Prenatal Care Plan (Risk-Stratified/Tailored)

Plan Metadata

(This is a longitudinal prenatal care plan. Update as risk status, patient preferences, or clinical findings change. Use explicit status values such as "Unknown," "Not yet obtained," "Pending," or "Declined" for safety-critical fields.)

Plan Status:	[Draft / Active / Superseded]
Version:	[Version number and brief change reason]
Created:	[Date] — [Author name, role]
Last Reviewed:	[Date]
Next Review Milestone:	[e.g., "after anatomy ultrasound" / specific GA]

Pregnancy Summary

Gravida/Para:	[Gravida/Para]
Gestational age (on plan date):	[GA in weeks+days / Unknown]
Estimated Due Date (EDD):	[EDD date / Pending dating ultrasound] — Basis: [LMP / Ultrasound / IVF / Pending]
Pregnancy type:	[Singleton / Multifetal] (If multifetal: [Dichorionic-Diamniotic / Monochorionic-Diamniotic / Monochorionic-Monoamniotic / Unknown])
Primary prenatal clinician & site:	[Clinician name, role] — [Clinic/site]
Intended delivery facility:	[Facility name / Unknown]
Maternal age at EDD:	[Age in years] (Include if relevant to risk assessment.)
Key obstetric history flags:	[Brief list / None] (e.g., prior preterm birth, prior cesarean)

Risk Stratification

Risk Tier Summary

Risk Tier (clinician-attested):	[Average/Low Risk / Increased Risk / High Risk]
Effective date:	[Date]
Basis for classification:	[1–2 line summary of key drivers]
Co-management status:	[None / MFM consult / MFM co-management / Other specialty lead (specify)]

Risk Drivers

(Omit categories with no relevant factors.)

• Medical factors: [List relevant medical conditions]
• Obstetric history factors: [List relevant OB history]
• Current pregnancy factors: [List current pregnancy factors]
• Social/structural factors: [Transportation, housing, language access, etc.]

Risk-Linked Care Implications

(Include when risk tier is above average/low. Map each significant risk driver to specific care actions.)

• [Risk factor] → [Specific care action(s), monitoring plan, delivery planning implications]

Prenatal Contact Schedule

(Adjust cadence and modality to risk tier and patient preferences.)

GA Window	Contact Type	Purpose	Responsible Clinician/Team	Status
[e.g., 8–10w]	[in-person / telehealth video / telehealth phone / group prenatal / nursing visit]	[Brief purpose]	[Name/Team]	[Planned / Scheduled / Completed / Missed]
[GA window]	[Contact type]	[Purpose]	[Responsible]	[Status]

Telehealth planning (if applicable): [Patient preference and feasibility] — Home data capture: [BP/weight device availability, charting method] — In-person conversion criteria: [Symptoms requiring in-person evaluation]

Gestational Age-Keyed Services

(Use explicit status values: Due / Completed [date] / Declined / Not Yet Obtained.)

GA Window	Service	Indication	Status
Early pregnancy	Infectious disease screening (HIV, syphilis, hepatitis B, hepatitis C)	Universal	[Status]
Early pregnancy	Blood type/Rh with antibody screen	Universal	[Status]
Early pregnancy	Baseline CBC	Universal	[Status]
Early pregnancy	Urine culture/screening	Universal	[Status]
Early pregnancy	Genetic screening options counseling and carrier screening	Universal	[Status]
10–14w	Prenatal genetic screening execution or documented declination	Universal	[Status]
15–22w	Anatomy ultrasound	Universal	[Status]
24–28w	Gestational diabetes screening (Screen ASAP if late to care.)	Universal	[Status]
24–28w	Repeat antibody screen with RhIG plan	Risk-triggered: Rh-negative	[Status]
24–28w	Syphilis rescreen	Universal	[Status]
24–28w	Repeat CBC	Universal	[Status]
27–36w	Tdap vaccination (earlier in window preferred)	Universal	[Recommended / Accepted / Declined (reason)]
32–36w (seasonal)	RSV vaccination or infant monoclonal antibody plan	Universal (Sept–Jan)	[Status]
36–37w	GBS screening with labor prophylaxis plan if positive	Universal	[Status]
Third trimester/delivery	Syphilis rescreen	Universal	[Status]
Third trimester/delivery	Hepatitis B status confirmation for infant prophylaxis	Universal	[Status]
[Per risk protocol]	Serial growth ultrasounds	Risk-triggered	[Status]
[Per risk protocol]	Antenatal testing (NST/BPP) schedule	Risk-triggered	[Status]
[16–24w or per protocol]	Cervical length surveillance	Risk-triggered	[Status]
[12–16w through 36w]	Aspirin prophylaxis	Risk-triggered: preeclampsia prevention	[Status]

