Obstetrical Care & Orders

Obstetrical Care & Orders

Meadows Maternity and Family Practice

Early Pregnancy Issues:

·  Hyperemesis:

o  Diclectin 2 tabs qhs, 1 tab qam, 1 tab midday

Max 6 tablets per day

(Advise pt is has a delayed onset of action and can cause drowsiness)

·  Thyroid Disease

o  Need TSH each trimester

o  Guidelines TSH level is posted at the office

o  Document history under “problems in current pregnancy”

·  Abnormal Ultrasound

Choroid Plexus Cyst

Intracardiac Echogenic focus

Fetal Pelviectasis

Echogenic Bowel

Single umbilical Artery

**Info from SOGC in the information binder at the office (Fetal Soft Markers in Obstetrical Ultrasound)

**Handout on CPC and EIF in the bottom drawer of big filing cabinet

·  Patient with history of previous c-section

* Trial of Labor (Pts wanting VBAC)

o  Get copy of C-Section operative report from Hospital

o  Review with the pt the options of TOL vs repeat c-section

o  Refer pt to OB at 20-24 wks gestation for consultation re: risks of TOL

o  At 36 wks, when send forms to hospital, also send OR report and consult letter from OB

* Pt wanting repeat C-section

o  Refer pt to OB at 20 -24 wks for consultation and to book c-section

o  At 36 wks, when send forms to hospital, also send OR report and consult letter from OB

·  Infectious Disease

Chlamydia:

** treat with Amoxil 500mg po TID only IF you think they will be compliant and complete the treatment

**Use Azithromycin 1 g PO x 1 dose for all other pts

**partner needs to be treated (Azithromycin) & please document this on the chart

**Fill in STD form

**Have the pt do a REPEAT urine Chlamydia at approx 1 month after they have completed the treatment to ensure it is now negative (don’t test any earlier as there may be false positives). Document negative result on the chart.

Bacterial Vaginosis:

** Swab if symptomatic

UTI:

**Macrobid 100mg po BID if < 36wks (don’t use close to term as can cause fetal erythroblastic crisis and acute anemia)

**Keflex 500mg po QID

**Amoxil 500 mg po TID

**10 day treatment if symptomatic and 7 days if asymptommatic

**Ensure to repeat urine culture post treatment to ensure the bacteruria has resolved.

**If UTI in the pregnancy then do monthly Urine C & S until delivery

Chickenpox:

**If NOT IMMUNE and have been exposed to chickenpox, offer Varicella Immune Globulin within 96 hrs of exposure (need to get this via the blood bank and probably will have to contact the Infectious Disease MD at the RVH and they can organize the treatment through Day Medicine)

**If pregnant pt does develop chickenpox IN pregnancy then consult OB ASAP regarding possible need for treatment with Acycovir and they should have a referral to MFM for fetal assessment.

·  Diabetes screening

o  IDDM pts need to be referred to OB for obstetrical care

o  All pts are screened with the 50g GTT test.

**If >7.8 & <11 then need to do 75g 2hr GTT of pregnancy test. If this is positive then refer to Diabetes in Pregnancy clinic

**If > 11 then automatic Dx of GDM and need to be referred to DIP clinic

o  Gestational Diabetic (GDM) pts NOT on insulin are followed as normal non-diabetic pts (i.e. no extra ultrasounds unless concerns of LGA)

o  Gestational Diabetic (GDM) pts placed ON insulin the 3rd trimester may continue to be managed at our clinic but they need the following:

**weekly BPP starting at 34 weeks

**plan to induce at approx 38-39 wks (increased risk of stillbirth if GDM &

on Insulin)

**warn patients the if insulin requirements suddenly drop then they need to contact our office or go to WSU

Late Pregnancy & Delivery Issues:

Management of Trauma at > 20 wks:

