At Your Fingertips - Before, Between & Beyond Pregnancy

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Components of Care	Key Questions/Assessments	Key Recommendations/Patient Education Supports
Family Planning Guidance	Would you like to become pregnant in the next year? (Woman indicates “not sure”, “haven’t thought about it” or other indicator of uncertainty or ambivalence.)	• Encourage woman to consider whether she wants any or any more children during her lifetime. If so, encourage development of reproductive life plan. • Refer to Family Planning tab in full Clinical Toolkit for reproductive life planning tools and strategies to reduce unintended conception. • If relevant, educate about safest interconception lengths (18-59 months). • Encourage use of highly effective method of contraception such as one of the LARCs. • Encourage her to return to your office for further guidance if her desires change.
Nutrition Status	BMI Assess use of Folic Acid and other nutritional supplementation.	• Counsel about advantages of achieving weight as close as possible to ideal BMI (18.5-24.9) and specific risks of underweight, obesity to future pregnancies; • Recommend a varied and balanced diet and a multivitamin with at least 400 mcg folic acid daily. • Refer to detailed guidance for specific nutrients and nutrition related disorders under Nutrition tab in full Clinical Toolkit.
Infectious Disease Status and Immunizations	Review immunization status Assess risks for, at a minimum, influenza, Hepatitis B, rubella, varicella, tuberculosis, HIV, HPV	• Offer Hepatitis B, Rubella and Varicella immunizations, as indicated; offer HPV vaccine to non-immunized women ages 13-26. (if administer live vaccines, stress precautions against unintended pregnancy for appropriate interval); • Test for infectious diseases listed on left, as indicated and provide counseling on risk reduction behaviors. • Refer to detailed guidance for specific diseases under Infectious Disease tab in full Clinical Toolkit.
Chronic Diseases	Review patient history for evidence of chronic disease (e.g. hypertension, diabetes, seizure disorder, etc).	• Educate woman on implications of the disease on her own health should she conceive, especially without planning to do so, and on her pregnancy outcomes; • Evaluate target organs affected by disease (e.g. kidneys in diabetes); • Strive for optimal control with fewest/safest medications;•Enlist specialists (e.g. maternal-fetal medicine, internists) for guidance.•Refer to detailed guidance for specific diseases under Chronic Disease tab in full Clinical Toolkit.
Medications	Assess prescription, OTC and herbal medication profile.	• If woman not using a highly effective method of contraception, help her achieve safest medication profile given her risk for an unintended pregnancy. • For essential medication, aim for the choice(s) that balance optimal effectiveness with lowest teratogenic potential at the lowest effective dose; • Stress that herbal products are not required to be tested for safety in and around pregnancy.•Educate woman NOT to stop prescription drugs prescribed for chronic diseases without medical consultation—even if she thinks she has become pregnant.
Substance Use	Use a tool such as the NIDA Quick Screen to assess substance exposures: In the past year how often have you used the following? • 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily) • Tobacco products (never, once or twice, monthly, weekly, daily or almost daily) • Prescription drugs for nonmedical reasons (never, once or twice, monthly, weekly, daily or almost daily) • Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily).	• Advise all women that no amount of alcohol has proven safe at any time in pregnancy;• Use best practice such as SBIRT to counsel women who screen positive for alcohol, prescription and illegal drug abuse;• Use best practice of 5As to counsel women who use tobacco products. • Refer women who disclose signs of symptoms of addiction for more extensive treatment. • More detailed intervention strategies are provided under Substance Use tab in full Clinical Toolkit.
Previous Pregnancy Outcomes	If history of prior pregnancy, assess if complicated by: miscarriage, preterm birth, low birthweight, congenital anomalies, cesarean birth, preeclampsia, GDM, uterine anomalies.	• If yes to any of these explain to the woman that the likelihood of recurrence can be lessened by planning for future pregnancies and addressing any risk factors before becoming pregnant. • Refer to guidance for specific outcome under Reproductive History tab in full Clinical Toolkit.
Genetic Risks	Undertake a quick genetic screen:• Do you, your partner, previous children or other relatives have a birth defect, genetic condition, developmental delay or learning disability? • Are you or your partner of Eastern European Jewish ancestry? Of Caucasian, non-Hispanic ancestry? Of French-Canadian or Cajun ancestry? Of African, Mediterranean or Asian ancestry? • Have you had two or more miscarriages? • Have you or your partner had a previous pregnancy end because of a birth defect, genetic disease, or death before or after birth? • Will you be 35 years old or older when you plan to give birth?	• If yes to any to any of the queries in the screen, refer to guidance under Genetic History tab in full Clinical Toolkit;
Mental Health History	All women should be assessed for depression at least once a year (an assessment tool such as the PDQ-9 screen can be used) In addition, ask about: history of mental illness; mood disorders, suicidal ideation, homicidal ideation, postpartum depression, behavioral changes.	• If under current treatment, assess safety of drug profile (see Medication tab in full Clinical Toolkit) • Underscore the risks of stopping any medication without medical supervision, even if she thinks she has become pregnant; • Counsel woman about potential for exacerbations or recurrences in and following pregnancy, about benefits of actively planning if and when to become pregnant and strategies to identify and manage such occurrences; • Refer to specific guidance for depression, bipolar disorders and schizophrenia under Mental Health tab in full Clinical Toolkit.
Intimate Partner Violence	Explain that you regularly ask all women a series of questions to assess their safety. Suggested queries include: • Are you in a relationship with a person who threatens or physically hurts you? • Within the past year have you been hit, slapped, kicked or otherwise physically hurt by someone? •Do you ever feel afraid of your partner? •Has anyone forced you to have sexual activities that made you feel uncomfortable?•Have you and your partner discussed whether you want a pregnancy together?	• If the woman answers “yes” to any of the first 4 questions: • Acknowledge the trauma • Express your concern for her welfare • Provide referrals to local and national resources (refer to Intimate Partner Violence tab in full Clinical Toolkit for specific guidance): • Educate women in violent relationships, that there is no evidence that pregnancy resolves violence and that, in fact, it often increases during pregnancy.• Encourage woman to create a safety plan. • If woman indicates she and her partner have not discussed pregnancy plans (or that they are not of the same opinion), explore more fully.

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