17 Maternity Care
Maternity Care
Learning Objectives
- Describe the approach to a prenatal visit at various gestational ages
- Identify key prenatal tests and interventions
- Name the important components of a postpartum visit
Case 1
Andrea Pena is a 34 yo F, G1P1, s/p 1 vaginal delivery in 2003, with a history of chronic hypertension and generalized anxiety disorder. She presents to your office for hypertension follow up. She has stopped her previous anti-hypertensive. She is only using condoms for contraception currently with a new partner. She is undecided about whether having another baby is a good idea, especially because of her health issues, and how soon she should start trying to conceive if she wants to have a baby.
She is a non smoker and works as a house cleaner.
Her vitals are: T 98 BP 154/92, P75, Wt 190lbs Ht 5’4”, BMI 32.6
Questions to Consider: Case 1
How would you approach this visit? Please outline a plan for antihypertensives, contraception options as well as pre-conception counseling.
List her assessment and plan is a problem-based outline.
Case 2
Andrea Pena is a 34 year old G2P1 who presents at 6 weeks by last menstrual period (LMP) to your office wondering if she could be pregnant because she missed her period. She would be excited to be pregnancy. History of uncomplicated NSVD in 2003.
She has past medical history of essential hypertension which is well controlled on labetalol 200mg BID, and generalized anxiety disorder for which she has been sporadically engaged in psychotherapy. Non smoker, works as a house cleaner.
Her vitals: T 98, BP 129/80, P75, Wt 190lbs, Ht 5’4”, BMI 32.6
Urine HCG: Positive.
Questions to Consider: Case 2
Andrea will come back for her official prenatal intake the following week where full blood/urine testing will be done, but for today please address the patient’s questions in a problem based fashion:
- What extra risks are present and testing is indicated because of her obesity and hypertension?
- What do you recommend for her anxiety? In particular consider a medication if she starts having more panic attacks which she had in her previous pregnancy.
- Finally, she also hasn’t been sleeping well and wonders how much coffee would be safe for her to drink so she can get through her work day.
Case 3
Andrea Pena is a 34 yo Brazilian female, G2P1 at 28 wks gestation currently. 1 prior vaginal delivery in 2003 which was uncomplicated. She has chronic hypertension, which is well-controlled on labetalol, and generalized anxiety disorder, for which she sees a therapist occasionally and is taking low dose sertraline 25mg/day. Her pre-pregnancy BMI was 32lbs. She has only gained 8lbs so far in the pregnancy and is feeling well.
She has some questions about the third trimester. She is worried about the delivery because she gets extremely anxious when she has pain and is asking about whether a primary C-section could be a good option for her. She also worries about pre-eclampsia and is asking any ways to monitor for this or even prevent it. Finally, she wants to know if it’s safe to fly to Arizona for a brief vacation.
Questions to Consider: Case 3
Please outline a problem based plan for her including routine testing for her at this gestational age, counseling regarding mode of delivery, any prevention/surveillance for pre-eclampsia and whether travel is safe for her.
Case 4
Andrea Pena is a 34 yo G2P2 comes in 5 weeks postpartum after a successful NSVD with her baby Sofia to the office for the baby’s 1 month well child check and also wants to add-on a sick visit for herself She has a history of hypertension which is controlled with labetalol 200mg BID, she has anxiety for which she is taking sertraline 25mg daily and she has continued her prenatal vitamins.
She is breastfeeding exclusively but she still struggles sometimes with nipple soreness, the baby is terribly fussy and her husband is working a lot and is not so helpful. She seems exhausted and overwhelmed. Now on top of this she has a bad cold (headache, stuffy nose and cough) and she wonders what medications are safe for her to take for her cold while breastfeeding. She also has heard about some over the counter remedies for colic for her baby and wonders which could be safe or effective.
Her vitals are: T99.5, BP 135/89, P99, Wt 205lbs O2 98% Ht 5’4” BMI 35
Questions to Consider: Case 4
Please outline a problem based plan for her to address her cold symptoms, lactation struggles and questions about colic remedies. Address her mental health issues and hypertension, and if there is time think of a good birth control plan for her.
