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LCH OB/GYN CNM protocol for GME
New OB, 20 week, ultrasound visits, 36 and 40 week visit seen by CNM
All charts of patients not seen with CNM should be sent to P LCH OB CNM
OB Visit Timeline
New OB Visit
• Full history: medical, surgical, OB, social, family
• Screenings: Depression, Anxiety, 5P’s
• Genetic testing (must be drawn at Lee health lab)
Myriad Prequel (cfDNA after 8 weeks)
Myriad Foresight (silent carrier testing for 14 traits)
• Pap/Physical Exam if needed
- Per ASCCP guidelines (use the app!)
• Choose EDD based on LMP vs US dating:
- 6–9 wks: ±5 days
- 9–14 wks: ±7 days
- 14–16 wks: ±7 days
- 16–22 wks: ±10 days
- 22–28 wks: ±14 days
- 28+ wks: ±21 days
• Prenatal Labs: CBC, type & screen, Hep B, Hep C, RPR, HIV, sickle cell, Rubella, Varicella, UC, GC/CT/trich
- Early GDM screen if high risk (BMI > 35, hx GDM, Hx macrosomia, PCOS, immediate FHx DM)
o Do not order if known diabetic or hx bariatric surgery
- UDS if patient reports hx (Must have verbal consent and document in note)
• Discuss feeding plan
• Teen pregnancy → Social Work
• Initiate/ discuss ASA therapy (81mg per ACOG)
10–16 Weeks
• Review labs
• Offer quad screen or AFP1 if cfDNA done
- QS and AFP1 can only be done between 15w0d-21w6d
• Schedule anatomy scan (60 minutes) at 20-22 weeks
• Start ASA at 12-16 weeks
• Start CL and Prometrium if indicated
20 Weeks
• Anatomy US
- If incomplete, f/u US in 2-4 weeks (30 minutes)
• Review quad screen/ AFP1 results
24–28 Weeks
• Order 3rd trimester labs: GCT, CBC, Hep B, HIV, Hep C, RPR
- Add antibody testing if Rh-
- If patient declines repeat STD testing, document in chart
- If patient is refusing GCT, may track BS levels qid x2 weeks
• Rhophylac given at 28wks (antibody testing must be done first)
• If anatomy incomplete after 2 attempts, may refer to MFM if patient desires
• If only cardiac views incomplete, may refer to peds cardiology
• Refer to peds cardiology with personal or immediate FHx cardiac defect
28–30 Weeks
• Sterilization consent if patient desires (scan into chart)
• Submit C/S paperwork if indicated
• Tdap vaccine (repeat each pregnancy in 3rd trimester)
• Initiate growth US q4–6 weeks if BMI ≥35 (if not seeing MFM)
32–35 Weeks
• Start weekly NSTs if indicated (Per MFM, AMA, obesity, polyhydramnios, IUGR, GHTN, PreE)
• Review pediatrician & postpartum contraception
• Growth US if no 3rd trimester US has been completed
• RSV vaccine (September-January, 32-36 weeks)
36 Weeks
• C/S consult with surgeon (appts made by OB scheduler)
• GBS (with sensitivities if PCN allergy)
• GC/CT/Trich
• IO Hgb
37–40 Weeks
• Labor precautions
• Vaginal exams (if desired)
• Schedule inductions if medically indicated
40-41 Weeks
• BPP OR NST with AFI at 40w5d-41w
• Repeat NST + AFI/BPP if going to 42w
• Schedule induction at 41–41w5d
Postpartum (1–2 wks)
• Appt may be telemed if low risk, no significant repair, and does NOT have a Medicaid insurance
• IO Hgb
• EPDS (must follow up within 2 weeks if score >9)
• Contraceptive counseling
- If patient wants IUD or Nexplanon, order at this appt. Make 6wk PP visit 40 minutes for insertion.
o Order outpatient medication to Lee Specialty Lab
Postpartum (6 wks)
• IO Hgb (if previous hgb low)
• EPDS (must follow up within 2 weeks if score >9)
• Counsel on self-breast exams in encounters
• Pap if due
• Place IUD or Nexplanon if desired
• Resolve pregnancy episode at 6wk visit
How to…
• Schedule IV iron infusions
- Route encounter/ results to P OB NURSE TRIAGE with instructions to schedule number of infusions
• Order diabetic supplies
- Route encounter/ results to P OB NURSE TRIAGE stating patient has GDM and needs appropriate supplies along with referral to DTC. They will pend everything needed and route back or send to CNM pool.
- We route to our nurses so they can pend the correct supplies that each insurance will cover.
• Schedule C/S
- At 28wks fill out C/S form. MA should fax to hospital and forward chart to P LCH OB SURG SCH.
- The OB scheduler will schedule patient with MD performing surgery.
- C/S form is the same as induction form. Indicate why C/S is needed and provide a date. (39 weeks if M-F)
• Schedule induction
- Bishop score must be done. Fill out induction form, MA to fax and send chart to P LCH OB SURG SCH
• Transfer care to MDs
- Confirm plan of care is appropriate with CNM.
