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

The M3 Survival Guide to OB

or

“ Here I am, now what do I do???”

“What do I do in prenatal clinic?

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

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)

PRENATAL CARE – 1st VISITPhysical•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

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

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

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.”

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

Review the Anatomy of the Bony Pelvis!

•Symphysis pubis•Ischial spines•Ischial

tuberosities•Sacrum•Inferior pubic

rami•Subpubic arch•Sacrum•Sacral

promontory

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

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

Clinical Pelvimetry

Subpubic arch: *normal = 90° *pelvic outlet

Intertuberous diameter:

*between the ischial tuberosities

*pelvic outlet

Pelvic Types

PRENATAL CARE – 1st VISITEstablish 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!

PRENATAL CARE – 1st VISITRoutine 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)

PRENATAL CARE – Return Visit (ROB)Review the chart!

•Calculate the EGA•Review lab results•Review objective data

▫Weight gain▫Blood pressure

PRENATAL CARE – Return VisitKeep in mind the “3 Bs”

BABY

BELLY

BOTTOM

PRENATAL CARE – Return VisitSubjective Data

•BABY – is the baby moving?▫“Quickening” noted starting at 18-20 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?

PRENATAL CARE – Return VisitObjective 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


•Auscultation of fetal heart tones with a Doppler

•Heart tones are heard best over the fetal back


What is in the fundus?

Where is the fetal back?

What is the presenting part?

“Leopold’s maneuvers”

PRENATAL CARE:PRESENT THE PATIENT

“26-year-old Hispanic Gravida 3 Para 2-0-0-2 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 . . . ˝

PRENATAL CAREOther routine evaluation -• First trimester screen at

11-13 weeks (optional)▫ Ultrasound measurement

of nuchal transluncency▫ 2 biochemical markers:

free hCG & PAPP-A• Quad Screen at 15-22

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 24-28 weeks▫ Consider early 1-hour GTT if

risk factors▫ If early 1-hour GTT normal,

still need repeat at 24-28 weeks

• Hemoglobin & hematocrit at 24-28 weeks

• Repeat antibody screen and rhogam, if indicated, at 28 weeks

• Group B strep culture at 35-37 weeks

PRENATAL CAREPatient 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 18.5-24.9 25-35 1 (0.8-1)

Overweight 25.0-29.9 15-25 0.6 (0.5-0.7)

Obese (includes all classes)

≥30.0 11-20 0.5 (0.4-0.6)

Calculations assume a 0.5–2 kg (1.1–4.4 lbs) weight gain in the first trimester

PRENATAL CAREPatient 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


•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


•Things to discuss during ROB visits▫Prenatal classes/education▫Pain relief in labor▫Post partum contraception options▫Circumcision, if male fetus

PRENATAL CARECommon Symptoms

• Nausea/vomiting• Heartburn• Fatigue• Constipation• Headaches• Leg cramps

• Back pain• Round ligament pain• Varicose veins and

hemorrhoids• Increased vaginal

discharge• Edema

One ChartOB Charts

•Highlight patient

•Chart - click•Snapshot-click•Pregnancy-tab▫Use wrench

One ChartOB Charts

•Look at specialty comments▫Under specialty

snapshot•Look at problem list•Check overview

▫Under diagnosis▫Problem list

The Postpartum Visit

•Typically 6 weeks after delivery

•What to ask… Remember the “Bs”

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

THE OB ROTATION . . . you can do it!

Learn a lot

and have fun!

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

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