Limited or No Prenatal Care & Preterm Labor Notes

Limited or No Prenatal Care

Definition

Late or no prenatal care (PNC) is defined as births occurring to mothers in the third trimester with no documentation of PNC, or documented no PNC on the child's birth certificate, according to the U.S. Department of Health and Human Services (DHHS, 2015). Prenatal care, ideally beginning in the first trimester, involves regular check-ups with a healthcare provider to monitor the health of both the mother and the developing fetus. It includes screenings for potential complications, vaccinations, and education on healthy behaviors during pregnancy. Early and consistent prenatal care is associated with better maternal and infant outcomes.

Incidence

• In 2014, there were $3,988,076$ live births in the U.S. (CDC, 2014).

• 4-11% of all reported births were to women with late or no PNC (DHHS, 2015).

• American Indian and Alaska Native women were the most likely to receive late or no PNC (11%), followed by Black (10%) and Hispanic women (8%). These disparities may reflect systemic inequities in access to healthcare and social services. Culturally competent care and targeted outreach programs are needed to address these disparities.

• 6% of births among Asian or Pacific Islander women and 4% of births among White women received late or no PNC (DHHS, 2015).

• Young women are the least likely to receive timely PNC; in 2014, 25% of births to females under age 15 and 10% of births to teens ages 15-19 were to those receiving late or no PNC (DHHS, 2015). This is often due to factors such as lack of awareness, fear of parental involvement, and limited access to confidential healthcare services. Programs that provide comprehensive sex education, confidential healthcare, and support services can help improve PNC rates among young women.

• Almost 40% of annual births in the United States result from an unintended pregnancy (Guttmacher Institute, 2015). Unintended pregnancies are associated with delayed initiation of PNC, as women may not realize they are pregnant until later in gestation. Increased access to contraception and family planning services can reduce the rate of unintended pregnancies and improve PNC rates.

• Infants born to mothers who receive no PNC are:-

  • Three times more likely to be born with low birth weight. Low birth weight infants are at higher risk for numerous health complications, including respiratory distress syndrome, infections, and developmental delays.

  • Five times more likely to die (DHHS, 2015). This stark statistic underscores the critical importance of PNC in preventing infant mortality.

  • Have twice the risk of preterm birth (Cunningham et al., 2014). Preterm birth is a leading cause of infant morbidity and mortality, and adequate PNC can help identify and manage risk factors for preterm labor.

Reasons for Not Seeking Prenatal Care

Pregnant women may not seek PNC for various social, economic, and medical reasons. Addressing these barriers requires a multifaceted approach involving healthcare providers, policymakers, and community organizations.

• CDC analysis of birth certificate data found risk factors for inadequate PNC including ethnicity, socio-economic status, age and method of payment for services (CDC, 2014; Every Mother Counts, 2014), undocumented status (Guttmacher Institute, 2016a), or other problems (Guttmacher Institute, 2016a).

• Common reasons cited:-

  • Woman did not know she was pregnant.

  • Lacked money or insurance.

  • Had no transportation (DHHS, 2013, 2015).

• In 2015, the number of uninsured women of childbearing age (ages 15-44) in the United States decreased from 19.6% in 2012 to 13.3% due to the Affordable Care Act (Shartzer et al., 2015); however, this still leaves approximately $530,400$ women annually without insurance. Despite progress, disparities in health insurance coverage persist, particularly among low-income and minority women. Continued efforts to expand access to affordable health insurance are essential.

• Uninsured women are less likely to access PNC (Schartzer et al., 2015).

• Lack of money or insurance is the second most likely reason for a woman to delay or not obtain PNC, the most common being late identification of pregnancy (Cunningham et al., 2014, p. 167). This highlights the need for affordable and accessible healthcare services, as well as increased awareness of early pregnancy symptoms.

