Intro to OB Flashcards
FHT/ FHR SVE SSE PIH DT FS FOC
FHT or FHR = fetal heart tones / rate SVE = sterile vaginal exam SSE = sterile speculum exam PIH = pregnancy-induced hypertension DT = Doptone (doppler) FS = fetoscope FOC = father of child MOC = mother of child
ROM AROM PROM PPROM SROM BOW IBOW BBOW
ROM = rupture of membranes AROM = artificial ROM PROM = premature (prior to onset of labor) ROM PPROM = Pre-term PROM (<37 weeks) SROM = spontaneous ROM BOW = “bag of waters” IBOW = intact BOW BBOW = “bulging” BOW
FH GDM IDM UC GBS TOCO
FH = fundal height (in cm – SP to top of fundus) – only valid after 20 weeks GDM = gestational diabetes IDM = infant of a diabetic mother UC = uterine contraction GBS = group B beta-hemolytic streptococcus TOCO = tocodynamometer – records UC’s
CX NST CST VTX BPD EFW
CX or Cx = cervix NST = non-stress test CST = contraction stress test VTX or Vtx = baby’s occipital region Vtx can also mean baby is coming “head first” BPD = biparietal diameter EFW = estimated fetal weight
EDC EGA QHCG LBW IOL LGA/ SGA
EDC = estimated date of “confinement” = the “due date”
EGA = estimated gestational age (in weeks)
QHCG = quantitative human chorionic gonadotropin
LBW = low birth weight (<2500 gm)
IOL = induction of labor
LGA, SGA = large/small for gestational age
SOOL
FLM
IAI
SOOL = spontaneous onset of labor FLM = fetal lung maturity IAI = intraamniotic infection - chorioamnionitis
The days and weeks
Weeks gestation = COMPLETED weeks from the first day of the LNMP
Accepted notation is to use a “sevenths” fraction: 31 weeks, 5 days = 31 5/7 weeks
Verbally, this is usually stated as “31 and 5”
Leopold’s
Leopold’s maneuvers
Used to determine LIE and PRESENTATION
(palpation of the baby)
Clinical jargon - station
“Station” = baby’s head relative to ischial spine 0 = at the spine -1, -2, -3, -4 = cm ABOVE the spine \+1, +2, +3, +4 = cm BELOW the spine “Descent” = of baby’s head
Clinical jargon - cervix
Dilation or “dilatation” = 0 to 10 cms 10 cm = “fully dilated” Practice in paper bag w/ plastic model Measure your own fingers (mine – index + middle = 3 cms)
“Effacement” = expressed as a %
Degree of thinning or shortening of cervix
Normally, not in labor, cx = 2+ cms in “length” (= 0 % effaced)
“Effaces” all the way to “paper thin”
Jargon - positioning
LIE = vertical, oblique, transverse – it’s about the whole baby
PRESENTATION = what part is “presenting” = “coming first”. Vtx = usual. Also: breech, hand, brow, face
POSITION = orientation of presenting part – if Vtx, is baby “facing” up, down, sideways, e.g.
ROA, LOA, OA, ROP, LOP, ROT, LOT
Baby head landmarks
anterior fontanelle:
- metopic suture (north)
- coronal suture (east)
- sagittal suture (south)
- coronal suture (west)
posterior fontanelle:
- sagittal suture- north
lambdoid sutures- east/west
birth planning statistics
< 50% are “intended”
Fewer still are truly “planned”
50+% of births in Colo are under Medicaid
questions to ask at first encounter
Is patient sexually active? “Are you involved with a sexual partner?”
Using a birth control method (“BCM”)?
If no BCM – “Do you want to become pregnant?”
If no – assist with decision on BCM
If “yes” or “I’m fine with it if it happens” –
Pre-Conception Appointment
OK to do with another service, BUT a separate appt is MUCH BETTER
This is a consult only – no exam. Billable!
Invite the (proposed) father!!!!
Providing this service is YOUR RESPONSIBILITY if you are a PCP or an Ob/Gyn.
March of Dimes will be HAPPY.
Trial lawyers will be UNHAPPY.
Standardized Format
Same discussion takes place with all encounters. Extras are added on individual basis. Use a questionnaire and a pre-developed document. (ACOG)
This becomes part of the Medical Record. “You see here, Mr. Lawyer, I did, in fact, tell your client to stop smoking – and why.”
Review the past (and male stuff)
Current state of health – BOTH partners
Past health issues – BOTH
Male – mumps early teens, trauma, meds, substances, his family history
Sorry, dude, smoking weed DOES interfere with your swimmers!
Review the past- female
Trouble getting Pg in past?
