SCPCN Maternity Clinic Guidelines
First Prenatal Visit (Before 12 weeks):
- Confirm pregnancy if not already confirmed
- Estimate due date, book dating ultrasound if necessary
- Discuss how the obstetrical call group works
- Get “From Here To Maternity” and other handouts
- Get requisitions to have prenatal blood work done
Second Prenatal Visit (Before 12 weeks):
- Comprehensive prenatal history is obtained and lifestyle factors are discussed
- Discuss Genetic Screening and book First Trimester or Nuchal Translucency screen if desired and available o Discuss and treat nausea if necessary
12 weeks:
- Complete physical, including Pap and vaginal swabs o Get requisition for routine 18‐20 week ultrasound
16 weeks:
- Review lab, Pap and if applicable, ultrasound results
- If genetic screening is desired and the Nuchal Translucency or First Trimester screen was not done, consider having
- Maternal serum screen (MSS) done
20 weeks:
- Review 18‐20 week ultrasound results
- Discuss signs & symptoms of preterm labour
- Hospital pre‐registration is sent off
24 weeks:
- Get requisition for Gestational Diabetes Screen, as well as routine blood and urine tests o If blood type is Rh (‐), then get requisition to repeat blood antibodies
28 weeks:
- Review lab results
- Get fetal movement count chart
- If blood type is Rh (‐) then get Rhogam injection in office
30 – 34 weeks:
- Routine visits every 2 weeks. Topics of discussion may include cord blood donation, prenatal classes and/or breastfeeding
36 weeks:
- Do Group B Strep (GBS) Swab and have vaginal exam to confirm head is down
- If not head down (i.e., breech), discuss and arrange external cephalic version (ECV) to attempt to rotate baby to proper position
- Discuss when to go to hospital and what to expect in the delivery room - Prenatal record is printed and given to patient
37 weeks:
- Review GBS results
38 weeks – 39 weeks:
- Offer membrane sweep
40 weeks (Due date):
- Book 41 week biophysical profile (BPP) ultrasound o Consider booking induction for 41 weeks + 4days
41 weeks:
- Review 41 wk BPP, book another BPP for 41 weeks + 3 days if needed o Book induction if not already booked
Postpartum care:
- We want to see your baby within the first 5‐7 days of life – please call the office as soon as you are discharged from hospital. We will then book follow‐up baby checks as needed after the first visit.
If you have any concerns about your own health in the first 6 weeks, we will see you as needed – if you want to discuss your concerns at a well baby check, please let the staff know so that they can schedule enough time for this.
EDC determination:
- U/S > 9 weeks; CRL> 10mm
- If 1st U/S is detailed at EFW – go by their calculated date
BMI (pre-pregnancy):
- >30 – US at 36 wks for fetal growth/assessment/presentation; refer to dietician
- >40 – do not accept
- During pregnancy: (F6) (Wolf alert!)
- >40 – consult OB/US q2wks (36wks)
- >40 – anaesthesia consult – (Pre-op assessment clinic – SHC)
Maternal age >40:
- Increased risk for perinatal morbidity/mortality
- US @ 32-34 wks and 36 wks – weekly after 37 wks
- Induce at 39 wks – SOGC guidelines
Previous history of IUGR/Oligohydramnios:
- MFM U/S at 32 wks and then at MFM discretion/guidance
Previous history of preterm birth (<34 wks):
- Don’t accept
Previous stillbirth:
- Don’t accept
Gestational Diabetes:
- If any risk factors@ 1st PN: do HbA1C – if>or= 6.3 refer to DIP clinic – may need TOC
- Risk factors: BMI>30, age>35, prior GDM, FHx DM(1st degree), previous macrosomia, hx PCOS, acanthosis nigricans, ethnicity (Asian, Aboriginal, Hispanic, African)
- BMI >35: GDS in 1st and 2nd trimester
- If previous GDM – refer to DIP clinic
- Diet controlled: US at 36 wks with MFM (if sugars poorly controlled)
- Insulin: US at 32 wks with MFM and induce by 40wks (38-40wks)
Hypothyroidism:
- Screen pregnant women early in pregnancy: trimester-specific reference ranges for TSH
- First trimester 3.3
- Second trimester 4.1
- Third trimester 4.5
- if treatment necessary, check TSH q 4 weeks
- - Discontinue synthroid after delivery and recheck TSH @ 6 weeks PP if started during pregnancy
- - Reduce synthroid dose to pre-pregancy level if already taking med prior to pregnancy and recheck TSH @ 6 weeks PP
LGA:
- >90%ile – consider OB consult – while in L&D (>4500gm)
- Repeat GDS if MFM recommends
Hypertension:
- Essential HTN: transfer to OB
- If previous PIH/pre-eclampsia, START ASA 81 mg at 12 weeks and consider continuing until 32 weeks
- PIH at <34 wks: consult OB with potential TOC
- Keep on labetalol until 7 day post partum visit
- Keep in hospital 36-48 hrs post partum
- Acetylsalicylic acid should be: taken in a low dose (75–162 mg/d), administered at bedtime, initiated after diagnosis of pregnancy but before 16 weeks gestation and considered for continuation until delivery.
-
Idiopathic Thrombocytopenia:
- <150 – repeat CBC as per prenatal appointment schedule
- <100 – consult MDC (no scalp clip or vacuum)
- CBC for baby post delivery (from cord blood) if Mom is known to have ITP or platelets under 100 in pregnancy
Post Dates:
o MFM U/S at 41 wks and 41+3 wks if cervidil required
o Book induction with hospital when pt is 41 wks or sooner
o Cervidil inductions and AFI:
§ AFI>10 – insert and send home if NST normal (f/u in 12hrs)
§ AFI 5-10 – admit and insert
§ AFI<5 – admit; OB consult for cervidil vs foley
Epilepsy:
- Don’t accept
Placental Management:
- Low-lying placenta: US with any concern about bleeding. May repeat US between 28-32 weeks
- Marginal placenta: US Between 28-32 weeks and request patient to decrease activity and no intercourse
- Placenta previa: US as above; consult OB; decrease activity and no intercourse, >30wks TOC to OB
Preterm PROM:
- <34wks – TOC to OB
- >34 wks – consult OB
Pap smear:
- Review TOP guideline
SSRI in Mom:
- Keep in hospital for 48 hrs – watch for CNS irritability in babe
Partially treated GBS:
- Old guideline – d/c after 24 hr unless sxs
U/S Reports:
- One LEEP – PTB screen @ 18-20 week US to check cervical length
o EFW recommends booking 18wk PTB screen at 12 wk NT US
- Marginal Cord insertion, May repeat US @ 28 wk for fetal growth
- Placental Lakes – if radiologist states placental abnormality, MFM would like to do non-urgent f/u US to assess
- Low PAPPA – go by MFM recommendation (ie ASA)
- AFI < 10 – repeat US closer to term
Primary HSV:
- Automatic C/S
- If chronic: start anti-viral at 36 wks: Valtrex 500mg po bid or Acyclovir 400mg po tid
Breech Presentation at 36 - 37 weeks
- Arrange OB consult