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Prenatal Care

2. Goal of Prenatal Care. Assess the risk factors to attempt to predict complicationsInsure the health of the motherAssess the growth of the fetusTo educate the patientTo establish an EDCTo treat conditions that could affect the outcome of the pregnancy. 3. History. Age- Young patients have an

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Prenatal Care

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    1. 1 Prenatal Care Acer_user

    2. 2 Goal of Prenatal Care Assess the risk factors to attempt to predict complications Insure the health of the mother Assess the growth of the fetus To educate the patient To establish an EDC To treat conditions that could affect the outcome of the pregnancy

    3. 3 History Age- Young patients have an increased risk of preterm delivery, STDs and IUGR, patients over 35 have an increased risk of genetic abnormalities, DM, HTN, and spontaneous losses Race- Certain races can carry genes that can affect the pregnancy (i.e. sickle cell, thalasemias, tay sachs) also certain medical disorders can be more common

    4. 4 History Medical history Surgical history (cones, D&C,TOP) Allergies Habits- Tobacco use decreases fetal weight, can be associated with increased risk of placental abruption, increases risk of preterm delivery and lowers patients overall health

    5. 5 History Tobacco use is associated with an increased incidence of placenta previa, Spontaneous abortion, preterm rupture of membranes, and Sudden infant death syndrome After birth risk of second hand smoke

    6. 6 History Habits continued ETOH use- Associated with other drug usage, risk of fetal alcohol syndrome, IUGG, poor maternal nutrition, failure to thrive, mental impairment, and preterm delivery Substance abuse- Cocaine causes increased risk of placental abruptions, IUGR, neonatal and childhood learning disorders, malformations,IUFDs

    7. 7 History Opioid abuse- IUGR, preterm delivery, decreased apgar score, meconium stained amniotic fluid, other substances Marijuana- No hard data implicating it in any complication although long term neurologic problems may occur Amphetamines- IUGR, preterm delivery, IVH and CNS abnormalities

    8. 8 History Medications-Did the patient ingest a medication that is contraindicated or harmful to the fetus (I.e. ACE inhibitors cause fetal death, Accutane orally can cause CNS abnormalities category X, etc.) Family history- Birth defects, DES use, genetic abnormalities, medical conditions (DM, HTN, etc.)

    9. 9 History Childhood diseases or immunizations OB/GYN history- Gravidity and parity Menstral history to help establish an EDC Prior pregnancies- length of gestation, complications, type of birth (C/S, forceps, vacuum, SVD, Induction, length of labor, birth weights, TOPs, ABs, Shoulder dystocias

    10. 10 History Marital status- family situation, single has increased risk of preterm delivery Employment- hours worked, what type of work, environmental exposures

    11. 11 Risk assessment Age- Young or old Substance abuse Maternal weight-Over or under weight Medical disorders Poor obstetric history- preterm delivery is best predictor of preterm delivery, if previous IUGR or IUFD need monitoring, congenital anomalies

    12. 12 Risk assessment cont. Previous PIH, how for along, outcome Uterine anomalies- septum, DES, fibroids Infections- Chorioamnionitis, Group B strep, GC, Chlamydia, BV Socioeconomic status 3 deliveries in 2 years

    13. 13 Risk assessment cont. Incompetent cervix Placental accidents or previas ( increased risk with previous previa X 8, and with cesarean sections X2 Maternal hemorrhage ( not all patients will have risk factors)

    14. 14 Physical Exam First visit complete physical including speculum exam and pap if indicated. +/- cultures for GC and Chlamydia Bimanual exam to assess uterine size (fundal ht = weeks in gestation from 17-32 weeks Weight, blood pressure in LLP, dip urine for protein and glucose, and FHR

    15. 15 Follow up Ob visits Fundal height Weight (total for pregnancy 25-35# if normal wt, if obese 15#, if underweight 35-40#) Blood pressure (lowest in second trimester) Fetal heart rate (120-160) Urine for protein and glucose

    16. 16 Follow up OB visits Check for edema Ask patients about any problems +/- pelvic exam Prenatal vitamins

