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The M3 Survival Guide to OB or “ Here I am, now what do I do???”

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Presentation on theme: "The M3 Survival Guide to OB or “ Here I am, now what do I do???”"— Presentation transcript:

1 The M3 Survival Guide to OB or “ 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

4 PRENATAL CARE – 1 st 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)

5 PRENATAL CARE – 1 st 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

6 One Chart OB Tools Chart review ▫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 ▫Chart review ▫Click on history

7 One Chart OB Tools Change domain ▫Inpatient versus outpatient setting  4 th 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

10 Review the Anatomy of the Bony Pelvis! Symphysis pubis Ischial spines Ischial tuberosities Sacrum Inferior pubic rami Subpubic arch Sacrum Sacral promontory

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) 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

13 Clinical Pelvimetry Subpubic arch: *normal = 90° *pelvic outlet Intertuberous diameter: *between the ischial tuberosities *pelvic outlet

14 Pelvic Types

15 PRENATAL CARE – 1 st 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!

16 PRENATAL CARE – 1 st 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) 1 st vs. 2 nd trimester genetic screening (discussed and offered)

17 PRENATAL CARE – Return Visit (ROB) Review the chart! Calculate the EGA Review lab results Review objective data ▫Weight gain ▫Blood pressure

18 PRENATAL CARE – Return Visit Keep in mind the “3 Bs” BABY BELLY BOTTOM

19 PRENATAL CARE – Return Visit Subjective Data BABY – is the baby moving? ▫“Quickening” noted starting at wks EGA ▫“Kickcounts” in 3 rd trimester BELLY – contractions, abdominal pain? BOTTOM – bleeding, loss of fluid, abnormal vaginal discharge, UTI symptoms, itching, lesions, odor? Any other concerns?

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

21 PRENATAL CARE – Return Visit Objective Data Auscultation of fetal heart tones with a Doppler Heart tones are heard best over the fetal back

22 PRENATAL CARE – Return Visit Objective Data What is in the fundus? Where is the fetal back? What is the presenting part? “Leopold’s maneuvers”

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... ˝

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 1 st 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

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) WeightPrepregnancy BMI (kg/m2) Total Weight Gain (lb) Rates of Weight Gain in 2 nd and 3 rd Trimesters (mean range, lb/wk) Underweight< (1-1.3) Normal weight (0.8-1) Overweight ( ) Obese (includes all classes) ≥ ( ) 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 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!


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