Prenatal Care: A Crash Course for the M3 Clerkship Laura E. Cudzilo , MD

1. Prenatal Care: A Crash Course for the M3 Clerkship Laura E. Cudzilo, MD Assistant Professor, Department of OB/GYN

2. Step one: logging into the computer! • Make sure you’re logged into the correct context in OneChart

3. Step two: accessing the clinic schedule • Click on schedule tab • Click on NM OBGYN OLSON drop-down folder • Select the appropriate clinic schedule • Utilize Chart Review tab to access the OB episode • Refer to Dr. Cudzilo’s excellent live demonstration for complete details

4. 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

5. 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 • Father of baby • Domestic violence • Alcohol, drugs, tobacco • Education • Employment • Language spoken (need for interpreter)

6. 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

7. Uterine Size Related to Dates • 6 weeks: tangerine • 8 weeks: baseball • 10 weeks: softball • 12 weeks: grapefruit, at pelvic brim • 16 weeks: halfway between symphysis and umbilicus • 20 weeks: at umbilicus

8. Review the anatomy of the bony pelvis! • Symphysis pubis • Ischial spines • Ischialtuberosities • Sacrum • Inferior pubic rami • Subpubic arch • Sacrum • Sacral promontory

9. Clinical Pelvimetry • Diagonal conjugate • Measured from middle of the sacral promontory to the inferior margin of the symphysis pubis • 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

10. 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

11. Clinical Pelvimetry • Subpubic arch • normal = 90° • pelvic outlet • Intertuberous diameter • between the ischial tuberosities • pelvic outlet

12. Pelvic Types

13. 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!

14. PRENATAL CARE – 1st VISITRoutine labs: • ABO/Rh • Antibody screen • CBC • Rubella • Syphilis (RPR or VDRL) • Hepatitis B • Varicella • HIV (recommended) • Need patient’s consent • Clean-catch urine sample for culture and sensitivities • Pap (if indicated) • GC & Chlamydia • Hemoglobin electrophoresis (if appropriate) • Cystic fibrosis and spinal muscular atrophy screening (offered) • Genetic screening/testing (offered)

15. PRENATAL CARE- 1st VISIT • Genetic Screening • First-trimester screening • Available between 11-13 wk gestation • Ultrasound (nuchal translucency, presence of nasal bone) • Maternal fingerstick: free hCG and PAPP-A • Quad screening • Available between 15-22 wk gestation • Maternal serum sample: AFP, hCG, unconjugated estriol, inhibin A • Non-invasive prenatal testing (NIPT) • Available from 10 wk gestation onward • Maternal serum sample: fetal genetic material in maternal blood • Genetic Diagnostic Testing • Chorionic villus sampling • Available from 11-13 wk gestation (varies depending on where performed) • Amniocentesis • Available from 15 wk gestation onward

16. PRENATAL CARE – Return Visit (ROB)Review the chart! • Use Pregnancy Episode to find current gestational age • Review any L&D visits, laboratory tests, ultrasound results • Review objective data • Weight gain • Blood pressure

17. PRENATAL CARE – Return VisitKeep in mind the “3 Bs” BELLY BABY BOTTOM

18. PRENATAL CARE – Return VisitSubjective Data • BABY – is the baby moving? • “Quickening” noted starting at 18-22 wks EGA • “Kick counts” in 3rd trimester • BELLY – contractions, abdominal pain? • BOTTOM – bleeding, loss of fluid, abnormal vaginal discharge, UTI symptoms, itching, lesions, odor? Any other concerns?

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

20. PRENATAL CARE – Return VisitObjective Data • Fundal height measurement • Measurement in cm from the symphysis pubis to the top of the uterine fundus • Start at 20wk gestation • Assesses for size-date 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 CAREOther routine evaluation • 20 weeks • Ultrasound for fetal anatomy • 24-28 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 • 27-36 weeks • TDAP (tetanus, diptheria, acellular pertussis) vaccination • 28 weeks • Rh negative • Repeat antibody screen and administration of Rhogam • 35-37 weeks • Group B strep screening

24. 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

25. PRENATAL CAREPatient Education

26. PRENATAL CAREPatient Education • Exercise-great time to start! • 30 minutes/day of moderate exercise recommended • Starting new vigorous exercise programs not recommended • Avoid activities with fall risks • Aerobic exercise is okay! • Avoid prolonged periods in the supine position after the first trimester • Stop activity if warning signs develop (pain/discomfort, shortness of breath, vaginal bleeding/leaking of fluid, dizziness, contractions)

27. PRENATAL CAREPatient Education • Tobacco use • Intrauterine growth restriction/small for gestational age neonates • SIDS • Childhood asthma • Alcohol use • Fetal alcohol spectrum disorders • Substance use

28. PRENATAL CAREPatient Education • Anticipatory guidance • Breastfeeding • Prenatal classes/education • Pain relief options in labor • Postpartum contraception options • Circumcision, if male fetus

29. PRENATAL CARE:PRESENT THE PATIENT • “Ms. A is a 26-year-old Gravida 3 Para 2-0-0-2 at 25 2/7 weeks presenting for routine OB care. Baby active, no contractions, no bleeding, no loss of fluid. Her only complaint is heartburn.” • “I auscultated fetal heart tones in the 150s. Fundal height is 25 centimeters. BP is normal and weight gain has been appropriate.” • “My plan would be to do a 1-hour GTT and H&H today. I recommend Tums for heartburn, discussing preterm labor precautions, and seeing her again in 4 weeks.˝

30. The Postpartum Visit • Typically 6 weeks after delivery • Important information (“The Bs”, Part Two) • Breast or Bottle, any breast concerns • Bleeding • Bowel/bladder function • Bottom/belly • Blues • Birth control • Baby

31. THE OB ROTATION . . . you can do it!