent
    acquisition of CMV during pregnancy.

**I-44 Screening for Parvovirus**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine testing for parvovirus in pregnancy.
    (Guidozzi, Ballot, & Rothberg, 1994) (***QE*: II-3; *Overall
    Quality*: Fair; *R*: D**)

**I-45 Screening for Toxoplasmosis**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine testing for toxoplasmosis in pregnancy.
    (Wallon et al., 1999; Frenkel, 1995; Wong & Remington, 1994)
    (***QE*: I, II-3; *Overall Quality*: Fair; *R*: D**)

2.  Recommend counseling pregnant women about methods to prevent
    acquisition of toxoplasmosis during pregnancy. (***QE*: III;
    *Overall Quality*: Poor; *R*: C**)

**I-46 Screening for Bacterial Vaginosis**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine screening for bacterial vaginosis in
    asymptomatic pregnant women. (Guise et al., 2001; Carey et
    al., 2000) (***QE*: I; *Overall Quality*: Good; *R*: D)**

**I-47 Vitamin Supplementation**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend that multivitamin supplements taken one month
    preconceptually should be continued through the first trimester.
    (Werler et al., 1999) (***QE*: II-3; *Overall Quality*: Good; *R*:
    B**)

2.  Strongly recommend that folate supplement taken one month
    preconceptually should be continued through the first trimester.
    (Lumley et al., 2001) (***QE*: I; *Overall Quality*: Good; *R*: A**)

3.  The evidence is insufficient to recommend for or against routine
    multivitamin, pyridoxine, and vitamin D supplementation beyond the
    first trimester. (Mahomed \"Folate supplementation,\" 2001; Mahomed
    \"Iron and folate supplementation,\" 2001; Mahomed \"Iron
    supplementation,\" 2001; Mahomed & Gulmezoglu, \" Pyridoxine,\"
    2001; Mahomed & Gulmezoglu, \"Vitamin D,\" 2001) (***QE*: III;
    *Overall Quality*: Fair; *R*: I**)

4.  Recommend that women who have delivered a child with an open neural
    tube defect (NTD) should supplement their diets with 4 mg folate for
    at least one month prior to conception and through the first
    trimester to reduce the risk of recurrence.

5.  Recommend that pregnant women taking nutritional supplements for a
    medical condition should continue that supplementation throughout
    pregnancy (e.g., B-12 with pernicious anemia and folate with seizure
    disorders).

6.  Recommend that pregnant women on restrictive diets should have
    nutrition consultation to customize vitamin supplementation regimen.

**I-48 Immunization -- Measles, Mumps, Rubella (MMR)**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine measles/mumps/rubella (MMR) immunization
    during pregnancy. (Krogh et al., 1989) (***QE*: II-2; *Overall
    Quality*: Poor; *R*: D**)

**I-49 Immunization - Varicella**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine varicella vaccination in pregnancy. (Smith
    et al., 1998) (***QE*: II-2; *Overall Quality*: Poor; *R*: D**)

2.  Recommend serological testing early in pregnancy for all pregnant
    women with a negative or uncertain history. (Smith et al., 1998)
    (***QE*: II-2; *Overall Quality*: Poor; *R*: B**)

3.  Recommend offering vaccination postpartum for pregnant women who are
    non-immune. (***QE*: III; *Overall Quality*: Fair; *R*: B**)

**I-50 Ultrasound (US) Evaluation of Cervical Length at Week 24**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine cervical length screening at 24 weeks´
    gestation. (Iams, Goldsmith, & Weiss, 2001; Heath et al., 2000;
    Heath et al.,1998; Hibbard, Tart, & Moawad, 2000; Heath et al.,
    1998; Taipale & Hiilesmaa, 1998; Iams et al., 1996) (***QE*: II-2;
    *Overall Quality*: Fair; R: D**)

**I-51 Repeat Screening for Anemia, Syphilis, and Isoimmunization**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against routine repeat screening for blood group
    antibodies. (Davis & Abbott, 1986) (***QE*: II-2; *Overall Quality*:
    Fair; *R*: D**)

2.  Recommend against routine repeat screening for anemia and syphilis.
    (***QE*: III; *Overall Quality*: Poor; *R*: D**)

3.  Recommend providers consider repeat testing for anemia or syphilis
    at 24 to 28 weeks for women who are at higher risk for these
    conditions. (***QE*: III; *Overall Quality*: Poor; *R*: C**)

**I-52 Screening for Hypothyroidism**

*The Working Group´s Recommendations for Women in Low Risk Pregnancy*:

1.  Recommend against screening for thyroid hormone status of the
    mother. (Morreale de Escobar et al., 2000; Haddow et al., 1999; Pop
    et al., 1995) (***QE*: III; *Overall Quality*: Poor; *R*: D**)

