Prenatal care

Last updated: October 25, 2023

Summarytoggle arrow icon

Prenatal care is the health care provided throughout a pregnancy; it is aimed at optimizing maternal and fetal outcomes. Prenatal visits allow high-risk pregnancies to be identified and are used to monitor maternal health and fetal development. After an initial visit (usually in the first trimester), follow-up prenatal visits generally occur once monthly until 28 weeks' gestation, twice monthly between 28 and 36 weeks, and weekly after 36 weeks. Components of prenatal visits include evaluation of the medical history, physical and gynecological examinations, laboratory testing, and ultrasonography. More frequent assessment may be indicated in pregnancies deemed high-risk for the fetus or pregnant individual. This article covers the general principles of prenatal care, including recommended screening studies, elective prenatal genetic screening, fetal surveillance, and patient education.

For other aspects of peripartum care, see also “Preconception counseling,” “Normal labor and delivery,” “Abnormal labor and delivery,” and “Postpartum visit.” For prenatal care for transgender and nonbinary individuals, see “Pregnancy in transgender individuals.”

General principlestoggle arrow icon

Diagnosis of pregnancy is covered in “Pregnancy.”

Ethics of prenatal care [1][2]

  • Healthcare providers have an ethical obligation to obtain informed consent from patients for prenatal care.
  • Patients may refuse recommended screening or procedures.
  • Use shared-decision making when discussing treatment options with patients in order to:
    • Ensure a safe environment for asking questions and addressing concerns
    • Encourage voluntary, informed decisions
    • Avoid miscommunication

Because pregnancy outcomes are unpredictable, pregnant individuals should be informed about the potential need for obstetric interventions (e.g., cesarean delivery) and encouraged to discuss any concerns ahead of time. [1]

Legal aspects of prenatal care

Frequency of prenatal visits [1]

High-risk pregnancies generally warrant more than the usual number of follow-up visits for maternal and/or fetal surveillance. [1]

Monitoring fetal growth and wellbeing

General principles [6][7]

Gestational age and estimated date of delivery [1][8]

Symphysis-fundal height measurement [6]

Fundal height and gestational age [11][13]
Week of pregnancy Fundal height during pregnancy
12th Just above the symphysis
16th Between the symphysis and navel
20– 24th Navel
32nd Between the navel and xiphoid
36th Peak: at the costal arch
40th Two finger widths below the costal arch

Prenatal ultrasound

Standard examinations [10]

Additional ultrasounds [10][14]

Additional US may be performed for further evaluation of potential pregnancy complications, follow-up of abnormal US, and for imaging guidance during procedures.

Overview of maternal and fetal vessel doppler ultrasound [7][16]
Vessel Indication for imaging Pathological findings
Maternal uterine artery
Umbilical artery
Fetal middle cerebral artery

High-risk pregnancies [1][19][21]

Risk factors for adverse pregnancy outcomes [1][19]

Management of high-risk pregnancies

First-trimester caretoggle arrow icon

General principles

Initial prenatal visit [1][23]

Live attenuated influenza, varicella, and MMR vaccine are contraindicated during pregnancy; delay administration until after delivery. [25]

History and physical examination [1][5]

Screening for medical comorbiditiestoggle arrow icon

The following laboratory studies are recommended during the initial prenatal visit to screen for conditions associated with negative obstetric and fetal outcomes.

All patients

Recommended initial prenatal screening tests [1][5]
Tests Management of abnormal results
Complete blood count to screen for anemia and thrombocytopenia [29]
Blood typing (ABO and rhesus) and RBC antibody screening to prevent hemolytic disease of the newborn [31][32][33]
Urine dipstick to screen for proteinuria [1]
Urine culture to screen for asymptomatic bacteriuria [35]
Screening for STIs and bloodborne pathogens HIV testing [1]
HBV serology
Anti-HCV antibody [37][38][39]
Prenatal syphilis screening [40]

HIV screening in pregnancy is opt-out; inform individuals an HIV test will be sent as part of the routine prenatal studies unless they decline testing. [1]

Patients with select indications

Prenatal screening studies for patients with select indications
Indications Management of abnormal results
Rubella antibody
  • All patients without evidence of immunity [1]
Varicella antibody
Prenatal chlamydia screening (using NAAT) [45][46]
Prenatal gonorrhea screening (using NAAT)
Pap smear and/or HPV DNA testing
Screening tests for latent TB [1][5]
Hyperglycemia testing [1] [47][48]

Psychosocial screeningtoggle arrow icon

Psychosocial assessments should be performed for all pregnant individuals in the first trimester.

