9.2 Preconception Care
Pregnancy planning involves discussing preconception care and fertility awareness methods for individuals considering starting a family. Preconception care is an important health promotion strategy in planning for a future pregnancy. The purpose of preconception care is to assess physical, psychological, environmental, or social risk factors that could affect the health of a future pregnancy and initiate treatment before pregnancy begins. Preconceptual care involves several components, including assessing reproductive health and medical and genetic history, examining self-care practices, assessing nutritional and immunization statuses, reviewing medication, performing a physical examination, providing psychological support, and making referrals for follow-up care. The goal of preconception care is to optimize a person’s health and readiness for pregnancy, mitigate potential risks to promote healthy pregnancies, and provide necessary support and education for a healthy conception and pregnancy journey.[1]
A preconception visit includes a thorough health history, physical examination, and diagnostic testing. Preconception health teaching is provided as the nurse provides anticipatory guidance and education.
Assessment
Health History: Pregnancy Risk Factors
When providing preconception care, the nurse and/or health care provider obtains a health history that focuses on pregnancy risk factors. Pregnancy risk factors are conditions or factors that may increase the likelihood of complications occurring during pregnancy, childbirth, or postpartum. Table 9.2a provides an overview of pregnancy risk factors.
Table 9.2a. Pregnancy Risk Factors[2],[3]
| Preconception Risk Factors | Description |
|---|---|
| Age | Women aged 35 years or older at conception have an increased risk of certain pregnancy complications, such as gestational diabetes, preeclampsia (i.e., elevated blood pressure during pregnancy that can cause organ damage), and fetal chromosomal abnormalities. Adolescents less than 18 years of age may also have increased risks during pregnancy. |
| Chronic health conditions | Preexisting medical conditions are assessed such as diabetes, hypertension, thyroid disorders, and autoimmune diseases because they can impact pregnancy outcomes. |
| Previous pregnancies | The number of a woman’s previous pregnancies and the interval between pregnancies increases risks for complications. Women who have experienced previous complications during pregnancy, such as miscarriage, preterm birth, or cesarean section also have increased risk for experiencing complications in future pregnancies. |
| Medication use | Current medication use, including prescribed medications, over-the-counter medications, and herbal or dietary supplements, is assessed. Certain medications may be teratogenic (i.e., cause fetal development malformations) or require adjustments in dosage during preconception and/or pregnancy. |
| Substance use | Smoking or use of tobacco before or during pregnancy can lead to complications such as miscarriage, preterm birth, low birth weight, and sudden infant death syndrome (SIDS). Use of substances such as alcohol or drugs increases the risk for congenital anomalies, neonatal withdrawal, and fetal alcohol syndrome. Nurses play a crucial role in screening for substance use, promoting recovery, and providing health teaching. |
| Nutrition and diet | Poor diet and nutritional deficiencies, particularly in folate and other essential nutrients, can impact fertility and increase the risk of birth defects. Low pre-pregnancy maternal weight (BMI< 18.5) is associated with low-birth-weight infants and premature birth, as well as infertility issues. High pre-pregnancy maternal weight (BMI>30) is associated with increased risk for hypertension, prolonged labor, a large-for-gestational-age infant, cesarean birth, wound infections, gestational diabetes, thromboembolic disorders, and postpartum hemorrhage. |
| Reproductive health conditions | Several components of reproductive health are assessed, such as menstrual history, including cycle regularity and duration; preexisting conditions affecting the reproductive system, such as polycystic ovary syndrome (PCOS) or endometriosis; and history of sexually transmitted infections that can affect fertility. |
| Mental health | Psychosocial factors, such as mental health concerns, social support systems, or a history of trauma, are assessed and referrals are made as indicated. |
| Genetic and family history | Family history of genetic disorders or genetic conditions in the parents are assessed, and genetic counseling and testing are offered before conception. |
| Immunization status | Immunity to certain infections such as rubella and varicella is assessed, and vaccinations are updated according to the current CDC vaccination schedule to prevent birth defects. |
| Environmental exposures | Environmental and/or occupational hazards or exposure to teratogens such as toxins, radiation, or chemicals are assessed because they can impact fertility and pose risks to the fetus during pregnancy. |
| Social determinants of health | Social determinants of health are assessed because they can impact access to health care and prenatal care. Nonwhite individuals or those experiencing low socioeconomic status have an increased risk for preterm birth and low birthweight because of barriers that prevent them from receiving adequate prenatal care. |
| Emotional and relationship status | Relationship dynamics and stress levels are assessed because of their impact on fertility and emotional well-being. Nurses and health care providers are aware that pregnancy can trigger intimate partner violence (IPV) that can result in injury or death of the mother and/or fetus. Review information in the “Intimate Partner Violence” section of the “Maladaptive Coping Behaviors” chapter. |
Physical Exam and Diagnostic Testing
A preconception physical examination assesses overall health and identifies medical conditions or risk factors that may affect a woman’s ability to conceive and have a healthy pregnancy. Weight and blood pressure are measured, a gynecologic exam is performed, and specific screenings or diagnostic tests are ordered based on the client’s medical and reproductive history and risk factors. See Table 9.2b for an overview of common preconception blood and diagnostic tests and their rationale.
