1. The M3 Survival Guide to OBor
“ Here I am,
now what do I do???”

2. “What do I do in prenatal clinic?

3. PRENATAL CARE Routine prenatal care: First visit at 8-12 weeks
Every 4 weeks until 28 weeks
Every 2 weeks between 28 & 36 weeks
Weekly from 36 weeks until delivery
Routine prenatal care follows a pattern of visits.
The first visit should be between 8-12 weeks --- ideally --- but you might see patients starting prenatal care at any gestational age.
The patient is usually seen once a month until 28 weeks,
every 2 weeks between 28 and 36 weeks,
then weekly until delivery.
Obviously this schedule should be customized to the needs of the individual patient.

4. PRENATAL CARE – 1st VISIT (NOB) History
GYN history
Menstrual (LMP)
Contraceptive use
Pap hx
STI hx
OB history
Pregnancies (G __ P __)
Deliveries (term or preterm)
Abortions (spontaneous or induced)
Complications
Medical/surgical history
Family history
Social history
FOB
Domestic violence
Alcohol, drugs, tobacco
Education
Employment
Language spoken (need for interpreter)
At the first visit, the patient’s history will be obtained.
Usually a clinic nurse or tech will take the history for you, but it is your responsibility to review it with the patient and make sure that it is complete and accurate.
The complete history includes:
medical history – allergies, serious illnesses, operations, medications
GYN history – menstrual history and date of last menstrual period (the FIRST day), use of contraception, abnormal Pap smears, sexually transmitted infections
OB history – how many pregnancies, how many deliveries (term or preterm), what kind of deliveries (vaginal or C-section), how many abortions (spontaneous or induced), OB complications
social history – involvement of the father of the baby, assessment for domestic violence, use of alcohol, drugs, or tobacco, etc.

5. PRENATAL CARE – 1st VISIT Physical
Routine head-to-toe physical exam
Pelvic exam
Pap (if indicated) & GC/Chlamydia
Uterine size consistent with estimated gestation?
Clinical pelvimetry
Doppler heart tones
Typically heard at 10wks and greater
After obtaining the patient’s history, you will do a physical exam.
The New OB exam consists of a routine head-to-toe physical exam with special attention to the pelvic exam.
The pelvic exam includes:
Pap smear
testing for chlamydia and gonorrhea
evaluation of the size of the uterus to see whether it corresponds to the gestational age
clinical pelvimetry – evaluation of the bone structure of the pelvis to see whether it is conducive to vaginal birth

6. One Chart OB Tools Chart review Pregnancy episode report
Encounters tab-pregnancy
Pregnancy episode report
Open SnapShot
Select pregnancy episode from toolbar
Can use “wrench” to add to top button choices
To update pt’s history
Click on history

7. One Chart OB Tools Change domain Inpatient versus outpatient setting
4th floor inpatient (L and D and postpartum)
Olson Center General Ob/Gyn
Scroll down under Epic button to change
Options for notes differ
Brief op note-inpatient only

8. Medical Student as Scribe
Billing practitioner shall be present for the entire encounter and shall have performed all involved activities.
Scribe shall document his/her name and role in the medical record.
Example:
“Jane Doe, acting as a scribe for Dr. White, who performed this service.”

9. Uterine Size Related to Dates
*6 weeks –tangerine-sized
*8 weeks –baseball-sized
*10 weeks –softball-sized
*12 weeks – at the pelvic brim, grapefruit-sized
*16 weeks – midway between the symphysis & the umbilicus
*20 weeks – at the umbilicus
Here’s how the size of the uterus corresponds to the gestational age:
at 6 weeks, the uterus is round and the size of a tangerine
at 8 weeks, it’s the size of a baseball
at 10 weeks, it’s the size of a softball
at 12 weeks, it’s the size of a grapefruit and palpable above the symphysis pubis
at 16 weeks, the fundus is about halfway between the symphysis pubis and the umbilicus
at 20 weeks, the fundus is at the umbilicus

10. Review the Anatomy of the Bony Pelvis!
Symphysis pubis
Ischial spines
Ischial tuberosities
Sacrum
Inferior pubic rami
Subpubic arch
Sacral promontory
It’s a good idea to review the anatomy of the bony pelvis, since it plays a major role in OB! Make sure you are familiar with all these parts of the pelvis.