Recommended prenatal psychosocial screenings [1]
Method(s) Repeat screening Management of patients with positive screening results

Peripartum depression [49][50][51]

Anxiety [51]
Bipolar disorder [51]
  • Not routinely recommended
Intimate partner violence (IPV) [55][56]
  • In every trimester and postpartum
Substance use [1] Nicotine and tobacco [58]
  • Ask about use of nicotine and tobacco products.
  • Every prenatal visit
Alcohol [59]
  • Not routinely recommended
Drugs [61]
Social determinants of health
  • Ask about ability to meet needs of self and family (e.g., access to housing, food, transportation). [63]
  • Refer to social support services as needed, e.g.: [64]
    • Food assistance
    • Prenatal and nutrition education
    • Comprehensive social support

First-trimester ultrasoundtoggle arrow icon

Indications [10][14]

Estimating gestational age via ultrasonography is most accurate when performed in the first trimester. [14]

Modalities [10][14]

Components [10][14]

Prenatal genetic testingtoggle arrow icon

Approach [65][66]

Counseling prior to prenatal genetic testing [1][65][67]

  • Inform patients that all prenatal genetic testing is voluntary.
  • Explain the differences between screening and diagnostic testing
  • Discuss the patient's risk factors for fetal genetic abnormalities.
  • Discuss the benefits of early identification of disorders: [65]
    • Potential for prenatal treatment
    • Optimizing outcomes by referral to appropriate specialists and location for delivery
    • Possibility of pregnancy termination
  • Review all testing options and associated risks and benefits.
  • Use shared decision-making to decide whether to perform a test and the specific testing to perform.
  • Inform patients about follow-up options for a positive test result.

Inform patients that a negative screening test result for fetal chromosomal abnormalities does not guarantee that a fetus has no genetic abnormalities. [68]

Risk factors associated with fetal genetic abnormalities [65]

  • Fetal structural abnormality on ultrasound
  • Increased maternal age [65]
  • Increased paternal age
  • Parental genetic abnormalities
  • Previous child with aneuploidy [65]

Noninvasive fetal aneuploidy screening tests [1][66][69]

One-step screening tests

Overview of one-stop screening tests for fetal chromosomal abnormalities [66]
Test Timing [66] Components Interpretation [66]
Cell-free fetal DNA testing (cffDNA)
Sonographic nuchal translucency (NT screen) [66][70]
First-trimester combined screening
Triple screen test and quad screen test [66]

Cell-free fetal DNA testing can be performed in any trimester of pregnancy after ∼ 10 weeks' gestation. [66]

Multi-step screening tests

Overview of multi-step screening tests for fetal chromosomal abnormalities [66]
Test Timing [66] Components Interpretation [66]
Integrated screen [1]
  • The risk of aneuploidy is based on results of testing at both timepoints.
  • Results are only provided after second-trimester testing is completed.
Sequential integrated screening [66]
  • The risk of aneuploidy is calculated based on first-trimester testing results
  • Follow-up testing recommendations are made based on first-trimester testing.