2.  Recommend ensuring adequate iodine intake during pregnancy for
    pregnant women in areas of the country with questionable levels of
    dietary iodine. (Utiger, 1999) (***QE*: III; *Overall Quality*:
    Poor; *R*: C**)

**Definitions**:

**Quality of Evidence (QE)**

**I**: Evidence obtained from at least one properly randomized
controlled trial\
**II-1**: Evidence obtained from well-designed controlled trails without
randomization\
**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group\
**II-3**: Evidence obtained from multiple time series studies with or
without the intervention. Dramatic results in uncontrolled experiments
(such as the results of the introduction of penicillin treatment in the
1940s) could also be regarded as this type of evidence.\
**III**: Opinions of respected authorities, based on clinical
experience; descriptive studies and case reports; or reports of expert
committees

**Overall Quality**

**Good**: High grade evidence (I or II-1) directly linked to health
outcome\
**Fair**: High grade evidence (I or II-1 linked to intermediate outcome
or Moderate grade evidence (II-2 or II-3) directly linked to health
outcome\
**Poor**: Level III evidence or no linkage of evidence to health outcome

**Net Effect of Intervention**

**Substantial**:

-   More than a small relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A large impact on an infrequent condition with a significant impact
    on the individual patient level

**Moderate**:

-   A small relative impact on a frequent condition with a substantial
    burden of suffering, or

-   A moderate impact on an infrequent condition with a significant
    impact on the individual patient level

**Small**:

-   A negligible relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A small impact on an infrequent condition with a significant impact
    on the individual patient level

**Zero or Negative**:

-   Negative impact on patients, or

-   No relative impact on either a frequent condition with a substantial
    burden of suffering, or

-   An infrequent condition with a significant impact on the individual
    patient level

**Grade of Recommendation (R)**

**A**: A strong recommendation that the intervention is always indicated
and acceptable\
**B**: A recommendation that the intervention may be useful/effective\
**C**: A recommendation that the intervention be considered\
**D**: A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I**: Insufficient evidence to recommend for or against; clinical
judgment should be used

**Abbreviations**

AAP - American Academy of Pediatrics\
ACOG - American College of Obstetricians and Gynecologists\
AFI - Amniotic Fluid Index\
AFP - Alpha-fetoprotein\
AIDS - Autoimmune Disorder\
AIUM - American Institute of Ultrasound in Medicine\
ASB - Asymptomatic Bacteriuria\
Bid - Twice a Day\
BMI - Body Mass Index\
BP - Blood Pressure\
CAGE - Alcohol Abuse/Dependency Screening Instrument\
CBC - Complete Blood Count\
CDC - Centers for Disease Control\
CF - Cystic Fibrosis\
CI - Confidence Interval\
CMV -- Cytomegalovirus\
CPD - Cephalopelvic Disproportion\
CPG - Clinical Practice Guideline\
CPS - Clinical Preventive Services\
CREOG - Committee on Resident Education in Obstetrics and Gynecology\
CRS - Congenital Rubella Syndrome\
DE - Dependent Edema\
DoD - Department of Defense\
DM - Diabetes Mellitus\
DRG - Diagnosis Related Groups\
EDC - Estimated Date of Confinement\
EGA - Estimated Gestational Age\
GBS - Group B Streptococcus\
GDM - Gestational Diabetes Mellitus\
GTT - Glucose Tolerance Test\
HBIG - Hepatitis B Immune Globulin\
HCG - Human Chorionic Gonadotropin\
HIV - Human Immunodeficiency Virus\
HTN -- Hypertension\
IAP - Intrapartum Antibiotics for Prophylaxis\
ICSI - Institute for Clinical Systems Improvement\
IOM - Institute of Medicine\
IPA - Intrapartum Antibiotics\
IUFD - Intrauterine Fetal Demise\
IV -- Intravenous\
LEEP - Loop Electrosurgical Excisional Procedure\
MMR - Measles/Mumps/Rubella\
MOM - Multiples of the Median\
MSAFP - Maternal Serum Alpha-fetoprotein\
NDDG - National Diabetes Data Group\
NIH - National Institute of Health\
NNT - Number-Needed-To-Treat\
NST - Non-Stress Testing\
NTD - Neural Tube Defect\
OB/GYN - Obstetrician/Gynecologist or Obstetrical/Gynecological\
ONTD - Open Neural Tube Defects\
Pap -- Papanicolaou\
PID - Pelvic Inflammatory Disease\
PROM - Premature Rupture of Membranes\
RCT - Randomized Controlled Trials\
RPR - Rapid Plasma Reagin\
RR - Relative Risks\
SIDS - Sudden Infant Death Syndrome\
SOGC - Society of Obstetricians and Gynaecologists of Canada\
STD - Sexually Transmitted Disease\
Td -- Tetanus\
TOC - Test of Cure\
TSH - Thyroid Stimulating Hormone\
US -- Ultrasound\
USPSTF -- United States Preventive Services Task Force\
VDRL - Venereal Disease Research Laboratory\
VA - Veterans Administration\
VHA - Veterans Health Administration

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for
[Management of Uncomplicated
Pregnancy](http://www.oqp.med.va.gov/cpg/UCP/up_cpg/content/algorithms/algo_fr.htm).