**depending on the severity of the injury (e.i. MVA) the patient should be monitored for 4 hours at WSU. If NST is reactive, and if no fetal heart rate abnormality, then they may be discharged home. Discuss fetal movement with them (give Fetal Movement Chart if able)

Intrapartum Orders:

GBS positive:

o  If anaphylactic to Penicillin then need to order sensitivity testing on the GBS swab (needs to be done within 5 days of the swab collection).

o  If no Pen allergy use Pen G 5 mln Unit IV & then 2.5 mln U IV q4h when in active labour

o  Clindamycin 900mg IV q8h in active labor if anaphylactic to Penicillin

o  If non-anaphylactic Pen allergy then can use Ancef 2g initial dose then 1g q8h

o  Do not use Erythromycin because of resistance

VBAC Pts:

·  IV NS @ TKVO

·  CBC, Type & Screen

·  NPO in labour

·  Continuous monitoring

·  Consult OB regarding TOL when pt on Labor and delivery (not urgent)

·  If need augmentation or induction, then consult OB

Post Partum Hemorrhage:

·  Synto 20-40 U in 1 L and run wide open

·  Misoprostil 800 micrograms PR

·  Insert second IV.

·  Ergot 0.2 mg IM

·  Hemobate 0.25mg IM (can repeat q15min to max of 2 mg)

·  Call OB if needed

Threatened Preterm Labor

·  FIRST do sterile speculum exam for Fetel Fibronectin (fFN) and then do vaginal exam to assess cervix

·  If pt is contracting then reassess cervix in 2hrs. If NO change in cervix then have the lab run the fFN (takes about 1 hour).

·  If the fFN is NEGATIVE then let the pt go (low risk she will deliver in the next 2 wks)

·  If the fFN is POSITIVE then do the following:

o  Admit to AP bed (if <32 weeks then consult OB as pt has to be transferred to the FHH)

o  If signs of dehydration then start IV and can bolus RL or NS

o  Betamethasone 12mg IM q24h x 2 doses (if less that 34 wks)

o  Indocid PR 100mg x 1 dose followed by 50mg PO q6h (only if <32wks gestatation and NOT for more than 48hrs)

o  BPP with translabial US for cervical length

o  Consult OB

Pregnanacy Induced Hypertension:

Ø  Antenatal Community Care Program (referral letters are in the bottom drawer of filing cabinet and addition info in office info binder)

Ø  Protein/Creatinine ratio done weekly – if >0.3 g/mmol then a 24 hr urine total protein should be done

Ø  If admitting to hospital, common orders are:

·  DAT

·  Bedrest with BRP

·  BP q4h while awake

·  NST q4h while awake

·  Urine dip for protein qshift

·  Start 24hr urine protein ASAP

·  CBC, Creatinine, Uric Acid, ALT, LDH (Do lat q8h when in labour)

·  BPP in am

Advanced Maternal Age:

·  Do BPP at 38 and 39 weeks

·  Offer the patient induction between 39 and 40wks

·  If pt needs cervidil, make sure there is a BPP within the last 48hrs

Post Partum:

Immediate PP period:

·  Breast feeding and decreased milk supply – Rx with Motilium 20mg QID (can go up to 40mg QID if needed). Make sure patient pumps QID, in addition to breastfeeding, for the first few days. Warn patient of potential headache and diarrhea as SE of meds.

·  We see babies in the office until 6wks post partum. Should be gaining between 20-30g/day

·  Sacral Dimple Guidelines in office info book

·  Post partum depression – there are handouts in the bottom drawer of the filing cabinet. Can refer to our Behavioral Health consultant.

6 Week post partum:

·  Paps can by done by GP at 6 months post partum

·  BCP – Rx Micronor 28 (handouts are in file box in each room)

·  If ordering any labs, ensure GPs name is on the lab requisition and have pt f/u with GP for results

·  Mirena handouts in each room. Also give pt handout on Dr. Moss’s information seminar. Pt can get dates from office staff up front.