    17. 17 Laboratory tests CBC (H&H at 24-28wks) Type Rh and antibody screen RPR Rubella titer Hepatitis B surface antigen +/- GC and Chlamydia cultures +/- MSAFP at 16-20wks +/- HIV

    18. 18 Laboratory tests 1 hour post glucola 50gm load at 24-28 wks +/- Group B Strep at 34-37 wks +/- toxoplasmosis +/- Varicella zoster antibody titer +/- Parvovirus B 19 antibody titer H&H at 34-36 wks Wet prep if indicated

    19. 19 Tests Ultrasound at 20 weeks for anatomy Earlier if poor dates or size U/S to follow IUGR q 2-3 weeks NST at 41 weeks with AFI, NSTs for IUGR, previous IUFD, medical conditions, etc U/S at 39 weeks for EFW

    20. 20 Follow up test If 1 hour BS over 140 then 3 hour glucose test (3 days carbohydrate loading) If MSAFP is elevated repeat, if second is elevated offer genetic amniocentesis If MSAFP low offer genetic amniocentesis If older than 35 at delivery offer Amnio

    21. 21 Frequency of visits Every 4 weeks to 28wks Every 2 weeks 28-36 Weekly 36 weeks to delivery Alter this based on pt problems

    22. 22 Weight Gain 25-35# Underweight 28-40 Overweight 15-25 Twins 35-45 If weight gain is low watch for IUGR with U/S

    23. 23 Weight First trimester 3-6# to 1# week in second trimester # a week in last trimester Low weight gain is associated with low birth birth weight

    24. 24 Diet 25-30Kcal/Kg (2400kcal) Balance diet 6 meals Prenatal vitamin

    25. 25 Activity Normal levels of activity are acceptable if no complications are present Exercising is OK (80% target HR) Avoid traumatic activities (snowmobiling, dirt bike riding etc.) Travel is alright, pressurized aircraft do not affect the pregnancy Intercourse is acceptable

    26. 26 Establishing gestational age Naegeles rule- add 7days and subtract 3 months from FDLMP 280 days from FDLMP 266 days from conception Ultrasound 1st trimester within 7 days, second trimester within 10 days, third trimester 2-3 weeks Quickening 19weeks +/- 2 weeks 1st Quickening 17 weeks +/-2 weeks 2nd on

    27. 27 Establishing EDC FHR is auscultation at 20 week with fetascope +/- 2 weeks FHR with doppler at 12-14 weeks some earlier FHR seen with U/S at 7 weeks

    28. 28 Definitions Nulligravida- Never been pregnant Gravida- has been pregnant Nullipara- GxP0 Primipara- Has had 1 delivery Multipara- 2 or more births TPAL

    29. 29 Counseling VBAC- Only for LTCS not vertical uterine incisions 1/200 chance of uterine rupture Limited to 2 or less C/S Failed VBAC Assess risk and reason for C/S

    30. 30 Counseling Encourage smoking cessation Smaller babies Increased risk of fetal loss, mental retardation, and PTL CO inactivates maternal and fetal Hgb Decreased caloric intake IUGR. PTL decreased perfusion of placenta

    31. 31 Counseling Watch caffeine intake and nutra sweet intake Tylenol , Benadryl, Robitussin, Pseudophed, actifed are OK Avoid alcohol. Asa, tobacco, any medication unless cleared by physician, and avoid street drugs

    32. 32 Common complaints N/V- usually to 13 weeks Eat small amounts frequently Phenergan Tigan Reglan Compazine Benadryl

    33. 33 Common complaints Back ache Round ligament Hemorrhoids Varicosities Heart burn Leukorrhea Pica constipation

    34. 34 Warning signs Decreased fetal movement Vaginal bleeding Edema of hands and face Severe headache Blurred vision RUQ pain Dysuria Leakage of fluid

    35. 35 Pre-Pregnancy counseling Terminate bad behaviors Avoid environmental hazards Start folic acid supplementation 8 weeks prior to conception Plan management of medical disorders Rubella, HIV, Tay sachs, sickle cell, cystic fibrosis Determine genetic risks

    36. 36 Conclusions Bad prenatal care is worse than no prenatal care History tends to repeat itself Best prenatal care starts with Preconceptual care

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