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=3847)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Standardization to minimize variation in care

-   Early identification and management of factors that can cause
    adverse perinatal outcomes

-   Improved maternal, fetal, and neonatal outcomes, such as decreased
    morbidity, mortality, and complications of pregnancy

-   Improved patient and provider satisfaction

#### POTENTIAL HARMS

-   False-positive test results. Maternal serum analyte screening can
    yield high false-positive rate which may result in the need for
    subsequent non-invasive (targeted sonography) and invasive testing
    (amniocentesis)

-   False-negative test results. For example, a triple screen test can
    give false-negative results.

-   Injury from invasive tests. For example, amniocentesis can result in
    fetal loss.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Contraindications to tetanus diphtheria (Td) immunization include a
previous severe reaction to Td vaccination, such as anaphylaxis,
generalized urticaria or angioedema.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Clinical practice guidelines, which are increasingly being used in
    health care, are seen by many as a potential solution to
    inefficiency and inappropriate variations in care. Guidelines should
    be evidenced-based as well as based upon explicit criteria to ensure
    consensus regarding their internal validity. However, it must be
    remembered that the use of guidelines must always be in the context
    of a health care provider\'s clinical judgment in the care of a
    particular patient. For that reason, the guidelines may be viewed as
    an educational tool analogous to textbooks and journals, but in a
    more user-friendly format.

-   Modifications to the guideline will undoubtedly be necessary as a
    result of lessons learned and new research and practice-based
    evidence. The developers believe that this guideline should always
    be considered \"a work in progress.\"

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Pocket Guide/Reference Cards\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

U.S. Department of Veteran Affairs, Veterans Health Administration,
Veterans Health Administration. DoD/VA clinical practice guideline for
the management of uncomplicated pregnancy. Washington (DC): Department
of Veteran Affairs; 2002 Oct. Various p. \[533 references\]

#### ADAPTATION

The development of this guideline incorporated information from several
existing evidence-based guidelines/reports, to include the following:

-   Institute for Clinical Systems Improvement (ICSI) - *Health Care
    Guideline: Routine Prenatal Care*, July 2000.

-   Guide to Clinical Preventive Services (CPS) Second Edition, *Report
    of the U.S. Preventive Services Task Force*, 1996.

The Working Group also acknowledged the frequent use of the American
College of Obstetricians and Gynecologists (ACOG) technical bulletins
and guidelines as a respected source for expert opinion.

#### DATE RELEASED

2002 Oct

#### GUIDELINE DEVELOPER(S)

Department of Defense - Federal Government Agency \[U.S.\]\
Department of Veterans Affairs - Federal Government Agency \[U.S.\]\
Veterans Health Administration - Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Uncomplicated Pregnancy Working Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Editorial Panel of the Working Group*: Susan Altenburg, LTC/AN,
Certified Nurse-Midwife, Fort Carson; Lori Bond, LTC/AN, Certified
Nurse-Midwife, Womack Army Medical Center; Gwenn Garmon, Director of
Women´s Health, VA CHCS Westside Division; John R. Holman, MD, MPH,
FAAFP, CDR, Director for Medical Services, Naval Hospital Camp
Pendelton; Mary Krueger, DO, MAJ/MC, Family Practice, Madigan Army
Medical Center; Chip Taylor, MD, CDR, Family Practice, BUMED; Michael
Yancey, MD, COL, Director of Prenatal Services, Tripler Army Medical
Center; Oded Susskind, MPH, Medical Education Consultant (Facilitator);
Joanne Marko, MS, SLP, Senior Consultant, ACS Federal Healthcare, Inc.
(Coordinator)