11. Clinical Pelvimetry Diagonal conjugate:
*from the middle of the sacral promontory to the inferior margin of the symphysis pubis
*The only diameter of the pelvic inlet that can be measured clinically
*Normal is at least 11.5 cm (indirect measurement of the obstetric conjugate)
Clinical pelvimetry is the part of the pelvic exam that evaluates the “adequacy” of the pelvis – whether the dimensions are adequate for vaginal delivery.
The DIAGONAL CONJUGATE is measured from the inferior margin of the symphysis pubis to the sacral promontory using the examiner’s hand. You have to measure your own hand ahead of time.
The diagonal conjugate is the only diameter of the pelvic inlet that can be measured clinically.
When you are evaluating the diagonal conjugate, you also want to note whether the sacrum is concave, straight, or anterior.
Most of the time, the diagonal conjugate is NOT palpable! This means that the anteroposterior (AP) diameter of the pelvis is adequate.
Sacrum – concave, straight, anterior

12. Clinical Pelvimetry Interspinous diameter:
*measurement of the midpelvis
*smallest dimension of the pelvis
*must be at least 10 cm
*note whether ischial spines are blunt, prominent, encroaching
You should palpate for the ischial spines. They are palpable through the vaginal walls at about the 3 o’clock and 9 o’clock positions when the patient is lying down.
The INTERSPINOUS DIAMETER – the distance between the ischial spines – is an evaluation of the midpelvis.
This is the smallest dimension of the pelvis and needs to be at least 10 centimeters for the fetal head to be able to fit.
Notice also whether the ischial spines are sharp, encroaching into the vagina, or otherwise reducing the diameter of the midpelvis.

13. Clinical Pelvimetry Subpubic arch: *normal = 90° *pelvic outlet
Intertuberous diameter:
*between the ischial tuberosities
The subpubic arch – inferior to the symphysis pubis and created by the inferior pubic rami – is normally about 90 degrees. If you can fit two fingers side-by-side, that’s about 90 degrees.
The intertuberous diameter – the distance between the ischial tuberosities – can be palpated and compared to a measurement of your fist. Obviously you have to measure your hand ahead of time.
The subpubic arch and the intertuberous diameter are evaluations of the pelvic outlet.

14. Pelvic Types
From your clinical pelvimetry, you can categorize the pelvis into one of four types.
The GYNECOID pelvis is most common. The pelvic cavity is more-or-less round, with the A-P diameter and transverse diameter about the same. The gynecoid pelvic type is considered ideal for vaginal birth.
If you look at the ACOG form, you will notice that the physical exam section asks whether the patient has a gynecoid pelvis – YES or NO.
The ANTHROPOID pelvis is the second most common. The pelvic cavity is oval and there is increased room in the posterior pelvis. The anthropoid pelvic type is common in African and African-American women. It is also conducive to vaginal birth.
The ANDROID pelvic type is a “male” type of pelvis with a triangular cavity. It is not considered very conducive to vaginal birth.
The PLATYPELLOID pelvis has a wide transverse diameter but a shallow A-P diameter. The diagonal conjugate is easily reached. This pelvic type is the least favorable for vaginal birth, and also the least common.
Would we make a decision about the route of delivery based on clinical pelvimetry at the first prenatal visit? NO – since there are other factors to consider at the time of delivery, such as the size of the baby.

15. PRENATAL CARE – 1st VISIT Establish the EGA & EDC
Based on the LMP and physical exam, establish the EGA & EDD.
If LMP and exam findings do not correlate, consider US.
ACCURATE DATING IS ESSENTIAL FOR OB MANAGEMENT!
Based on the patient’s last normal menstrual period and your physical exam, establish the current ESTIMATED GESTATIONAL AGE and the ESTIMATED DATE of DELIVERY.
If the last menstrual period and your exam findings do not correlate, you should consider ultrasound to establish accurate dating for the pregnancy.
Accurate dating is essential because all of your management decisions throughout the pregnancy will be based on the gestational age.