Interpretation of test results

Results of first-trimester combined screening test

Overview of first-trimester combined screening test results [71][72]
Condition HCG PAPP-A Nuchal translucency
Trisomy 21

Trisomy 18 ↑↑
Trisomy 13

On US examination of fetuses with aneuploidy, increased nuchal translucency is usually visible in the first trimester and a thickened nuchal fold is visible in the second trimester. [73]

Results of quad screening and triple screening

Overview of quad and triple screening test results [71]
Condition HCG AFP Estriol Inhibin A (quad test only)
Trisomy 21
Trisomy 18 ↓↓ ↓↓ ↔︎ or ↓
Neural tube defects ↔︎ ↔︎
Abdominal wall defects

An abnormal maternal serum AFP may be due to inaccurate estimation of fetal gestational age. [74]

Invasive prenatal diagnostic testing [65]

Overview of invasive prenatal diagnostic tests [65]
Chorionic villus sampling (CVS) Amniocentesis Cordocentesis [75][76]
  • Evaluation for fetal genetic abnormalities, e.g.:
    • Follow-up of:
      • Abnormal noninvasive genetic screening results
      • Fetal structural abnormalities seen on US
    • Initial evaluation in patients who prefer diagnostic evaluation instead of screening
  • For amniocentesis, other indications include: [78]
  • Fetal hemoglobin testing to assess the severity of fetal anemia [76]
  • Rarely used to evaluate for fetal genetic abnormalities [65]
Complications [65][75]

Second-trimester caretoggle arrow icon

Routine prenatal visits in the second trimester are focused on maternal-fetal surveillance, symptom management, and prevention and management of pregnancy complications.

Components [1][23]

In uncomplicated pregnancies dated with a reliable last menstrual period, a single obstetric ultrasound may be performed, preferably at 18–22 weeks' gestation, to evaluate fetal anatomy and the EDD. [66][80]

Routine prenatal clinical assessment [1][23]

Pregnant individuals often begin to feel fetal movement (i.e., quickening) between 18 and 19 weeks' gestation in the first pregnancy and between 16 and 18 weeks in subsequent pregnancies. [23]

In most cases, the EDD should not be changed in the second or third trimester if the EDD was established by an ultrasound performed in the first trimester. [8]

Second-trimester laboratory studiestoggle arrow icon

Laboratory studies are performed between 24–28 weeks; screening may therefore take place in the second or third trimester.

Recommended laboratory screening studies at 24–28 weeks' gestation
Test Indication Purpose Management of abnormal results
CBC [29]
  • All patients
Oral glucose tests [47][48]
  • All patients

Second-trimester ultrasoundtoggle arrow icon

Fetal anatomy scan [10][14][82]

General principles

  • A scan offered at 18–22 weeks' gestation to all patients to assess for:
    • Fetal anomalies, e.g., abnormal growth or anatomic abnormalities [10]
    • Estimation of gestational age (if not already performed) [10][78]
  • If possible, the anatomy scan should be offered well in advance of the legal limit for pregnancy termination. [82]

Modalities [10][14]

  • Transabdominal ultrasound: usually initial modality
  • Transvaginal or transperineal ultrasound: if the transabdominal approach is suboptimal for evaluation


  • Evaluation of fetus, including:
    • Number of fetuses
    • Fetal presentation
    • Cardiac activity
    • Anatomy survey, including assessment for structural abnormalities and sex
    • Fetal biometric parameters ; [14]
      • Biparietal diameter
      • Fetal femoral length
      • Abdominal circumference
      • Head circumference
  • Evaluation of amniotic fluid volume and placenta (e.g., location, appearance, cord insertion)
  • Evaluation of maternal pelvic anatomy, including cervix [14][83]

Additional ultrasounds

Third-trimester caretoggle arrow icon

Third-trimester care is focused on monitoring maternal and fetal well-being and preparing for delivery.


In the third trimester, prenatal visits usually increase in frequency to every 2 weeks between 28–36 weeks and weekly thereafter. [1]

Third-trimester screening for sexually-transmitted infections (STI) [45]

Indications for third-trimester STI screening [1][45]
STI Indications for screening Timing
Prenatal chlamydia screening
Prenatal gonorrhea screening
HIV screening
Prenatal syphilis screening
Hepatitis B screening

Leopold maneuvers [23][86]

Antepartum fetal surveillance testingtoggle arrow icon

General principles [1][7]

Antepartum fetal surveillance testing is typically performed in the third trimester (at ≥ 32 weeks' gestation) to assess fetal well-being and reduce the risk of adverse fetal outcomes. [7]

Indications for antepartum fetal surveillance [19]

  • High-risk pregnancy (e.g., maternal medical conditions or fetal conditions associated with increased risk of fetal hypoxic injury or death)
  • Perceived reduction in fetal movement by mother

Modalities [7]

Results and ongoing management

Overview of management of antepartum fetal test results [7]
Result of test Next steps
Normal Resolved indication for testing
  • No further testing indicated
Ongoing indication for testing
  • Repeat testing; usually weekly.
Abnormal Kick count
NST or modified biophysical profile
  • Consider repeat testing or delivery.

