3 PRENATAL CARE Routine prenatal care: First visit at 8-12 weeks Every 4 weeks until 28 weeksEvery 2 weeks between 28 & 36 weeksWeekly from 36 weeks until deliveryRoutine 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 historyMenstrual (LMP)Contraceptive usePap hxSTI hxOB historyPregnancies (G __ P __)Deliveries (term or preterm)Abortions (spontaneous or induced)ComplicationsMedical/surgical historyFamily historySocial historyFOBDomestic violenceAlcohol, drugs, tobaccoEducationEmploymentLanguage 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, medicationsGYN history – menstrual history and date of last menstrual period (the FIRST day), use of contraception, abnormal Pap smears, sexually transmitted infectionsOB 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 complicationssocial 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 examPelvic examPap (if indicated) & GC/ChlamydiaUterine size consistent with estimated gestation?Clinical pelvimetryDoppler heart tonesTypically heard at 10wks and greaterAfter 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 smeartesting for chlamydia and gonorrheaevaluation of the size of the uterus to see whether it corresponds to the gestational ageclinical 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-pregnancyPregnancy episode reportOpen SnapShotSelect pregnancy episode from toolbarCan use “wrench” to add to top button choicesTo update pt’s historyClick 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/GynScroll down under Epic button to changeOptions for notes differBrief 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 umbilicusHere’s how the size of the uterus corresponds to the gestational age:at 6 weeks, the uterus is round and the size of a tangerineat 8 weeks, it’s the size of a baseballat 10 weeks, it’s the size of a softballat 12 weeks, it’s the size of a grapefruit and palpable above the symphysis pubisat 16 weeks, the fundus is about halfway between the symphysis pubis and the umbilicusat 20 weeks, the fundus is at the umbilicus
10 Review the Anatomy of the Bony Pelvis! Symphysis pubisIschial spinesIschial tuberositiesSacrumInferior pubic ramiSubpubic archSacral promontoryIt’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, encroachingYou 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 tuberositiesThe 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 TypesFrom 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/RhAntibody screenCBCRubellaSyphilis (RPR or VDRL)Hepatitis BVaricellaHIV (recommended)Need patient’s consentCCUA for C&SPap (if indicated)GC & ChlamydiaHemoglobin 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 typingantibody screencomplete blood countimmunity to rubellasyphilishepatitis BWe 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 EGAReview lab resultsReview objective dataWeight gainBlood pressureWhen 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 ---babybellybottomBELLYBABYBOTTOM
19 PRENATAL CARE – Return Visit Subjective Data BABY – is the baby moving?“Quickening” noted starting at wks EGA“Kickcounts” in 3rd trimesterBELLY – 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 fundusmeasured from 20 wks EGA and onwardAssesses for S/D discrepancy and serial growthBefore 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 DopplerHeart tones are heard best over the fetal backAuscultate 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 transluncency2 biochemical markers: free hCG & PAPP-AQuad Screen at weeks (optional)Maternal blood draw only4 markers: AFP, hCG, unconjugated estriol (E3), & inhibin AIf 1st trimester screen performed, only draw MSAFPUltrasound for fetal anatomy at approx. 20 weeks1-hour glucose tolerance test at weeksConsider early 1-hour GTT if risk factorsIf early 1-hour GTT normal, still need repeat at weeksHemoglobin & hematocrit at weeksRepeat antibody screen and rhogam, if indicated, at 28 weeksGroup B strep culture at weeksAfter 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 timeGroup B strep culture at weeks (vaginal / rectal)Ultrasound to evaluate fetal anatomy around 20 weeksNOW YOU KNOW HOW TO SURVIVE PRENATAL CLINIC!
25 PRENATAL CARE Patient Education Nutrition and weight gainNeed 300 additional calories/day (singleton)Calculate BMIWeight gain recommendations from IOM based on starting BMI (May 2009)WeightPrepregnancy BMI (kg/m2)Total Weight Gain (lb)Rates of Weight Gain in 2nd and 3rd Trimesters (mean range, lb/wk)Underweight<18.528-401 (1-1.3)Normal weight25-351 (0.8-1)Overweight15-250.6 ( )Obese (includes all classes)≥30.011-200.5 ( )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 acceptable30 minutes/day of moderate exerciseStarting new vigorous exercise programs not recommendedAvoid supine position after first trimesterStop activity if warning signs develop (pain/discomfort, SOB, vaginal bleeding/ROM, dizziness, ctx)Avoid activities with fall risks
27 PRENATAL CARE Patient Education Smoking cessationIncreased risks of IUGR, LBW, fetal mortalityIncreased risks of SIDSAvoidance of EtOHFetal alcohol syndromeHelp for substance abuseMercuryAvoid shark, king mackeral, tile fishLimit albacore tuna to 6 oz/weekLimit other fish/shellfish to 12oz/week
28 PRENATAL CARE Patient Education Things to discuss during ROB visitsPrenatal classes/educationPain relief in laborPost partum contraception optionsCircumcision, if male fetus
29 PRENATAL CARE Common Symptoms Nausea/vomitingHeartburnFatigueConstipationHeadachesLeg crampsBack painRound ligament painVaricose veins and hemorrhoidsIncreased vaginal dischargeEdema
30 One Chart OB Charts Highlight patient Chart - click Snapshot-click Pregnancy-tabUse wrench
31 One Chart OB Charts Look at problem list Check overview Look at specialty commentsUnder specialty snapshotLook at problem listCheck overviewUnder diagnosisProblem 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 concernsBleedingBowel/bladder functionBottom (or belly if CD)BluesBirth controlBaby
34 THE OB ROTATION . . . you can do it! Learn a lotand 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!