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:
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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
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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
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FOB
Domestic violence
Alcohol, drugs, tobacco
Education
Employment
Language spoken (need for
interpreter)
PRENATAL CARE – 1st 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
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!
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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
Sacrum – concave,
obstetric conjugate)
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 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!
PRENATAL CARE – 1st VISIT
Routine labs:
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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 Visit
Keep in mind the “3 Bs”
BELLY
BABY
BOTTOM
PRENATAL CARE – Return Visit
Subjective 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 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
PRENATAL CARE – Return Visit
Objective Data
• Auscultation of fetal
heart tones with a
Doppler
• Heart tones are heard
best over the fetal back
PRENATAL CARE – Return Visit
Objective Data
What is in the fundus?
Where is the fetal back?
“Leopold’s maneuvers”
What is the presenting
part?
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 CARE
Other 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 2428 weeks
• Repeat antibody screen and
rhogam, if indicated, at 28
weeks
• Group B strep culture at 35-37
weeks
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)
Weight
Prepregnancy
BMI (kg/m2)
Total
Weight
Gain (lb)
Rates of Weight Gain
in 2nd and 3rd
Trimesters (mean
range, lb/wk)
<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)
≥30.0
11-20
0.5 (0.4-0.6)
Underweight
Obese (includes all
classes)
Calculations assume a 0.5–2 kg (1.1–4.4 lbs) weight gain in the first trimester
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
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
PRENATAL CARE
Patient Education
• Things to discuss during ROB visits
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Prenatal classes/education
Pain relief in labor
Post partum contraception options
Circumcision, if male fetus
PRENATAL CARE
Common Symptoms
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Nausea/vomiting
Heartburn
Fatigue
Constipation
Headaches
Leg cramps
• Back pain
• Round ligament pain
• Varicose veins and
hemorrhoids
• Increased vaginal
discharge
• Edema
One Chart
OB Charts
• Highlight patient
• Chart - click
• Snapshot-click
• Pregnancy-tab
▫ Use wrench
One Chart
OB 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”
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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!