Immunization Plan

Vaccine	Target GA Window	Status
Influenza	Any trimester (seasonal)	[Recommended / Accepted / Declined (reason)]
Tdap	27–36w	[Recommended / Accepted / Declined (reason)]
COVID-19 (current formulation)	Any trimester	[Recommended / Accepted / Declined (reason)]
RSV	32–36w (Sept–Jan)	[Recommended / Accepted / Declined / Not eligible] (If declined or not eligible, document infant monoclonal antibody plan.)

Medications

(Include only when applicable.)

• Prenatal vitamin/folic acid: [Taking / Prescribed / Declined]
• Iron supplementation: [Status] — Indication: [anemia / prophylaxis]
• Low-dose aspirin: [Status] — Start: [week] — Stop: [week or delivery] — Indication: preeclampsia prevention
• Other medications: [Medication, indication, status]

Referrals and Coordination

Specialty/Service	Clinical Indication	Target Timeframe/GA	Status
[e.g., Maternal-Fetal Medicine]	[Indication]	[Timeframe or GA]	[Ordered / Scheduled / Completed / Declined]
[Community resource: WIC / Social work / Substance use treatment / Transportation]	[Indication]	[Timeframe]	[Referred / Connected / Declined]

(If no referrals indicated: "No referrals currently indicated.")

Patient Preferences and Shared Decisions

• Visit modality preference: [In-person / Telehealth / Hybrid]
• Genetic screening decision: [Plan chosen / Declined] — Counseling documented: [Yes / No]
• Preliminary delivery preferences: [Notes] (Revisable.)
• Key education topics planned: [Topics and timing]

(Use direct quotes only when they materially affect care planning, e.g., stated refusal of critical testing. Document "Declined" only when explicitly refused, not when results are pending.)

Escalation Criteria

• Severe headache or vision changes
• Right upper quadrant or severe epigastric pain
• Vaginal bleeding
• Leakage of fluid
• Regular contractions before term
• Decreased fetal movement (after quickening)
• Fever

Routing guidance: Call clinic: [number] for non-emergent concerns — Present to L&D triage for urgent obstetric concerns — Call 911/ED for life-threatening emergencies

Triggers for risk-tier revision: [Define specific clinical or social changes prompting plan reassessment]

Delivery and Postpartum Planning

• Intended delivery site/level of care: [Facility/level]
• Key intrapartum considerations: GBS [Pending / Negative / Positive with plan] — Rh plan [e.g., RhIG timing] — Glycemic management [if applicable] — Hemorrhage risk factors [list] — Anesthesia considerations [notes]
• Delivery timing (if indicated): [Induction/cesarean window and indication]
• Postpartum contact plan: Initial contact [timing/modality] — Comprehensive visit [target timing]
• Contraception: [Discussed / Plan / Pending]
• Chronic disease follow-up handoff: [Receiving clinician/service]

Plan Update Log

Date	Author (role)	Summary of Changes	Reason
[Date]	[Name, role]	[What changed]	[Why]

Clinician attestation: This plan reflects current risk assessment and incorporates patient preferences.