Kick counts [7]

  • Maternal counting of the number of fetal movements within a particular time period (e.g., 1 or 2 hours).
  • Number of kicks reduced compared to prior assessments: Perform additional antepartum surveillance testing.
  • Limitations [7]
    • No consensus on the optimal duration of monitoring or abnormal number of counts
    • Limited evidence monitoring kick counts affects perinatal adverse outcomes.

Nonstress test (NST) [1][7]

NST is a noninvasive test that measures how fetal heart rate (FHR) responds to fetal movements; a rise in fetal heart rate is expected with fetal movement.

Method [7]

Interpretation [1]

  • Reactive nonstress test: a normal NST that shows ≥ 2 FHR accelerations over the course of 20 minutes
    • If the indication for testing has resolved, offer reassurance; further testing is not required.
    • If the indication persists, repeat the test (usually at weekly intervals).
  • Nonreactive nonstress test: an abnormal NST that shows < 2 FHR accelerations over the course of 20 minutes (after at least 40 minutes of monitoring) [7]
    • Causes of a nonreactive NST include:
      • Fetal sleep (most common)
      • Hypoxemia or acidemia
      • Neurologic or cardiac abnormalities
      • Fetal immaturity [7]
      • Maternal drug use
    • Next steps: Perform a BPP or CST. [1]
  • Concerning decelerations : Consider further monitoring or delivery.

Contraction stress test (CST) [1][7]

  • CST is a test that measures how FHR responds to uterine contractions.
  • Can be safely performed, provided there are no contraindications to labor or vaginal delivery. [1][89]


  • Perform cardiotocography to assess both FHR and uterine contractions.
  • If < 3 contractions lasting at least 40 seconds are observed over 10 minutes, induce contractions using either:

CST may induce early labor; consider alternative methods of assessing fetal well-being in patients with contraindications to labor or vaginal delivery. [1]

Interpretation [1][7]

Biophysical profile (BPP) [7]

The BPP is a noninvasive test consisting of fetal ultrasound of four specified parameters and NST.

Method [7]

  • An ultrasound examination is performed over 30 minutes to assess the following four parameters:
  • An NST is then performed if any ultrasound parameter is abnormal but may be omitted if all are normal.
  • Each parameter of the ultrasound examination and the NST is given a score of either 0 (abnormal) or 2 (normal)
Biophysical profile scoring criteria [1]

Normal results (= 2 points)

Fetal movement
  • ≥ 3 body or limb movements in 30 minutes
Fetal tone
  • ≥ 1 episodes within 30 minutes of either:
    • Fetal extremity extension with return to flexion
    • Opening or closing of a hand
Fetal breathing
  • ≥ 1 rhythmic breathing episode(s) lasting ≥ 30 seconds in 30 minutes
Amniotic fluid volume
  • A single deepest vertical pocket > 2 cm with a horizontal dimension ≥ 1 cm [10]
Nonstress test

Interpretation [1][7]

Interpretation and follow-up of biophysical profile results
Total score Interpretation Follow-up
Oligohydramnios absent Oligohydramnios present
≥ 8 points
  • Normal/reassuring (i.e., not suggestive of fetal compromise at the time of testing)
  • Resolution of indication for testing: no further testing indicated
  • Persistence of the indication for testing: Consider weekly testing.
  • Gestational age ≥ 36 weeks: Delivery is often recommended.
  • Gestational age < 36 weeks: Consider surveillance or delivery depending on clinical context.
6 points
  • Equivocal (i.e., unclear risk of fetal compromise)
≤ 4 points
  • Abnormal (i.e., concern for potential fetal compromise)

