1 / 34

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.

tommy
Download Presentation

The M3 Survival Guide to OB

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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!

More Related