16. PRENATAL CARE – 1st VISIT Routine labs:
ABO/Rh
Antibody screen
CBC
Rubella
Syphilis (RPR or VDRL)
Hepatitis B
Varicella
HIV (recommended)
Need patient’s consent
CCUA for C&S
Pap (if indicated)
GC & Chlamydia
Hemoglobin electrophoresis (if appropriate)
CF screening (offered)
1st vs. 2nd trimester genetic screening (discussed and offered)
At the first visit, the patient will have this routine lab work.
Blood will be drawn for:
ABO/Rh typing
antibody screen
complete blood count
immunity to rubella
syphilis
hepatitis B
We encourage patients to be tested for HIV and we offer screening for the cystic fibrosis gene.
A clean catch urine is sent to the lab for culture & sensitivity.
The Pap and cervical cultures for chlamydia and gonorrhea are sent.
Hemoglobin electrophoresis is ordered, if appropriate, to detect sickle cell and thalassemias.

17. PRENATAL CARE – Return Visit (ROB) Review the chart!
Calculate the EGA
Review lab results
Review objective data
Weight gain
Blood pressure
When a patient comes in for a return OB visit –
First, REVIEW THE CHART!
Calculate the estimated gestational age today.
Review any lab or ultrasound results.
The patient will have had her weight and blood pressure taken so check those results.
A urine dip will be done for protein, glucose, and ketones. If there are other findings such as blood, leukocytes, or nitrites, the nurse will note that as well.

18. PRENATAL CARE – Return Visit Keep in mind the “3 Bs”
When you go to see the patient, keep in mind the THREE B’S ---
baby
belly
bottom
BELLY
BABY
BOTTOM

19. PRENATAL CARE – Return Visit Subjective Data
BABY – is the baby moving?
“Quickening” noted starting at wks EGA
“Kickcounts” in 3rd trimester
BELLY – contractions, abdominal pain?
BOTTOM – bleeding, loss of fluid, abnormal vaginal discharge, UTI symptoms, itching, lesions, odor?
Any other concerns?
BABY reminds you to ask, “Is the baby moving?” Keep in mind that if it’s her first baby, she probably won’t feel fetal movement until around 20 weeks. If she has had a baby before, she will notice it at weeks.
BELLY reminds you to ask about any uterine contractions or abdominal pain.
BOTTOM reminds you to ask about any vaginal bleeding, loss of fluid, abnormal discharge, UTI symptoms, itching, sores or bumps, odor, or any other problems.
Always ask the patient if SHE has any concerns or questions.

20. PRENATAL CARE – Return Visit Objective Data
Measurement of fundal height (FH) in cms from the symphysis pubis to the top of the uterine fundus
measured from 20 wks EGA and onward
Assesses for S/D discrepancy and serial growth
Before 20 weeks, assess the fundal height relative to the symphysis pubis or the umbilicus.
After 20 weeks, measure the fundal height in centimeters from the symphysis pubis to the top of the uterine fundus.
The fundal height in centimeters should be approximately equal to the gestation in weeks.

21. PRENATAL CARE – Return Visit Objective Data
Auscultation of fetal heart tones with a Doppler
Heart tones are heard best over the fetal back
Auscultate the fetal heart tones with a Doppler. You can usually hear heart tones starting around weeks.
Listen for a normal rate and regular rhythm.
If you have assessed the fetal position correctly by Leopold’s maneuvers, you will know where to put the Doppler. The heart tones are usually heard best over the fetal back.

22. PRENATAL CARE – Return Visit Objective Data
Start your physical assessment by palpating the abdomen to locate the uterine fundus.
In the third trimester, do “Leopold’s maneuvers” –
Start with your hands at the fundus and outline the fetus, trying to determine what is in the fundus.
Move your hands down the sides of the uterus, trying to locate the fetal back. The back will feel smooth, while the small parts will feel lumpy.
Grasp the presenting part over the symphysis pubis.
After 32 weeks, the presenting part should be the HEAD.
What is in the fundus?
Where is the fetal back?
“Leopold’s maneuvers”
What is the presenting part?