Regardless of total biophysical profile score, delivery or close monitoring may be indicated if oligohydramnios is identified. [7]

Modified biophysical profile [1][7]

Doppler velocimetry of the umbilical artery [7]

Group B streptococcus screening and prophylaxistoggle arrow icon

General principles [93][94]

Prenatal screening for GBS [93]


  • Routine screening for all women from 36+0 to 37+6 weeks' gestation, regardless of planned delivery method, unless prophylaxis is already indicated, e.g.: [93]
  • Urgently: women in labor or with ruptured membranes with unknown GBS culture status

Regardless of whether a cesarean or vaginal delivery is planned, screen all pregnant women with indications for GBS screening in order to guide management if unexpected early labor or rupture of membranes occurs. [93]

Method of collection

Laboratory studies

Next steps

Prophylaxis for neonatal GBS infection [93][95]

  • Required for all patients presenting with ruptured membranes or in labor with any indications for GBS prophylaxis.
  • Not required if indications are absent or the patient is undergoing a pre-labor cesarean delivery with no rupture of the membranes.

Indications for GBS prophylaxis

Regardless of GBS culture results, intrapartum antibiotic prophylaxis for neonatal GBS is not needed if cesarean delivery is performed prior to the onset of labor and with intact membranes. [93]

Antibiotic regimens

Antibiotics should ideally be initiated at least 4 hours prior to delivery.

If an intraamniotic infection is suspected, initiate treatment with broad-spectrum antibiotics rather than prophylactic antibiotics. [93]

While administration of antibiotics for at least 4 hours prior to delivery is preferred, it should not delay any necessary obstetric interventions. [93]

GBS prophylaxis considerations in preterm labor

Prenatal patient educationtoggle arrow icon

Nutrition and weight gaintoggle arrow icon

General principles [27][96]

  • Dietary intake during pregnancy should be optimized to meet the demands of both the mother and the fetus. [96]
  • Appropriate weight gain and nutrition should be assessed on an individual basis.
  • Encourage pregnant women to follow a well-balanced diet and avoid restrictive diet plans.
  • A daily multivitamin that includes folic acid is generally recommended for the duration of pregnancy. [96][97]
  • For patients with special dietary needs (e.g., those with diabetes, vegetarians), consider referral to a nutritionist. [1]

Recommended dietary intake and supplementation [97][98]

  • Calories: Average daily calorie requirements increase in the second and third trimesters.
  • Protein: 71 grams/day is recommended. [98]
  • Carbohydrates: 175 grams/day is recommended, including 25–36 grams of fiber per day. [98]
  • Fats
    • It is recommended that 20–35% of daily calorie intake come from fats. [98]
    • Adequate intake of Omega‐3 fatty acids is recommended. [98][99][100]

Micronutrients during pregnancy

Patients considering pregnancy should aim for similar intakes (see “Preconception counseling”).

Recommended vitamin and mineral supplementation in pregnancy [1][98]
Supplementation Reason for increased demand Consequences of deficiency
Folic acid [101]
Vitamin B12 [104]
  • Pregnant women who follow a vegan diet: 2.6 mcg/day daily [97]
Iron [1]
  • All pregnant patients: 27–30 mg daily [1][105]
Calcium [106]
  • Pregnant women with low calcium intake : 1,500–2,000 mg daily recommended to reduce risk of preeclampsia [98][107]
  • Increased fetal demand (e.g., for bone development) [108]
  • Lactation [108]
Iodine [43]
  • All pregnant patients: 150 mcg daily [43][111]
  • Maternal and fetal hypothyroidism
  • Impaired fetal neurocognitive development

Excessive consumption of vitamin A during pregnancy may be teratogenic. [1]

Vegetarian mothers are at risk of deficiencies in vitamin D, iron, calcium, vitamin B12, and zinc; consider laboratory evaluation as indicated. [1][97]

Dietary restrictions during pregnancy [105]

  • Limit caffeine: to < 200 mg daily (∼ 2 cups of coffee or ∼ 4 cups of caffeinated tea) [112]
  • Avoid alcohol use throughout pregnancy. [113]
  • Avoid foods associated with higher risk of foodborne illness, e.g.: [23]
  • Avoid seafood with possibly high levels of methylmercury: such as tilefish, swordfish, shark, mackerel, and bigeye tuna. [1]

