|Components of Care||Key Questions/Assessments||Key Recommendations/Patient Education Supports|
|Family Planning Guidance||Would you like to become pregnant in the next year?
Assess whether the woman has a Reproductive Life Plan by asking:
Are you hoping to have any (more) children in the future? If so, have you thought about how many you would like and how soon you would like to have them?
Ask: What would you like to do to avoid a pregnancy until you want to conceive?
|• Encourage the woman to consider whether she wants any or any more children and, if so, when she hopes to become pregnant (Reproductive Life Plan).
• Offer contraceptive counseling (considering CDC MEC if medical conditions are present) consistent with the woman’s Reproductive Life Plan, preferences, and medical conditions/contraindications.
• If relevant, educate about fertility issues with advancing maternal age.
• If relevant, educate about ideal interconception interval (18-59 months).
• Refer to detailed guidance for strategies to encourage higher levels of intendedness under Family Planning tab in full Clinical Toolkit.
|Nutrition Status||Assess BMI
Assess use of Folic Acid and other nutritional supplements
|• Counsel about advantages of achieving weight as close as possible to ideal BMI (18.5-24.9) for own health;
• 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, HPV, HIV
|• 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 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).||• If woman hopes to have one or more pregnancies in future, educate woman on optimal timing of pregnancy as well as implications of the disease on her own health should she conceive and on pregnancy outcomes. Full guidance may require engagement of specialist.
• Encourage woman to contact your office if her desires to conceive change prior to next routine visit;
• 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 is on medications for chronic disease control, educate about medicines that could be risky for a developing embryo;
• 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).
|• 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.
• Advise all women that no amount of alcohol has proven safe in pregnancy and that the safest choice is to avoid ALL alcohol if she is having intercourse without using a reliable contraceptive method.
• 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 woman indicates the possibility of a pregnancy at some time in her future, indicate that exploration of opportunities to increase the likelihood of a subsequent health pregnancy and outcome should begin before pregnancy; offer to facilitate as desired.
• Refer to guidance for specific outcome under Reproductive History tab in full Clinical Toolkit.
|Genetic History||If the woman indicates she EVER hopes to become pregnant, 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 condition, or death before or after birth?
• Will you be 35 years old or older when you plan to become pregnant?
|• If yes to any to any of the queries in the screen, refer to guidance under Genetic History tab in full Clinical Toolkit;
• Educate the woman that the risks of a child being afflicted with a genetic disease are almost always less than imagined and that exploring these topics further may be useful (and reassuring) prior to stopping her method of birth control.
• In most situations, the couple will benefit from consultation with a qualified health care provider for appropriate counseling and potential testing; encourage woman to advise you if and when she desires more information about potential genetic risks
|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 woman indicates she might ever become pregnant again:
• Assess safety of drug profile (see medications) and recommend discussion with mental health provider for anticipatory guidance for conception, pregnancy and postpartum periods.
• 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 and about 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?
• Does your partner agree about not becoming pregnant in the next year?
|• If the woman answers “yes” to any of the first 4 questions:
• Acknowledge the trauma
• Express concern for her welfare
• Provide referrals to local and national resources (refer to Intimate Partner Violence tab in full Clinical Toolkit for specific guidance).
• Encourage woman to create a safety plan.
• If woman indicates partner not supportive of pregnancy plans, explore more fully.