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The M3 Survival Guide to OB

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.

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The M3 Survival Guide to OB

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  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 – 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)

  5. 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

  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 • 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

  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 • Ischialtuberosities • 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 ischialtuberosities *pelvic outlet

  14. Pelvic Types

  15. 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!

  16. 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)

  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 VisitKeep in mind the “3 Bs” BELLY BABY BOTTOM

  19. 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?

  20. 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

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

  22. PRENATAL CARE – Return VisitObjective Data 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 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 . . . ˝

  24. PRENATAL CAREOther routine evaluation - • First trimester screen at 11-13 weeks (optional) • Ultrasound measurement of nuchaltransluncency • 2 biochemical markers: free hCG & PAPP-A • Quad Screen at 15-22 weeks (optional) • Maternal blood draw only • 4 markers: AFP, hCG, unconjugatedestriol (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

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

  26. 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

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

  29. PRENATAL CARECommon Symptoms • Nausea/vomiting • Heartburn • Fatigue • Constipation • Headaches • Leg cramps • Back pain • Round ligament pain • Varicose veins and hemorrhoids • Increased vaginal discharge • Edema

  30. One ChartOB Charts • Highlight patient • Chart - click • Snapshot-click • Pregnancy-tab • Use wrench

  31. One ChartOB 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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