Obstetric and Post-Partum Care

Objectives

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

Introduction

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.
 
 

The Diagnosis of Pregnancy

Positive Signs of Pregnancy

Probable Evidence of Pregnancy Presumptive Evidence of Pregnancy
Initial Obstetric Visit

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 Placental Insufficiency Risk Factors Congenital Anomalies/Disease Risk Factors Accurate Dating

Clinical Criteria

Laboratory Measures Ultrasound Routine Screening Tests Patient Education Follow-Up Prenatal Care Parameters to Follow Each Visit
Initial Management of Complications

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.
Post Dates Family History of Congenital Anomaly, Genetic Disease, or Advanced Maternal Age Herpes Hypertension Vaginal Bleeding
(more than bloody show)
HIGH RISK OB CRITERIA
Prior OB Complications

Previous stillborn
> 2 miscarriages
History of preterm delivery
Prior C/S (VBAC eval) 

Maternal Medical Problems
Diabetes 
High blood pressure
Asthma (COPD)
Thyroid disease
Liver disease
Chronic renal disease
Acute pyelonephritis
Cardiac disease (not murmur)
Hematologic disorders
     
  • severe anemias
  • sickle cell
  • hemoglobinopathies
  • thrombocytopenia
  • Rh sensitization
Seizure disorders
Lupus
Actibe tuberculosis
Active hepatitis
Active mumps, rubella
Present OB Complications
Age <14 or> 34
Preterm labor this pregnancy
Premature rupture of membranes
Third trimester bleeding
Fetal anomaly
Post-term>41 weeks
Pre-eclampsia
Incompetent cervix
Polyhydramnios
Poor weight gain
Fetal growth retardation
Mutiple gestation
Fetal demise/missed abortion

Premature Labor

Premature Rupture of Membranes
Six Week Postpartum Check-Up

History

Physical Examination Lab Discuss methods of contraception.

R. Richter, MD
updated 8/30/05


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