23. PRENATAL CARE: PRESENT THE PATIENT
“26-year-old Hispanic Gravida 3 Para at 25 2/7 weeks baby active, no contractions, no bleeding, no loss of fluid, her only complaint is heartburn . . .
“fetal heart tones auscultated in the 150s, fundal height 25 centimeters, BP and UA are normal . . .
“My plan would be to do a 1-hour GTT and H&H today, recommend Tums for heartburn, discuss preterm labor precautions, and see her again in 4 weeks ˝
Present the patient to your supervising physician, midwife, or nurse practitioner.

24. PRENATAL CARE Other routine evaluation -
First trimester screen at weeks (optional)
Ultrasound measurement of nuchal transluncency
2 biochemical markers: free hCG & PAPP-A
Quad Screen at weeks (optional)
Maternal blood draw only
4 markers: AFP, hCG, unconjugated estriol (E3), & inhibin A
If 1st trimester screen performed, only draw MSAFP
Ultrasound for fetal anatomy at approx. 20 weeks
1-hour glucose tolerance test at weeks
Consider early 1-hour GTT if risk factors
If early 1-hour GTT normal, still need repeat at weeks
Hemoglobin & hematocrit at weeks
Repeat antibody screen and rhogam, if indicated, at 28 weeks
Group B strep culture at weeks
After the initial OB visit, other routine evaluation includes –
Quad Screen at weeks (optional)
1-hour glucose tolerance test at weeks, hemoglobin & hematocrit at the same time
Group B strep culture at weeks (vaginal / rectal)
Ultrasound to evaluate fetal anatomy around 20 weeks
NOW YOU KNOW HOW TO SURVIVE PRENATAL CLINIC!

25. PRENATAL CARE Patient Education
Nutrition and weight gain
Need 300 additional calories/day (singleton)
Calculate BMI
Weight gain recommendations from IOM based on starting BMI (May 2009)
Weight
Prepregnancy BMI (kg/m2)
Total Weight Gain (lb)
Rates of Weight Gain in 2nd and 3rd Trimesters (mean range, lb/wk)
Underweight
<18.5
28-40
1 (1-1.3)
Normal weight
25-35
1 (0.8-1)
Overweight
15-25
0.6 ( )
Obese (includes all classes)
≥30.0
11-20
0.5 ( )
Calculations assume a 0.5–2 kg (1.1–4.4 lbs) weight gain in the first trimester

26. PRENATAL CARE Patient Education
Exercise-great time to start!!
aerobic exercise is acceptable
30 minutes/day of moderate exercise
Starting new vigorous exercise programs not recommended
Avoid supine position after first trimester
Stop activity if warning signs develop (pain/discomfort, SOB, vaginal bleeding/ROM, dizziness, ctx)
Avoid activities with fall risks

27. PRENATAL CARE Patient Education
Smoking cessation
Increased risks of IUGR, LBW, fetal mortality
Increased risks of SIDS
Avoidance of EtOH
Fetal alcohol syndrome
Help for substance abuse
Mercury
Avoid shark, king mackeral, tile fish
Limit albacore tuna to 6 oz/week
Limit other fish/shellfish to 12oz/week

28. PRENATAL CARE Patient Education
Things to discuss during ROB visits
Prenatal classes/education
Pain relief in labor
Post partum contraception options
Circumcision, if male fetus

29. PRENATAL CARE Common Symptoms
Nausea/vomiting
Heartburn
Fatigue
Constipation
Headaches
Leg cramps
Back pain
Round ligament pain
Varicose veins and hemorrhoids
Increased vaginal discharge
Edema

30. One Chart OB Charts Highlight patient Chart - click Snapshot-click
Pregnancy-tab
Use wrench

31. One Chart OB Charts Look at problem list Check overview
Look at specialty comments
Under specialty snapshot
Look at problem list
Check overview
Under diagnosis
Problem list

32. The Postpartum Visit Typically 6 weeks after delivery
What to ask… Remember the “Bs”

33. The Postpartum Visit… the “Bs”
Breast or bottle feeding; any breast concerns
Bleeding
Bowel/bladder function
Bottom (or belly if CD)
Blues
Birth control
Baby

34. THE OB ROTATION . . . you can do it!
Learn a lot
and have fun!
We hope this presentation has made you feel more comfortable to GET OUT THERE and see OB patients!
We hope you will learn a lot on your rotation and enjoy it!
If we can help you, please let us know.
Thanks for your attention and GOOD LUCK IN OB!