Consumption of raw or undercooked meats, unpasteurized dairy products, and unwashed fruits and vegetables by pregnant women can increase the risk of congenital toxoplasmosis and congenital listeriosis and should be avoided. [23]

Recommended weight gain during pregnancy [1][105]

  • Total recommended weight gain is determined by BMI prior to pregnancy. [27]
  • Both excessive and inadequate gestational weight gain can impact fetal and maternal outcomes. [114]
Risk factors and outcomes of inadequate or excessive gestational weight gain
Inadequate weight gain Excessive weight gain
Risk factors
  • Pre-pregnancy BMI ≥ 25 [120]
  • Low physical activity [120]
Fetal outcomes [121]
Maternal outcomes [114][122]

During the second and third trimesters, recommended weekly weight gain is 0.5 lb/week if pre-pregnancy BMI ≥ 30, 0.6 lb/week if pre-pregnancy BMI 25–29.9, and 1 lb/week if pre-pregnancy BMI < 25. [27]

Physical activitytoggle arrow icon

General principles [124]

  • Evaluate all patients for contraindications to aerobic exercise in pregnancy prior to recommending physical activity.
  • Regular physical activity is recommended during most pregnancies.
    • Educate patients on safe and unsafe activities and advise activity avoidance or modification as needed. [124][125]
    • Patients should aim for ≥ 20–30 minutes of aerobic and/or strength-training exercise most days of the week. [1]
    • In the absence of medical or surgical complications, physical activity may resume soon after delivery. [124]
  • Consider occupational accommodations for women with jobs requiring high levels of physical effort or potentially unsafe activities. [126]

Contraindications to aerobic exercise in pregnancy [1]

Safe and unsafe sports during pregnancy [124][125]

Safety of physical activity during pregnancy [1]
Safe activities High impact training
  • Running, jogging
  • Strength training
Low impact training
  • Swimming
  • Walking
  • Stationary cycling
  • Pilates
  • Yoga [124]

Unsafe activities [124][125]

  • Contact sports (e.g., soccer, basketball)
  • Activities associated with a high risk of falling (e.g., snow and water skiing, gymnastics, surfing)
  • Activities associated with high risk of dehydration (e.g., hot yoga, hot pilates)
  • Extreme sports (e.g., skydiving)
  • Scuba diving [124]

Physical activity should be stopped and the patient should notify their provider in the event of any the following: antepartum or postpartum hemorrhage, uterine contractions, amniotic fluid leakage, chest pain, dyspnea before exertion, dizziness, headaches, calf pain/swelling, and/or muscle weakness with impaired balance. [124]

Other health and safety counselingtoggle arrow icon

Dental care during pregnancy [1]

  • Poor oral health may be associated with preterm delivery.
  • Encourage regular brushing, flossing, and cleanings.
  • Educate patients about common dental problems seen in pregnancy.

Travel during pregnancy

Pregnant women should be informed that the most common obstetric emergencies occur in the first and third trimesters and they may, therefore, prefer to restrict travel to the second trimester. [128]

Medications and substance use [1]

  • Advise the patient to avoid tobacco, alcohol, and recreational drugs.
  • Ensure all prescribing clinicians are aware the patient is pregnant.
  • Have the patient check with a healthcare professional before taking over-the-counter medications, supplements, or herbal preparations.

Work during pregnancy [126]

  • Educate patients on occupational hazards, e.g.:
    • Known hazards: toxic exposures (e.g., heavy metals, pesticides, ionizing radiation)
    • Suspected hazards
      • Standing/walking for long periods of time (> 3 hours a day)
      • Heavy lifting
      • Working > 40 hours a week
  • Support patients in seeking workplace accommodations where appropriate.

When writing a work accommodation note for pregnant patients, make sure to be specific and outline reasonable limitations to avoid the note being used as grounds for dismissal. [126]

Counseling related to peripartum caretoggle arrow icon

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Referencestoggle arrow icon

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