Obstetric and Post-Partum
Given a clinical scenario, the student should be able to:
- Recognize the number one cause of secondary amenorrhea in childbearing
- Establish the diagnosis of pregnancy
- Determine the estimated gestational age of the fetus
- Define the health status of the mother and the fetus
- Establish the plan for ongoing care
- Determine when to consult and/or refer to High Risk OB Clinic.
Involvement with the pregnant patient offers the privilege of participation
in the early development of an individual and a family. Proper management
of physical and psychological needs can effect far-reaching results. The
physician has the opportunity to offer advice, guidance, and intervention
when indicated. The possible effects of treatment on the patient, the developing
fetus, and involved others must be considered.
The above having been stated, of primary importance is an awareness
that every physician who assumes responsibility for the medical care of
any woman under the age of 50, irrespective of the physician's type of
practice or special interest, must always raise the question, "Is she pregnant?"
Failure to do so may lead to incorrect diagnoses, inappropriate therapy,
and, at times, to medicolegal problems.
In the patient record, you will find standard forms that must be completed
for initial and follow-up visits. For brevity, in your SOAP note you need
only include the basic history, assessment, and plan for each visit.
Diagnosis of Pregnancy
Positive Signs of Pregnancy
Probable Evidence of Pregnancy
identification of fetal heart action separate from the mother's (normal:
perception of active fetal movements by the examiner (by palpation of the
recognition of the embryo or fetus sonographically (may be detected after
only 5 weeks of amenorrhea).
Presumptive Evidence of Pregnancy
enlargement of the abdomen (by 12 weeks gestation, the uterus can be felt
through the abdominal wall just above the symphysis).
changes in the size, shape, and consistency of the uterus (uterus becomes
softened or "doughy"), softening of the isthmus between the still firm
cervix and the softened uterus (Hegar's Sign).
changes in the cervix (softening of the cervix at 6-8 weeks gestation-can
also occur with OCPs).
Braxton Hicks contractions (palpable but ordinarily painless contractions
at irregular intervals from early stages of gestation).
ballottement (near midpregnancy, pressure on the uterus will cause the
fetus to sink in the amniotic fluid, and with release of pressure, the
rebound to its original position will be felt as a tap).
outlining the fetus (in the second half of pregnancy).
results of endocrine tests (presence of hCG in matemal plasma and its excretion
cessation of the menses (especially after predictable menstruation).
changes in breasts (tenderness, tingling, increase in size).
discoloration of vaginal mucosa (dark bluish or purplish-red and congested-
increased skin pigmentation and the appearance of abdominal striae (can
be absent during pregnancy or present with the use of OCPs).
nausea with or without vomiting (appears usually at 6 weeks, lasting 6
to 12 weeks).
sensation of fetal movement (16-20 weeks).
Major goals are identification of risk factors, determination of the
estima-ted gestational age of the fetus, patient education, and initiation
of a plan for ongoing obstetric care.
Identification of Risk Factors
History and Physical Exam
Prematurity Risk Factors
Assess general health and risk factors.
Attempt dating of pregnancy: Last menstrual period (LMP) - accurate
if verified by calendar or coincident with holiday, etc.; reliable
if no interfering factors present (i.e., prior menstrual irregularity,
Bimanual exam for uterine size and pelvic adequacy (esp. diagonal conjugate).
Auscultation or doppler exam for FHT
General exam of all other systems.
Placental Insufficiency Risk Factors
Age <18, low socioeconomic status, sexual promiscuity, DES exposure,
prior premature delivery, 2 or more spontaneous abortions, uterine anomalies
or fibroids, thin patient or poor weight gain, multiple gestation, polyhydramnios,
UTI/renal disease, acute infections.
Congenital Anomalies/Disease Risk Factors
Post dates, previous stillbirth, intrauterine growth retardation, anemia/hemoglobinopathies,
medical illness (DM, HTN, thyroid disease, renal disease, cardiac disease,
collagen vascular disease.