Prior OB history?
Include miscarriages and terminations. If she is a G4P0040 (4 miscarriages) - red light.
OB complications? (pre, delivery, PP)
Health – thyroid, obesity, diabetes, hypertension, lupus, renal disease, heart, pulmonary – this is basically a “ROS” with these highlights.
Is she seeing another physician for chronic condition? If yes – consult him/her ALSO.
Diet
Exercise (avoid high-impact)
Substances (tobacco, rec drugs, ALCOHOL)
Meds: Rx, supplem, OTC
Plans to travel? (a very BAD IDEA)
ethnicity and birth issues
Ashkenazi Jews (Tay-Sachs) African-American (sickle cell anemia) Northern European (cystic fibrosis)
preconception Lab work
TSH Rubella immunity CF carrier status Hgb electrophoresis (HgbS in A.A. popul) Consider doing HIV Ab Other, specific to patient – e.g. if diabetic you need a HgbA1C, FBS, renal functions
Substances, Meds- preconception
Discontinue EVERYTHING, PREFERABLY PRIOR TO CONCEPTION.
Exception is a needed Rx provided by you or another physician. Counsel as to risk. Is there an alternative? Example is anti-seizure meds.
FOLIC ACID (FA)
Supplement of 400 mcg daily
Reduces risk of certain anomalies by as much as 50%. (spina bifida)
Begin BEFORE CONCEPTION - these anomalies occur within DAYS of conception.
FA = water soluble – can’t have “too much”.
OTC PNV’s (OTC prenatal vitamins).
Keep a calendar
Record “Day ONE” of each menses.
Dating is EDC = 40 “completed” weeks from day one of LNMP.
Self-pregnancy test – record date/result.
Stopping BCPills (BCP)
Ideally, stop BCP @ end of package and have that period (called a “pill period”) AND TWO MORE “natural” periods and THEN conceive.
May help restore endometrium – and may reduce miscarriage risk.
A recorded and “reliable” LNMP makes it far easier to calculate a preliminary EDC.
Removal of IUD
Remove on last day of a normal period.
Have one more period and then conceive.
Numbering the days of the cycle
Days are numbered. “Day 1” = first day of a normal menses.
When next period begins, the “count” starts over – first day of that period = “day 1”.
Conception – FUN facts
The ovum is “fertilizable” for only about 22-23 HOURS after ovulation.
Ideally, ovulation takes place into a “rich sperm environment” (ampulla of tube) → 0 hours from ovulation to fertilization.
Sperm likely “live” in oviduct for ~72 hours.
Sperm are “in” the oviduct within minutes.
Conception - timing
Daily ejaculation, for most men, will gradually reduce overall sperm count.
Ovulation, in the “ideal” cycle = day 14, but few women have “perfectly-timed” cycles.
Therefore (!)………. Recommend: Coitus every OTHER day from about days 10-20.
This (1) enhances chances of conception AND (2) reduces risk of an “OLD EGG” being fertilized. (OLD → greater miscarriage risk.)
Conception - misc.
Lube kills sperm.
“Male retention” – after ejaculation, he “stays inside” for short interval.
Want a Girl – or Boy ?
Shettles’ criteria
Alter vaginal environment to “favor” one type of sperm over the other – “tilt” odds by 5-10%
Agar gel “swim-up”
Special cases – for example…
FHx hemophilia – try to avoid male baby
Pregnancy testing?
OK to do OTC – but no insurance coverage.
OTC – wait until about 5-7 days “late”.
Better = have patient come to office/clinic for testing ~~ 7 days “late”.
This gives opportunity for office staff (even physician if available) to assess early risk factors and be sure patient is on FA.
“New OB” = NOB appointment
If had preconception appointment, at 6-7 weeks.
If unplanned or no pre-appointment, at 5-6 weeks or ASAP after + Pg test.
If risk factors – ASAP after + test.
NOB appt should take ~~ one HOUR: Comprehensive H&P, labs, counseling, answering questions, start “prenatal record”, risk assessment. (OK, if low-risk, for “extender” [= NP, PA] to do this, with physician appointment ~~ 1 week later.)
DIABETES & ALCOHOL
Both MUST be dealt with Pre-conception.
“Safe” dose of EtOH = NONE. This is your BEST CHANCE to prevent FAS = Fetal Alcohol Syndrome!
HgbA1C should be ~~ 5-6% before conception
> 7-8 % = doubles risk of anomalies
11-12% = very high risk
COMPLICATED HX??
Consult with Bd Cert Medical Geneticist
ULTRA HIGH RISK OB HX??