Table 9.2b. Common Preconception Diagnostic Tests[4]
| Tests | Rationale |
|---|---|
| Blood tests |
|
| STI screening |
|
| Urinalysis |
|
| Genetic screening |
|
| Pap smear |
|
| Pelvic ultrasound/Transvaginal ultrasound |
|
Preconceptual Counseling
Pregnancy counseling is provided to the woman and her partner based on the identified risk factors found during the health history, physical exam, and diagnostic testing. Nurses may provide counseling on one or more of the following topics[5]:
- Interpregnancy Interval: The recommended spacing of pregnancies, also known as interpregnancy interval, refers to the time between the birth of one child and the conception of the subsequent pregnancy. Research funded by the March of Dimes recommends a minimum interpregnancy interval of at least 18 months after a full-term birth before attempting another pregnancy. Allowing the woman’s body to recover from the previous pregnancy reduces the risks of premature birth, neonatal morbidity, low birth weight, developmental delays, vision and hearing problems, and asthma. Women who have previously experienced pregnancy complications, such as preterm birth or cesarean delivery, may require longer interpregnancy intervals for proper healing and reduced risk of recurrence.[6] Contraceptive counseling is also provided to help maintain a minimum interpregnancy interval. Read more about “Contraception” in the “Reproductive Concepts” chapter.
- Age: Women 35 years or older at the time of birth are considered to be at advanced maternal age and may require additional screening and diagnostic testing due to increased risks for pregnancy complications.
- Chronic Health Conditions and Previous Pregnancy Complications: Women with certain medical conditions, such as diabetes or high blood pressure, may benefit from longer interpregnancy intervals to optimize their health and manage their condition before a subsequent pregnancy.
- Medication and Supplement Use: If a woman is currently taking prescription or over-the-counter medications or supplements, their safety during a future pregnancy is reviewed, and safety recommendations are made as indicated.
- Substance Use: Women who smoke are referred to smoking cessation programs, and health teaching is provided about the importance of abstinence from tobacco, alcohol, or recreational drugs before becoming pregnant and during pregnancy.
- Nutritional Status: Guidance is provided on eating a balanced diet rich in essential nutrients needed for a healthy pregnancy, as well as recommended supplementation with folic acid and prenatal vitamins. Many foods, such as bread, flour, cornmeal, rice, pasta, and other grain products, are fortified with folic acid to prevent birth defects. Folic acid supplements are also recommended for all women before and after conception to prevent neural tube defects. The American College of Obstetrics and Gynecology recommends that all women who are capable of becoming pregnant should ingest folic acid supplements of 400 mcg daily to reduce the occurrence of fetal neural tube defects. Nurses can also teach about natural foods rich in folate, such as leafy green vegetables like spinach and kale, legumes such as lentils and chickpeas, citrus fruits, and avocados.[7] In addition to folic acid, nurses teach clients about healthy, balanced diets such as the Mediterranean diet. Read more about the components of a healthy diet during pregnancy and the Mediterranean diet in the “Healthy Diets” chapter. Women who are obese can also receive counseling on weight loss strategies to increase fertility, prevent complications, and decrease the risk of gestational diabetes.
- Reproductive Health Status: Sexually transmitted infection (STI) screening is recommended because STIs can affect fertility and pose risks to the developing fetus if present during pregnancy. Preexisting reproductive system disorders such as PCOS and endometriosis may be treated to improve fertility. Furthermore, nurses teach clients about fertility awareness and optimal timing of sexual intercourse to achieve conception. Read more about fertility awareness in the “Reproductive Conditions” chapter.
- Vaccination Status: If the client is not immune to rubella, varicella, or hepatitis B, vaccines are strongly encouraged to protect the individual and the fetus during pregnancy. The client is instructed to wait at least one month after the administration of vaccines to try to conceive.