Race (Asian, Jewish, Mediterranean, Black), mother >34 yers of age, advanced
paternal age, family history of congenital anomaly, previous delivery of
child with anomalies, teratogen exposure, infection exposure, diabetes.
LMP, bimanual exam in first trimester, doptone FHTs at 10-12 weeks, fetoscopic
FHTs at 20 weeks, quickening (primiparous at 18-20 weeks and multiparous
at 17-19 weeks), fundus reaches umbilicus at 20 weeks, after 20 weeks fundal
height in cm = weeks gestation.
The UPT in our lab can be positive within 5 days post-conception.
Routine Screening Tests
Approximate accuracy: <10 weeks - 3-7 days, <20 weeks - 10 days,
<30 weeks - 2 weeks, 30-40 weeks - 3 weeks.
Best single scan for dates and anomalies is 16-18 weeks.
CBC (r/o anemia).
Sickle cell prep (Black or Hispanic patients).
Urinalysis (r/o bacteriuria, proteinuria, glycosuria).
VDRL/RPR (r/o syphilis).
Type, Rh, and antibody (r/o potential hemolytic disease of the newborn.
If Rh- and neg antibody screen, repeat antibody screen at 28 weeks and
administer Rhogam if still neg. Administer Rhogam for threatened abortions.
If antibody screen is positive, consult HR OB immediately. If positive
for any other antibodies except Anti I, Anti Lewis A, and Anti Lewis B,
refer to HR OB).
Rubella titer (r/o need for post-partum vaccination).
PAP smear (inflammation - repeat PAP in 6-8 weeks and treat possible etiology;
other abnormalities - refer for colposcopy).
Glucose screening (Patients at risk, i.e., age >25, family history of DM,
previous stillbirth, previous anomalous child, previous child >4000 gm,
obesity, HTN, glycosuria. O'Sullivan abn if 1 hour glucose >140. Do at
first prenatal visit if very high risk; follow up at 26-28 weeks if normal.)
Triple Screen (should be done at 15-19 weeks; if patient declines, a disclaimer
should be signed.)
Hepatitis screening (r/o chronic hepatitis carriers).
Follow-Up Prenatal Care
Avoidance of possible teratogens; i.e., cigarettes, ethanol, medication,
illicit drugs, radiation, work hazards.
Healthy diet and appropriate weight gain (ideally 20#-28# total), prenatal
Physiologic changes in pregnancy - quickening should occur at 17-20 weeks.
Sexuality during pregnancy.
Warn of potential hazards1 that may require immediate attention.
Schedule prenatal classes.
Parameters to Follow Each Visit
Frequency - monthly until 30-32 weeks (weekly frorn 17-20 weeks if necessary
for dating), then biweekly until 36 weeks, then weekly.
Brief history (see hazards1 below).
Management of Complications
Weight (ideal - 20-28 pounds; think PIH for rapid weight gain).
Blood pressure (Think PIH if B/P >140/90 or if systolic increases >30 or
diastolic increases >15 from first trimester B/Ps).
Urine protein (if >1+, think PIH; if no signs of PIH, think UTI).
Fundal height (ultrasound if EGA <36 weeks and size > or < dates
by 3 cm, fundal height not increasing over a 2-week period, or fundal height
increases by more than 3 cm in 1 week).
Fetal heart tones (120-160).
Fetal presentation (after 32 weeks).
New problems/patient complaints.
Repeat Rh antibody screen and titer on Rh negative mothers following eny
episode of supracervical vaginal bleeding or abdominal trauma, and at least
once during second trimester and twice during third trimester. Rh negative
mothers should receive Rhogam at 28-32 weeks.
Repeat pelvic exam at 36-38 weeks and as indicated.
Encourage preparation for breast feeding of infant.
Explain false labor and onset of labor (i.e., when to come to the hospital).
Schedule parenting classes.