*Members of the Working Group*: Deborah Bostock, MD, LtCol, Family
Medicine; Beth Bowers-Klaine, LtCol, Certified Nurse-Midwife; Dana
Bradshaw, Col, MC, USAF, Chief, Preventive Medicine; John Brehm, MD,
Internal Medicine, West Virginia Medical Institute; Jay Carlson, LTC,
MC, USA, OB/GYN Consultant to Army OTSG, Walter Reed Army Medical
Center; Laurie Davis, COL (R), AN, Certified Nurse-Midwife, Walter Reed
Army Medical Center; Katherine Dolter, RN, PhD, LTC, USA, Chief, Outcome
Management, Medical Command, US Army; Rhonda Earls, LTC/AN, Certified
Nurse-Midwife, Dewitt Army Community Hospital; Bardett Fausett, MD, Maj,
Director of Maternal-Fetal Medicine and Obstetrics, Keesler Medical
Center; Pauline Gross, MAJ, Physician´s Assistant, PERSCOM, Hoffman;
Barbara Hector, WHNP, RN, LTC, OB/GYN, Brooke Army Medical Center;
Brenda Hoolopa, CDR, Perinatal Clinical Nurse Specialist, Navy Hospital
Camp Lejune; Nancy Hueppchen, CDR, MFM/OB, National Navy Medical Center;
Jack Klausen, MD, OB/GYN, Camp Pendelton, Connie LaRosa, OB/GYN
RN/Women\'s Health, Veterans Administration; Rob Manaker, Lt Col, Family
Practice Consultant, USAF, Air Force Medical Operations Agency; Carole
Most, WHCNP, Program Director, Women´s Health; DVA Medical
Center-Portland; Louis Nelson, RN, West Virginia Medical Institute; Lori
Newman, LTC/AN, Certified Nurse-Midwife, Family Nurse Practitioner,
Bassett Army Community Hospital; Peter Nielson, MD, OB/GYN Residency
Program Director, Madigan Army Medical Center; Jackie Parsons, CDR,
Labor and Delivery RN, Naval Healthcare Support Office; Maria Perry, RN,
LCDR, Naval Hospital Bremerton; Jeffery Quinlan, LCDR, Family Practice,
Naval Hospital Jacksonville; Mark Reeves, MD, MAJ, Family Practice,
Tripler Army Medical Center; Steve Remenga, CAPT, MC, USN, Deputy
Director Clinical Operations, Tricare Northwest; Andrew Satin, LTC,
OB/GYN, USUHS; Brooke Thompson, MD MAJ, Chief, Obstetrics Service,
Medigan Army Medical Center; Cynthia Thumser, RN, West Virginia Medical
Institute; Carole Turner, RN, Women´s Health, Veterans Administration;
Ada Ventura-Braswell, MD, MAJ, OB/GYN, Womack Army Medical Center; Debby
Walder, RN, MSN, Director of Quality and Performance, VHA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Department of Veterans Affairs
Web site](http://www.oqp.med.va.gov/cpg/UCP/UP_base.htm).

Print copies: Department of Veterans Affairs, Veterans Health
Administration, Office of Quality and Performance (10Q) 810 Vermont Ave.
NW, Washington, DC 20420.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Management of uncomplicated pregnancy. Washington (DC): National CPG
    Council; 2003. Various p.

-   VHA/DoD clinical practice guideline for the management of
    uncomplicated pregnancy. Summary guideline. Washington (DC):
    Department of Veterans Affairs (U.S.); 2002 Sep. 27 p. See the
    related QualityTool summary on the [Health Care Innovations Exchange
    Web site](http://innovations.ahrq.gov/content.aspx?id=1119).

-   VHA/DoD clinical practice guideline for the management of
    uncomplicated pregnancy. Pocket guide. Washington (DC): National CPG
    Council; 2002 Sep. 2 p. See the related QualityTool summary on the
    [Health Care Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1243).

-   VHA/DoD clinical practice uncomplicated pregnancy. Key points.
    Washington (DC): National CPG Council; 2002 Sep. 2 p. See the
    related QualityTool summary on the [Health Care Innovations Exchange
    Web site](http://innovations.ahrq.gov/content.aspx?id=1132).

-   VHA/DoD clinical practice uncomplicated pregnancy. Algorithm.
    Washington (DC): National CPG Council; 2002 Sep. 1 p. See the
    related QualityTool summary on the [Health Care Innovations Exchange
    Web site](http://innovations.ahrq.gov/content.aspx?id=1118).

Electronic copies: Available from the [Department of Veterans Affairs
Web site](http://www.oqp.med.va.gov/cpg/UCP/UP_base.htm).

Print copies: Department of Veterans Affairs, Veterans Health
Administration, Office of Quality and Performance (10Q) 810 Vermont Ave.
NW, Washington, DC 20420.

The following is also available:

-   Putting clinical practice guidelines to work \[online tutorial\].
    Available from the [Department of Veterans Affairs Web
    site](http://www.oqp.med.va.gov/Training/WWW/010000000010.html).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 5, 2004. This summary was
updated by ECRI Institute on October 3, 2007 following the U.S. Food and
Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium).

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008