REFER TO “NEXT UP” LEVEL OF CARE:
YOU = PCP………………REFER TO OB/GYN
YOU = OB/GYN………..REFER TO MFM
(MFM – Maternal Fetal Medicine, aka a “Perinatologist”)
stuff to do at normal case First or “New OB” = NOB = 8 weeks
8 weeks US – ensure single, viable (gives also the most-reliable EDC)
The most “complete” history you’ve ever done
Physical exam
Lab work – ABO, Rh, Ab sceen, rubella titer, RPR, CBC, Urine C&S, GC & chlamydia, Pap, TSH, HIV, HBsAg
Start PN record
Risk assessment
Q&A
12 weeks appt
BP, weight, UA (S,P,N)
** Use Doppler to find FHT’s
Fundus is @ SP
Genetics background finalized
16 weeks appt
BP, weight, UA Fundus ½ way between SP and umbilicus FHT’s with DT Hematocrit (Hct) or hemoglobin Order US for ~~ 19 weeks
20 weeks appt
BP, weight, UA ** Review US from 19 wks Counsel pt to choose physician for baby FHT’s with DT and FS Begin FH measurements Fundus @ umbilicus, FH = ~~20 cms Cms = weeks (+ or – 2cm) until ~~ 34 weeks
“DATING” IS IMPORTANT!
You need a “good” EDC to work from
Calculate the “final EDC” from the ~ 8 week US in most cases - use the “CRL”
LMP, LNMP, 19 week (or later) US = OK, but not as good
“The later the worse” for US to tell EDC
“Clinical sizing” can be WAY OFF
NEVER change the EDC w/o compelling reason
24 weeks appt
BP, weight, UA Measure FH FHT’s w/ DT Register for prenatal classes **Vaccines? (influenza + pertussis)
28 weeks appt
BP, weight, UA FHT’s w/ DT FH = ~28 cm Consider SVE - ? Prem. Dilation **Test for GDM (1 hr BS) Hct Begin L&D counseling
30 week appt
Optional in normal case BP, weight, UA FHT’s w/ DT FH ~ 30 cms L&D counseling
32 week appt
BP, weight, UA FHT’s w/ DT FH = ~~ 32 cms Begin Leopold’s maneuvers L&D counseling
34 week appt
BP, weight, UA FHT’s w/ DT FH begins to “lag” Leopold’s to check lie/presentation L&D counseling, Q&A
36 week appt
BP, weight, UA FHT’s with DT FH lags ** Leopold’s Hct ** GBS culture SVE to check cervix status L&D discussion
37 week appt
BP, weight, UA FHT’s w/ DT FH – lags Leopold’s SVE L&D discussion Discuss future BCM (birth control method)
38 weeks appt
BP, weight, UA FHT’s w/ DT FH – lags Leopold’s SVE L&D discussion WTC (when to call)
39 weeks appt
BP, weight, UA FHT’s w/ DT FH – lags Leopold’s SVE Q&A
40 weeks appt
BP, weight, UA FHT’s w/ DT FH – lags Leopold’s SVE “Post-dates” planning Q&A
Normal weight gain?
10 lbs before 20 weeks and one pound per week from 20 – 40 weeks
Total = 30 lbs
Advice varies, depending on where patient started
Weight loss is NEVER advised
Ultrasound abbreviations
= Sonogram
Abbreviate as “US”
May be “TVUS” = transvaginal US
OR, “transabdominal US”
Routine” US
~~ TVUS @ 8 weeks for viability, dates, fetal number
“Transabdominal” @ 19 weeks for “anatomy scan” – may tell fetal gender
Any others, in normal case, are for “marketing” purposes/souvenirs
US – threatened AB
Sac + embryo + FHT’s = likely viable
Misshapen sac, no embryo, no FHT’s = likely non-viable
May be used serially in conjunction with QHCG levels
TVUS – standard of care
US – for cervical length
For the “at-risk” patient TVUS @ 12 – 22 weeks Look for shortening or “funneling” MAY (MAY) show risk for preterm birth Cerclage - debatable
US for growth
Transabdominal method
IUGR (intrauterine growth RESTRICTION)
Used serially
Watch abdominal circumference, AFV = amniotic fluid volume
Macrosomia (large!)? Near EDC. OK to do it, but notoriously unreliable for EFW.
US for twins
TVUS if < 12 weeks, then transabdominal Diagnosis Growth concordancy (are we learning to share?)
US for bleeding – 3rd trimester
(transabdominal, TVUS in 2nd trimester) Abruption of the placenta = “Abruptio” May show if very large separation Not reliable Placenta previa - May “migrate” - Can follow serially - Assess that it’s “only” a previa