• Compared with women having planned births, those who have unplanned births are less likely to recognize pregnancy early, to receive early PNC or to breastfeed, and are more likely to have low-birth-weight babies (Guttmacher Institute, 2015). Promoting family planning and contraception can reduce the number of unplanned pregnancies and improve maternal and infant health outcomes.

• National trends toward restrictive access to abortion services can create a situation where a woman does not desire a pregnancy yet cannot terminate it (Guttmacher Institute, 2015). These restrictions can lead to delayed or absent PNC, as women may feel conflicted or hopeless about their situation. Ensuring access to comprehensive reproductive healthcare services, including abortion, is crucial for promoting maternal and infant well-being.

• The 6.4 million women of reproductive age who are not U.S. citizens are much less likely to be insured, especially those who live in poverty and are often barred from Medicaid (Guttmacher Institute, 2016a). Immigration status can be a significant barrier to accessing healthcare, and policies that restrict access to services for undocumented individuals can have detrimental effects on maternal and infant health. Addressing these issues requires comprehensive immigration reform and policies that ensure access to healthcare for all.

• Other barriers may include social pressures such as undocumented legal status, relocation, drug abuse, fear of interacting with "the system", difficulty with assessing care, or being a woman who has experienced intimate partner violence or reproductive coercion (Guttmacher Institute, 2016c). These complex social and personal factors can make it challenging for women to seek and receive PNC. Addressing these barriers requires a trauma-informed approach that recognizes the impact of violence, substance abuse, and mental health issues on women's health.

Emergency Medical Treatment and Active Labor Act (EMTALA)

• Mandates a medical screening exam (MSE) for any pregnant woman, regardless of age, who presents to obstetric triage with uterine contractions, or who might be in active labor (CMS, n.d.). EMTALA ensures that all pregnant women have access to emergency medical care, regardless of their ability to pay.

• The examination includes assessment of:-

  • Vital signs.

  • Fetal heart tracing (FHT) status.

  • Frequency and intensity of uterine contractions.

  • Fetal presentation.

  • Cervical dilatation.

  • Status of membranes.

  • Rapid assessment of the presenting complaint (CMS, n.d.).

• The MSE examination must be performed by a "qualified medical examiner" (QME; CMS, n.d.), who is someone credentialed to perform this function within this setting and who meets hospital credentialing requisites, as well as state rules and regulations for practice (CMS, n.d.). QMEs play a critical role in ensuring that pregnant women receive timely and appropriate medical care.

• The QME may include physicians, certified nurse midwives, nurse practitioners, physician assistants, or RNs (CMS, n.d.). The diversity of QMEs reflects the importance of a multidisciplinary approach to maternal healthcare.

Care of Minors

• State law is superseded by EMTALA in the case of pregnant minors who are pregnant and contracting (CMS, n.d.). EMTALA provides essential protections for pregnant minors, ensuring that they receive necessary medical care regardless of state laws.

• In the case of a minor who is pregnant but not contracting, regulations differ by state.

• The great majority of states and the District of Columbia currently allow a minor to obtain confidential PNC, including regular medical visits and routine services for pregnancy (Guttmacher Institute, 2016b). Confidential PNC is essential for ensuring that pregnant minors receive the care they need, without fear of parental involvement or judgment.

Examination of the Woman with Late or No PNC at Term

• Even when a woman is obviously pregnant, the presenting complaint may not include pregnancy (Minnerop, Garra, Chohan, Troxell, & Singer, 2011). This highlights the importance of a thorough assessment of all women presenting to obstetric triage.

• The history alone is not a reliable method of confirming pregnancy.

• Key Questions to Ascertain Relevant Pregnancy History:1. When was your last menstrual period?

1. Do you know when your due date is?

2. Were you using contraception?

3. What number pregnancy is this for you?

4. What happened with your previous pregnancies?-

   • Were they term?

   • Were they normal vaginal deliveries or cesarean sections?

