2. Every Prenatal VisitEvery Prenatal Visit  Physical exam and counseling on prenatal topics pertinent to current gestational age of pregnancy  Urinalysis OB (usually ordered by our nurses and done before you see the patient in the room)  Vital signs, height and weight  Doppler for fetal heart tones starting after week 10  Fundal height measurement after 20 weeks  Fetal lie by Leopold maneuvers after 36 weeks (you can also do transabdominal US to confirm vertex positioning)  Pelvic exam for cervical change and station after 36 weeks

3. Initial prenatal visitInitial prenatal visit  Urine pregnancy test to confirm pregnancy  Pap smear only if age >21 and not current  GC/Chlamydia genprobe (if positive treat with Rocephin & Zithromax respectively)  Wet prep only if they complain of discharge (if trich positive treat with Flagyl)  Pelvic exam  Dating based on LMP (Naegle’s rule)  LMP (1 st day) + 1 year – 3 months + 7 days  LMP- 07/24/2014, EDD- 05/01/2015  Refer immediately for OB ultrasound to confirm gestational age (earlier the US, the more accurate the dates)

4. Initial prenatal visitInitial prenatal visit  Prescribe prenatal vitamins, can also recommend prenatal/ OB gummy vitamin if patient does not tolerate regular prenatal vitamins  Influenza vaccination (can be given in any trimester)  Genetic screen/ Risk assessment  If high risk OB  recommend referral to fetal-maternal medicine, Dr. Rodts-Palenik  Order OB panel labs

5. OB Panel LabsOB Panel Labs  CBC, CMP  Urinalysis, Urine culture, UPT (treat asymptomatic bacteriuria in pregnancy)  RPR (treat with Penicillin G Benthazine)  HIV (antiretroviral therapy)  Rubella IgG (if non-immune, vaccinate after delivery)  Hepatitis B surface antigen (treatment is active and passive immunization of infant after delivery)  Antibody screen  ABO/Rh (if Rh- neg will need rhogam)

6. At 16-20 weeksAt 16-20 weeks  Maternal quad screen (16 weeks)  If abnormal, patient may want further testing (amniocentesis)  Refer for OB ultrasound to assess fetal anatomy (20 weeks)  Perform transabdominal US in our clinic to determine fetal gender (Dr. Elkins is the best at this) (20 weeks)

7. At 24-28 weeksAt 24-28 weeks  Gestational diabetes screen (O’Sullivan)- 1 hour GTT  If CBS >140, recommend 3 hour GTT  3 hr GTT  1 hr<180, 2hr <155, 3hr <140  Administer RhoGam if Rh negative patient (28 weeks)  Repeat H&H to evaluate for anemia  STI testing if increased risk  Refer to OBGYN for BTL if requested by patient (they must sign consent forms several weeks in advance)  Tdap vaccination (28-32 weeks)

8. At 35-37 weeks At 35-37 weeks  Group B strep  If positive must treat with intrapartum antibiotic prophylaxis (PCN)  Fax records to L&D  Give patient pager number or cell number if you so choose  Counsel on labor & delivery preparation, where to go, who to call, signs of labor etc.

9. At 40-42 weeksAt 40-42 weeks  Induction of labor not recommened before 40 weeks  If you and your patient choose induction, you must speak with Dr. Madden ahead of time and reserve a room in L&D (they usually need 1-2 days notice)  L&D (318) 769-7030

10.  Clinic visits recommened every 4 weeks from intial visit to 28 weeks gestation  From 28-36 weeks recommend routine prenatal visits every 2 weeks  After 36 weeks recommend routine prenatal visits weekly  These are approximate and will change if patient is high risk OB

11. Pregnancy ComplicationsPregnancy Complications  Hypertension  Safe medications inlude: Methyldopa (Aldomet), Nifedipine (Procardia) and Labetalol (Trandate)  Gestational diabetes  Oral agents not recommened  Initial trial of diet control  Have patients bring sugar logs to each visit  Use NPH (BID) and Novolog (TID with meals)

12.  Using Naegele’s rule calculate the estimated due date: LMP – December 2 nd, 2013 Review QuestionsReview Questions

13. EDD= September 9 th, 2014 Answer

14.  Who’s due date is September 9 th, 2014?? BONUS QUESTIONBONUS QUESTION

15. Christian and Michelle Sonnier Answer