- Mental Health and Safety: Nurses provide resources on effective stress management techniques and positive coping strategies during the preconception period, pregnancy, and postpartum period. Review the “Stress and Coping” section of the “Mental Health Concepts” chapter for information on stress management and coping strategies. Referrals are made for clients with a history of mental health conditions, trauma, or intimate partner violence to promote optimal mental health and safety during pregnancy and after delivery. Nurses also provide information on available support systems, such as community resources and peer support groups.
- Genetic Counseling: Information about genetic counseling is provided to women with genetic disorders or a family history of genetic conditions that may impact the pregnancy or require further evaluation.
- Environmental Exposures and Teratogens: Potential risks and precautions related to specific occupations, travel, and exposures during the preconception period are discussed. Read more about teratogens in the following subsection.
- Referrals and Follow-up: Nurses ensure referrals to appropriate health-care providers, specialists, or support services are obtained based on the individual’s specific needs or risks. Follow-up appointments are scheduled as indicated to monitor progress, address concerns, and provide ongoing support throughout the preconception period.
Counseling Transgender Men or Gender Nonconforming People Contemplating Pregnancy
It is estimated that transgender individuals represent between 0.3% and 0.5% of the U.S. population. The terms “transgender” and “gender nonconforming” refer to individuals whose gender identity differs from their sex assigned at birth. Most transgender men retain their female reproductive organs and have the capacity to become pregnant. Research indicates a need for preconception counseling to include discussion of stopping testosterone while trying to conceive and throughout pregnancy, as well as anticipating increased feelings of gender dysphoria during and after pregnancy.[8] Read more about gender identity in the “Reproductive Conditions” chapter.
Teratogens in Pregnancy
Substances or agents that can cause congenital abnormalities or birth defects in a developing embryo or fetus during pregnancy are called teratogens. These substances can harm fetal development and may result in structural or functional abnormalities in the baby. The impact of teratogens on the fetus depends on factors such as the type of teratogen, the timing and duration of exposure during pregnancy, and individual susceptibility.[9]
Gestational age at exposure greatly influences the effect of the teratogen. The most harmful time for exposure is during gestational Weeks 1 through 8 when the fetal organs are developing, but the entire first trimester is a critical time when teratogen exposure can cause major birth defects. Teratogen exposure during the second and third trimesters typically affects fetal growth and may cause functional learning deficits but only causes minor birth defects because the fetal organs and structures have already developed. Other adverse outcomes from teratogen exposure include preterm birth and oligohydramnios (i.e., too little amniotic fluid).[10]
Teratogens can include various environmental factors, medications, infections, and other exposures. Table 9.2c provides an overview of common teratogens and their effects.
Table 9.2c. Teratogens and Their Effects on a Fetus
| Teratogen | Effects on a Fetus |
|---|---|
| Alcohol | Fetal alcohol spectrum disorder, abnormal facial features, small head and brain, or physical and behavioral disabilities |
| Cigarettes and Tobacco | Fetal growth restriction, premature birth, miscarriage, and lung and brain issues |
| Recreational Drugs | Low birth weight, heart problems, neonatal abstinence syndrome, or infections |
| Specific Medications
Isotretinoin Thalidomide Warfarin Methotrexate Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) Lithium Valproic acid Carbamazepine Phenytoin Misoprostol Trimethoprim-sulfamethoxazole Aminoglycosides Fluconazole Paroxetine |
Congenital abnormalities, organ malformation, developmental issues, and cognitive impairments, as well as increased risk for preeclampsia and gestational hypertension |
| Infections and Viruses
Toxoplasmosis Rubella Cytomegalovirus Herpes simplex virus Zika virus Parvovirus B19 Syphilis Varicella zoster virus Human immunodeficiency virus Listeriosis Hepatitis B and C |
Miscarriage, birth defects, pregnancy complications, or developmental disorders |
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
- Office on Women’s Health. (2022). Pregnancy complications. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/pregnancy-complications ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
- Lonhart, J. A., Mayo, J. A., Padula, A. M. et al. (2019). Short interpregnancy interval as a risk factor for preterm birth in non-Hispanic Black and White women in California. Journal of Perinatology, 39, 1175–1181. https://doi.org/10.1038/s41372-019-0402-1. ↵
- Viswanathan, M., Urrutia, R. P., Hudson, K. N., et al. (2023). Folic acid supplementation to prevent neural tube defects: A limited systematic review update for the U.S. Preventive Services Task Force [Internet]. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK593614/ ↵
- CDC - Reproductive Health. (2023, April 26). Infertility. https://www.cdc.gov/reproductivehealth/infertility/index.htm ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction ↵
The time between the birth of one child and the conception of the subsequent pregnancy.
Substances or environmental factors that can cause birth defects or abnormal development in a fetus.
Too little amniotic fluid