5. Have you received any prenatal care anywhere? If so, where?

6. Do you have any medical problems?

7. Do you take any medications? Any drug usage?

8. Do you have any allergies?

9. Do you feel fetal movement?

10. Do you have vaginal bleeding?

11. Are you having contractions, if so, how frequently?

12. Have you noticed leaking of fluid?

13. Intimate partner violence or control screening questions

14. Travel history and corresponding symptomology including specific questions regarding areas where Zika, Ebola, or tuberculosis are endemic

15. Drug and alcohol screen questions

Symptomatology

• The most frequent presenting symptomology includes: gastrointestinal and gynecologic complaints, urinary issues, trauma, psychiatric problems, syncope, chest pain, or respiratory difficulty. Recognizing these diverse symptoms is crucial for identifying pregnant women who may not be aware of their pregnancy or who have not received PNC.

• In addition to determining the chief complaint, it is crucial to obtain as much information as possible about the pregnancy to date.

Physical Examination

• Vital signs are performed at the point of care to evaluate maternal status and confirm a viable, intrauterine pregnancy. Monitoring vital signs such as blood pressure, heart rate, and temperature can provide valuable information about the mother's overall health and identify potential complications.

• Establishing gestational age is crucial at this time; ideally, this is performed and confirmed by ultrasound identifying the following:-

  • Fetal presenting part.

  • Number of fetuses.

  • Placental location.

  • Amniotic fluid index.

  • Biometry.

• Biometry is the measurement of fetal head circumference, abdominal circumference, and femur bone length that are used to calculate an estimated fetal weight (EFW).

• Fetal weight loosely corresponds to gestational age although the accuracy of ultrasound for estimation of EFW decreases as pregnancy advances, as the margin of error is 8% (Cunningham et al., 2014). Accurate estimation of gestational age is essential for guiding management decisions and predicting potential complications.

• The abdominal examination consists of:-

  • Observing for any scars suggestive of previous cesarean section or other uterine surgeries.

  • Palpation of fundal height for an estimation of gestational age.

  • Evaluation for uterine contractions.

• Leopold's maneuvers are performed, which are a series of gentle and deliberate palpations of the abdomen that can help to establish fetal position, lie, presentation, and EFW of the fetus (Cunningham et al., 2014). Leopold's maneuvers are a valuable tool for assessing fetal position and presentation, which can help guide decisions about mode of delivery.

• An external fetal monitor is applied to assess the fetal heart rate and frequency/intensity of uterine contractions. Continuous fetal monitoring allows for the detection of fetal heart rate abnormalities that may indicate fetal distress.

• Establishing fetal well-being is a vital part of the evaluation; a normal fetal heart rate baseline is between 110 to 160 beats per minute.

• Fetal Doppler or external fetal monitor is used to ascertain the fetal heart rate and assess for baseline, variability, and presence or absence of accelerations and decelerations. Assessing fetal heart rate variability and accelerations can provide important information about fetal oxygenation and overall well-being.

• An abdominal ultrasound is performed to eliminate the finding of placenta previa; a vaginal examination performed in the presence of placenta previa can cause a life-threatening hemorrhage to mother and fetus. Ultrasound is a non-invasive and essential tool for assessing placental location and ruling out placenta previa.

• A speculum examination is performed to observe for the following:-

  • Lesions.

  • Bleeding.

  • Fluid pool.

  • Vaginal discharge.

  • Signs of infection.

  • Cervical dilation.

  • Presenting part.

  • Prolapsing umbilical cord.

• A vaginal examination is performed to assess cervical dilation, effacement, station, and fetal presentation. Vaginal examination provides valuable information about the progress of labor and helps guide decisions about management.

Laboratory and Imaging Studies

• Specimens collected during the sterile speculum examination might include amniotic fluid testing for nitrazine and ferning, as well as a wet mount. These tests can help confirm rupture of membranes and identify potential infections.

