Prenatal Care

Prenatal Care (8)

%AM, %333 %07 %2015 %00:%Jul

OB-GYN Cerner Handbook

Written by Dr.D

Dr. Brecht-Doscher has put together a compilation of cerner tips and workflows related to OB-GYN care.  Prenatal care, labor and delivery (L&D), postpartum care, and perioperative surgical orders and documentation are covered.  The PDF of the ob-gyn book is available below:

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%AM, %333 %14 %2015 %00:%May

Disability During Pregnancy

Written by Dr.D

AMA Guidelines for
Continuation of Various Job Tasks During Pregnancy

This table is to be used as a guide to determine the appropriate gestational age to initiate disability for a pregnant patient depending on their job duties.

Task

Weeks
Gestation

Secretarial & Light Clerical 40
Professional & Managerial 40
Sitting with light tasks 40

Standing:   
    Prolonged (more than 4 hours at a time)
    Intermittent, >30 minutes per hour
    Intermittent, <30 minutes per hour


24
32
40

Stooping and bending below knee level:
    Repetitive (>10 times per hour)
    Intermittent (2-10 times per hour)
    Intermittent (<2 times per hour)


20
28
40

Climbing vertical ladders and poles
    Repetitive (4 or more times per 8 hour shift)
    Intermittent (<4 times per 8 hour shift)


20
28
Stairs:
    Repetitive (4 or more per 8 hour shift)
    Intermittent (<4 per 8 hour shift)


28
40

Lifting, repetitive:
    <25 lbs.
    25-50 lbs.
    >50 lbs.   

40
40
30

Taken from American Medical Association Council on Scientific Affairs, “Effects of Pregnancy of Work Perfomance"

Commercial Air Travel Guidelines

  • Up to 24 weeks’ gestation: No restrictions unless complicating obstetric or medical risk factors exist.
  • 24-36 weeks’ gestation: No restrictions unless complicating obstetric or medical risk factors exist.
  • Doctor should give the patient a letter specifying details of the pregnancy and permission to travel. The patient should have in her possession sufficient information to allow a physician to make appropriate emergency judgments (prior obstetric history and risk factors), blood group, rubel immune status, allergies, medications, blood pressure, recent complete blood count and urinalysis, and plans for delivery.   Medical courtesy and common sense require a doctor’s letter in the possession of the traveling gravida from the onset of fetal viability, namely 24 weeks of gestation.
  • After 36 weeks’ gestation: Air travel discouraged unless unavoidable.
  • All airlines require a doctor’s letter for patients at 36 weeks or more gestation. If travel is essential, a doctor’s letter is mandatory; not just to get the patient on the plane but also for the doctor(s) that may become involved in the patient’s obstetric care

This page adapted from Indiana University Health.

%AM, %375 %03 %2015 %00:%Feb

Induction of Labor Checklist

Written by Dr.D

Patient safety checklist for induction of labor.  If your patient is to be induced, this form must be submitted prior to scheduling the induction.  The indication will need to be clearly stated and a Bishop score must be documented.  The completed form may be faxed to labor and delivery at: (805) 652-6087


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%AM, %375 %03 %2015 %00:%Feb

Timing of Delivery

Written by Dr.D

Recommendations for the timing of delivery when conditions complicate pregnancy at or after 34 weeks gestational age.  ACOG Committee Opinion no. 560


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%AM, %333 %16 %2014 %00:%Sep

Prenatal Care Checklist

Written by Dr.D
  Discuss Do
 
Pre-conception
  • Prevention of preterm labor
  • Nutrition and Weight
  • Domestic violence
  • Accurate LMP recording
  • H&P
  • Vaccines: MMR/Rubella, Hep B (if at risk)
  • PNV with iron and folic acid 800 mcg
  • All labs/cultures/cytology listed for "Visit 1"

Visit 1
6-8 weeks

  • Nutrition (extra 340-450 cal/day)
  • Physical Activity
  • Domestic Violence
  • Depression
  • Discuss aneuploidy screening
  • 4Ps perinatal substance screen (drug or alcohol use in Parents, Partner, Past, or current Pregnancy)
  • Check pregnancy test
  • Calculate EDC based on LMP (LMP + 7 days - 3 months + year)
  • Prenatal labs (ABO type, Ab screen, CBC, RPR, HepBsAg, Rubella IgG), HIV, Varicella IGG
  • Cervical cytology + GC & chlamydia
  • urine for UA and culture (+GC/chlamydia if no cervical specimen)
  • Rx: PNV with iron and folic acid (800 mcg)
  • Ultrasound for dates (if uncertain LMP)
  • CPSP referral (if Medi-Cal)
  • Genetic counseling (if >35yo by EDC)
  • PPD (if indicated)
Visit 2
10-12 weeks
  • Review labs from 1st visit
  • Breast feeding
  • Nausea/vomiting
  • Vaccines: influenza (if in season)
  • Serum integrated screening (if desired)
    • PAPP-A & b-hCG (between weeks 100 - 136/7)
    • AFP, hCG, uE3, inhibin (between weeks 150 - 200)

Visit 3
16-18 weeks

  • preterm labor signs
  • OB teaching ultrasound
Visit 4
24-28 weeks
  • Pre-registration & length of stay
  • Awareness of fetal movement
  • Breast feeding
  • Domestic violence
  • Depression
  • Glucose tolerance test (50gm; 1 hr; goal <140).  If positive, send for 3-hour GTT.
  • HepBsAg
  • Hemoglobin
  • GC, Chlamydia, VDRL (if high-risk)
  • If Rh negative:
    • Repeat Ab screen
    • RhoGAM 300mcg IM @ 28 weeks

Visit 5
32 weeks

  • Travel
  • Sexuality
  • Pediatric care
  • Discussion of labor plan (when to come, what to bring, anaesthesia, c/s risk, etc...)
  • Warning signs & pregnancy-induced HTN
  • Tdap (all patients, after 27 weeks)
  • FeSO4 325mg po BID (if anemic)

Visit 6

34 weeks

  • Postpartum care
  • Managing late pregnancy symptoms
  • Contraception
 
Visit 7
36 weeks
  • When to call provider
  • Postpartum depression
  • GBS Culture

Visits 8+

38-41 weeks

  • Infant CPR
  • Post-term management
  • Labor & delivery update
Postpartum visit
  • Breast feeding
  • Birth control
  • Bonding
  • Blues
  • Bleeding