Previous Cesarean Section (C/S)
1. Eligible for vaginal trial (Vaginal Birth After Cesarean
- VBAC): Candidates with two or fewer low transverse C/S or undocumented
scar in a patient who underwent an uncomplicated term vertex C/S for failure
2. Ineligible for vaginal trial: Refer to HROB at 35 weeks for
Family History of Congenital Anomaly, Genetic Disease, or Advanced Maternal
Non-Stress Test at 41 weeks with referral to HR OB. Arrange at 40 weeks.
Less than 16 weeks EGA (schedule appointment with genetic counselor).
Greater than 16, less than 22 weeks EGA (refer immediately to genetic counselor).
Greater than 22 weeks EGA (make certain dates are correct and encourage
Culture prenatally only if patient complains of symptoms near term and/or
confirmation of the diagnosis has not been previously established.
1st or 2nd trimester: Consider chronic HTN and obtain OB evaluation.
3rd trimester: Consider pre-eclampsia. Refer to OB ER if B/P >140/90 and/or
if symptoms of scotomata, headache, or abdominal pain. Consult HR OB for
mild disease after obtaining CBC, BUN, creatinine, and LFTs.
(more than bloody show)
1st trimester: THINK ECTOPIC PREGNANCY. Check cervical os with ring
forceps to assess for inevitable abortion, check Hct and quantitative B-Hcg,
check for doptones if >10 weeks, ultrasound only if patient is having evidence
of abdominal cramping/pain, consult with GYN resident, and if agreeable,
obtain serial B-Hcgs every other day x 3.
2nd trimester: Assess for fetal cardiac activity; refer for ultrasound
3rd trimester: THINK PLACENTA PREVIA. Refer to OB ER immediately.
Do not perform cervical exam unless the placenta has already been evaluated
by ultrasound and is not a placenta previa
HIGH RISK OB CRITERIA
|Prior OB Complications
> 2 miscarriages
History of preterm delivery
Prior C/S (VBAC eval)
|Maternal Medical Problems
High blood pressure
Chronic renal disease
Cardiac disease (not murmur)
Active mumps, rubella
|Present OB Complications
Age <14 or> 34
Preterm labor this pregnancy
Premature rupture of membranes
Third trimester bleeding
Poor weight gain
Fetal growth retardation
Fetal demise/missed abortion
Premature Rupture of Membranes
OB ER evaluation for abnormal cervical exams or complaints of possible
Week Postpartum Check-Up
Confirm PROM by sterile speculum exam (pooling in vaginal vault, nitrazine
No digital exams.
Refer to OB ER ASAP.
Inquire in general about delivery; i.e., "difficult time," long, painful
General state of mother and family
How is she coping with the baby? mood, appetite, exercise activities, rest
Involvement and interest of father.
Reactions of siblings to new baby.
Problems with baby at birth or now.
Specifically ask the mother about:
Fever, vaginal bleeding, cramping, discharge, episiotomy pain, breast soreness
or discharge, swelling, headaches, urinary symptoms, and bowel movement.
Medications currently taking (particularly if breast feeding).
Contraception (consider BCPs, diaphragm, IUD, etc.).
Menses should start 6-8 weeks after birth (longer if breast feeding).
Vital signs (particularly BP and WT).
General PE: HEENT, breast. chest, abdomen, and extremities.
Brief HEENT, chest, abd. and ext.
Breast exam for infection or masses.
Pelvic examination: including
State of perineum (episiotomy, if done).
Character of discharge (should be scant blood or normal menses).
Cervix - laceration, uterine size and tenderness, adnexa for tenderness
Rectal - sphincter tone, fistula.
Uterine size - should be normal size and nontender in 6 weeks.
Discuss methods of contraception.
Pap and GC culture.
CBC if indicated by history.
Recheck rubella titer from prenatal lab (will need immunization if titer
< 1:8) if will not become pregnant within the two months following immunization.
R. Richter, MD