• When an abnormal vaginal discharge is observed, a swab may be collected for Affirm™ testing, which uses DNA probes to detect and identify the three most common sources of vaginal infection: Candida species, Gardnerella vaginalis, and Trichomonas vaginalis. Accurate diagnosis of vaginal infections is essential for providing appropriate treatment and preventing potential complications.

• Cultures for gonorrhea and chlamydia as well as a Group B Strep (GBS) culture need to be obtained. Screening for sexually transmitted infections (STIs) and GBS is crucial for protecting the health of both the mother and the newborn.

• A urine drug screen may be warranted, and the woman's consent is usually necessary before this can be collected and sent for analysis. Urine drug screening can identify substance abuse issues that may impact pregnancy and guide appropriate interventions.

• GBS is a bacterium associated with neonatal infection and sepsis and is transmitted from mother to fetus during the birth process. GBS screening is a routine part of prenatal care, and women who test positive are treated with antibiotics during labor to prevent transmission to the newborn.

• Women with unknown GBS status are treated based on risk factors; however, a confirming culture may prove useful in care of the neonate; treatment is comprised of appropriate antibiotics administered during labor and until the infant is born. This approach ensures that women with unknown GBS status receive appropriate treatment to prevent neonatal GBS infection.

Group B Strep (GBS) Risk Factors

If GBS status is unknown, the recommendation is to give intrapartum prophylaxis by risk factors:

1. Preterm labor less than 37 weeks.

2. Preterm premature rupture of membranes less than 37 weeks.

3. Rupture of membranes greater than 18 hours.

4. Maternal fever during labor greater than $38$°C or $100.4$°F.

5. Previous infant with GBS sepsis.

6. GBS bacteriuria during current pregnancy.

• In addition to the routine prenatal laboratory panel, additional labs may be necessary based on individual cases; Additional testing may be warranted based on individual risk factors and clinical presentation.

• For instance, if a woman has recently been out of the country or is a recent immigrant, she might have been exposed to a variety of infectious or communicable diseases, including viral or parasitic infections, such as measles, mumps, diphtheria; malaria, Ebola, or Zika may be considered in women from areas where these diseases are endemic. Travel history is an important consideration in assessing potential risks to the mother and fetus.

• Women may present with previously undiagnosed conditions such as tuberculosis and will need appropriate precautions and isolation as indicated. Early identification and management of underlying medical conditions is essential for optimizing maternal and infant health outcomes.

Prenatal Laboratory Panel for Women With No Prenatal Care at Term

Differential Diagnosis

The differential diagnoses often include assessment of labor, evaluation of ruptured membranes, and monitoring of other pregnancy or medical conditions. A comprehensive differential diagnosis is essential for ensuring accurate and timely management of pregnant women presenting with late or no PNC.

• Other conditions such as placental abruption, umbilical cord prolapse, and chorioamnionitis need to be addressed accordingly. These conditions can pose significant risks to both the mother and the fetus and require prompt recognition and management.

Clinical Management and Follow-Up

• Some pregnant women presenting to obstetric triage at term with scant or no previous PNC may be in active labor or could be close to delivery when they present for care. These women require immediate assessment and management to ensure the safety of both the mother and the newborn.

• In the case of those women not in active labor but with reassuring fetal status, referral for a prompt formal ultrasound and access to PNC are critical. Ultrasound can help confirm gestational age and identify potential complications, while PNC can provide ongoing monitoring and support.

• Some women may simply have been unaware of services available to them. Education and outreach efforts can help increase awareness of available resources and encourage women to seek PNC.

• Social services may identify needed supports and establish access to services and/or insurance. Addressing social determinants of health is essential for improving maternal and infant health outcomes.

• Still other women require substantial social services to address homelessness, abusive situations, drug use, or mental health problems. These complex social and personal factors can significantly impact pregnancy outcomes and require a multidisciplinary approach involving healthcare providers, social workers, and community organizations.