Prenatal Care Map
Used with permission from Boston University
| Physician | Patient Education | |
| INTAKE | History
Demographic information Medical history- update problem list History since last LMP Family history Obstetric history Genetic risk assessment Psychosocial assessment Substance use assessment Physical Send GC/Chlamydia Send pap if indicated Plan Labs: Type and screen, CBC, RPR, HIV, HepBsAg, urine culture. If not previously documented: Rubella Ab, CF screen or other genetic disorder, Hg electrophoresis, Varicella Ab, G6PD, TSH (optional) Additional labs: 1 hour glucola if high risk
Baseline HELLP labs if PHx pre-eclampsia or chronic HTN
TB assessment- place PPD if high risk Review immunizations with specific documentation of Tdap status of patient and anticipated newborn caregivers Order US for dating if indicated Send for first trimester testing (11-13wks) Prenatal vitamins prescription Offer Genetic Counseling if high risk (>35y @ delivery, FHx genetic abnormality etc.) Refer to MFM for high risk condition Review with Case Manager PRN Nutrition counseling Financial counseling Update Problem list and plans |
Orientation to System-What to expect at prenatal visits
First trimester tests Changes in body (months 1-3) Fetal development Safety in pregnancy Smoking cessation/Alcohol & drug addiction HIV risks First trimester warning signs Depression/anxiety Domestic violence Facts about breastfeeding |
| 12 TO 16 | Give first dose of Hepatitis B vaccine to high risk women who are HbsAg and HbsAb negative
Offer flu shot (indicated any trimester during flu season) CXR if PPD positive, no prior CXR Schedule appointment with nutritionist/WIC, if needed and not done previously Schedule appoint w/ Social Worker if needed |
Anatomy of pregnancy
Exercise/Nutrition/Weight gain Making love during pregnancy Second trimester testing |
| 15 TO 20 | Offer quad screen (if first trimester testing not done)
Offer MSAFP only if first trimester testing done Update genetic screening plan Give 2nd dose of Hepatitis B vaccine to high risk women (one month after first dose) Ultrasound for anatomy |
Changes in body (months 4-6)
Fetal development Breastfeeding-Getting Started |
| 20 TO 24 | Reassess adverse health behaviors, psychosocial risks, and financial status
Childbirth education referral |
Warning signs-signs of preterm labor (PTL)/pre-eclampsia
Depression/anxiety |
| 24 TO 28 | Reassess adverse health behaviors, psychosocial risks, and financial status
Nutrition counseling Ensure that patient is scheduled for childbirth classes and stress the importance of attendingOffer doula referral Refer to OB or fellowship trained FM if prior c/s to discuss TOLAC vs. C/S Diabetic screen (one hour Glucola), 3 hour GTT if glucola >140 Rhogam if indicated (Antibody screen should be drawn prior to Rhogam, but no need to wait for results) |
Breastfeeding-Infant cues/positions/frequency |
| 28 TO 32 | Tubal consent form signed (if indicated). Fax signed copy to L&D, give another copy to patient
Repeat CBC. Give Fe if anemic (hct <32) and follow Administer Tdap each pregnancy (CDC recommendation: optimal 27-36w EGA) |
Changes in body (months 7-9)
Warning signs/ signs of pre-eclampsia/PTL Fetal development/fetal movement Getting ready for baby/car seat/choosing baby’s doctor/circumcision/sibling care Breastfeeding-Common questions/Pumping Third trimester tests |
| 36 TO 40 | Reassess adverse health behaviors, psychosocial risks, and financial status
GC/chlamydia, RPR (if high risk) Check HIV, document if pt declines Check genital GBS culture 35-37w (unless GBS bacteruria this preg or previous infant with GBS disease). If high risk PCN allergy check clindamycin/ erythromycin susceptibility testing Give 3rd dose of Hepatitis B vaccine to high risk women (six months after dose) Prescribe anticipated postpartum prescriptions |
Changes in body after birth
Postpartum blues/depression Family planning Infant care |
| 40 | Rhogam (if >12 wks since last injection; Send Ab screen prior to Rhogam)
Discuss post dates management (options for monitoring vs. IOL) Check cervix if scheduling induction Call L&D to schedule postdates induction between 41-42 wks. |
Discuss induction indications and methods |
| 41 | Birth control method
Start biweekly NST/AFI at 41 wks |
Family Planning
Appointments with appropriate preventive service providers |
| Post-Partum |
Review discharge summary, update outpatient chart Screen for PP depression (2 step then Edinburgh) DM screening if h/o GDM Update all immunizations: finish HPV series if age appropriate |
Smoking cessation
Weight loss Exercise Healthy diet Breastfeeding issues Depression Birth control and inter-pregnancy interval |
Required Reading: Routine Prenatal Screening Tests
Required Reading: Prenatal Care
Required Reading: Postpartum Care
Resource: LactMed (database on medication safety during lactation)
Resource: ZipMilk (resources for breastfeeding support & links to local lactation consultants)
Resource: Centering (group prenatal care)
Resource: Perinatology (perinatal care)