Obstetric and Post-Partum Care

Given a clinical scenario, the student should be able to:

• Recognize the number one cause of secondary amenorrhea in childbearing years
• 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.
 
 

Positive Signs of Pregnancy

• identification of fetal heart action separate from the mother's (normal: 120-160 BPM).
• perception of active fetal movements by the examiner (by palpation of the abdomen).
• recognition of the embryo or fetus sonographically (may be detected after only 5 weeks of amenorrhea).

• 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 in urine).

• 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- Chadwick's Sign).
• 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).
• frequent micturation.
• easy fatigueability.
• 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

• 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, oral contraception).
• Bimanual exam for uterine size and pelvic adequacy (esp. diagonal conjugate).
• Auscultation or doppler exam for FHT
• General exam of all other systems.

• 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.

• 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.

Clinical Criteria

• 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.

• 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).

• 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 vitamins.
• 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.

• 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).

• 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 to progress.
2.  Ineligible for vaginal trial: Refer to HROB at 35 weeks for evaluation.

• 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 genetic counseling).

• 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.

• 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 exam.
• 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

Premature Labor

• OB ER evaluation for abnormal cervical exams or complaints of possible uterine activity.

• Confirm PROM by sterile speculum exam (pooling in vaginal vault, nitrazine positive, ferning).
• No digital exams.
• Refer to OB ER ASAP.

History

• Inquire in general about delivery; i.e., "difficult time," long, painful bleeding, etc.

• General state of mother and family
• How is she coping with the baby? mood, appetite, exercise activities, rest and sleep
• 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

rectal exam

• 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 or masses.
• Rectal - sphincter tone, fistula.
• Uterine size - should be normal size and nontender in 6 weeks.

• 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.