• The key factors in the assessment of the woman with little or no PNC at term include identifying labor and addressing immediate needs.

• Appropriate follow up care includes admission to the hospital or referral for appropriate services.

Clinical Pearls

The essential elements of care for the pregnant woman at term with late or no PNC include establishing maternal and fetal well-being; determining the gestational age of the pregnancy, number of fetuses, fetal presentation, and labor status; travel history; and addressing immediate needs. By focusing on these key elements, healthcare providers can ensure that women presenting with late or no PNC receive the best possible care.

• Four to eleven percent of all reported births were to women with late or no PNC.

• The risk factors for unknown GBS status include preterm labor at less than 37 weeks, preterm premature rupture of membranes, rupture of membranes at term greater than 18 hours, maternal fever, prior infant with GBS sepsis, and GBS bacteriuria during current pregnancy.

Preterm Labor

Definition

Defined as a delivery that occurs prior to 37 weeks gestation, preterm birth is the leading cause of perinatal mortality and long-term infant morbidity worldwide (Frey & Klebanoff, 2016). Preterm birth can lead to a variety of complications for the newborn, including respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Long-term sequelae may include cerebral palsy, developmental delays, and learning disabilities.

Incidence

• According to the National Center for Health Statistics, the preliminary preterm birth rate in the United States for 2015 was 9.62% (Hamilton, Martin, & Osterman, 2016).

• Although this represents a small percent rise from 2014 (9.57%), the preterm birth rate in the United States has been steadily decreasing since 2006 when the rate peaked at 12.8% (Hamilton et al., 2016). Despite this progress, the preterm birth rate in the United States remains a significant public health concern.

• Despite these trends, the preterm birth rate in the United States remains one of the highest among industrialized nations (Frey & Klebanoff, 2016). This disparity highlights the need for continued research and interventions to reduce preterm birth rates in the United States.

• Preterm births are classified as either spontaneous (i.e., premature rupture of membranes or preterm labor with cervical dilatation) or indicated (i.e., induction of labor for maternal or fetal complications). Spontaneous preterm births occur when labor begins on its own, while indicated preterm births are the result of a decision to deliver the baby early due to medical concerns.

• Preterm births are also categorized by gestational age at delivery; for example, preterm births occurring between 34 and 36 weeks are referred to as late preterm births (Hamilton et al., 2016). Late preterm infants are at increased risk for a variety of complications, including respiratory distress, feeding difficulties, and temperature instability.

• This chapter will present the diagnosis and management of spontaneous preterm labor in singleton pregnancies occurring between 24 and 34 weeks gestation.

Etiology and Risk Factors

• Regular and painful uterine contractions that result in cervical change have been the long-accepted definition of labor. Uterine contractions cause the cervix to dilate and efface, allowing the baby to descend into the birth canal.

• Until recently, this "common pathway of parturition" was thought to occur similarly in both full-term and preterm labor (Romero, Dey, & Fisher, 2014). However, research has shown that preterm labor is a more complex process than previously thought.

• Unlike labor at full-term gestations, however, spontaneous preterm labor is an enigmatic process that occurs when the normal labor pathway is triggered through various pathologic mechanisms. Identifying these mechanisms is crucial for developing effective strategies to prevent preterm birth.

• Intrauterine infection or inflammation, immunologic reactions, hormonal disorders, cervical insufficiency, and uterine ischemia, hemorrhage, or overdistention have all been implicated as associated factors in preterm labor (Romero et al., 2014). These factors can trigger a cascade of events that lead to preterm labor and delivery.

• More recently, specific genetic and genome pathways have been linked to birth timing (Frey & Klebanoff, 2016). These genetic factors may predispose some women to preterm labor. Furthermore, environmental factors such as smoking, substance abuse, and exposure to toxins have been linked to an increased risk of preterm birth. Understanding the complex interplay of genetic, environmental, and lifestyle.