- Route encounter to either P OB NURSE TRIAGE or P OB CSR with the indication for transfer. They can assist in scheduling the patient f/u care.
• Send to OBED
- If patient needs to go to OBED for triage or direct admission, either call OBED (36097) and CNM on call or send a secure chat message with the patient’s chart attached to the CNMs on call
- If unsure, contact the CNMs on call for appropriate plan of care
Common OB issues
Hypertensive Disorders
AMA (≥35 at time of delivery)
• Age 35-39
- ASA 81mg at 12 weeks
- Growth US at 34-36 weeks followed by weekly NST
• Age 40+
- ASA 81mg at 12 weeks
- Growth US at 32-34 weeks followed by weekly NST and US q4 weeks
- May refer to MFM if patient desires
Hx C/S
• If C/S x1 and confirmed LTCS, patient may opt for TOLAC
- If no op report in the chart, must request
• If > C/S x1 or no desire to TOLAC Repeat C/S to be scheduled for 39 weeks
- hx classical incision, hx myomectomy, hx uterine rupture deliver at 37 weeks (CONSULT MD OR CNM)
• Submit paperwork at 28 weeks. Scheduler will make appt with surgeon around 36 weeks.
• Discuss sterilization, especially if patient has ≥2 prior C/S.
Obesity (BMI > 35 prior to pregnancy)
• Early 1hr GCT
• ASA at 12 weeks
• US for growth at 28wks q4-6 weeks (unless seeing MFM)
• NSTs starting at 34 weeks
• IOL at 39-40 weeks
Hx PTD or PPROM (<37wks)
• Offer MFM referral
• Prometrium 200mg (vaginal suppository) nightly 16-37 weeks
• Serial CL US q2 weeks from 16-24 weeks (if not seeing MFM)
- If CL < 25mm, consult with MD
- Incidental cervix < 20mm vaginal progesterone
- If PTD was due to cervical incompetence (2nd trimester), refer to MD ASAP for possible cerclage
Gestational Diabetes
• If refusing GCT, may track BS QID x2 weeks at home. If > 30% elevated GDM diagnosis
• 1hr GCT ≥135 3hr GTT. 1hr GCT ≥ 200= GDM
• 3hr GTT cut off: 95 (fasting), 180 (1hr), 155 (2hr), 140 (3hr). 2 elevations= GDM
• Refer to DTC and order supplies patient to track BS levels at home QID until delivery
- Goal: fasting BS < 90 and 2hr PP BS < 120
• If diet-controlled (<30% abnormal), US at 36-39 weeks for growth
- Offer IOL at 39-40 weeks
• If not well-controlled consult for oral antihyperglycemic drug (if insulin, transfer to MDs)
- Weekly NSTs at 32 weeks
- US for growth q4 weeks if normal; q2 weeks if accelerated
- If poor-control, offer IOL at 38 weeks
- If well-controlled on oral medication, offer IOL at 39 weeks
- Offer C/S if EFW > 4500g
Possible Fetal Growth Restriction
• Overall EFW or AC < 10% OR growth scan 2 weeks apart with no growth
- Consult MD and refer to MFM
- Weekly NST (possible twice weekly)
Large for Gestational Age
• Overall EFW or AC (by Intergrow) > 90%
- Weekly NSTs if another condition present (obesity, GDM, poly, etc)
- Growth US q4 weeks
- Deliver at 39-40 weeks
- C/S offered if EFW >4500g and GDM or >5000g without GDM
- Counsel on risks- shoulder dystocia, broken clavicle, nerve damage, demise
Polyhydramnios
• AFI ≥ 24 or MVP ≥8 weekly NSTs
- Mild polyhydramnios= AFI 24-29.9 or MVP 8-11.9
o IOL at 39-40 weeks
- Moderate polyhydramnios= AFI 30-34.9 or MVP 12-15.9
o IOL at 39-40 weeks
- Severe polyhydramnios= AFI 35+ or MVP >16
o Consult MD and IOL at 37 weeks
• Increased AFI (21-23.9) repeat AFI at next appt
Oligohydramnios
• AFI ≤ 5 or SDP < 2 send to HPMC
• AFI 5.1-8 Repeat AFI in 1 week
Anemia
• Hgb < 11.0 in 1st and 3rd trimester, < 10.5 in 2nd trimester
- Order iron studies if hgb < 9.5; if MCV < 70 order thalassemia panel
o If IDA and not tolerating PO iron and/or symptomatic, can refer for IV iron infusions.
Must have TIBC, ferritin, and iron levels for referral
• Ferritin < 10 5 infusions
• Ferritin > 10 3 infusions
Thrombocytopenia
• Repeat CBC monthly throughout pregnancy and weekly after 36 weeks
• Transfer to MD/ refer to hematology if PLT drops below 90k
Itching/ suspected ICP
• Large chance of recurrence of ICP if patient has hx
• Order CMP and pregnancy bile acids if symptomatic
• Treatment if diagnosed with cholestasis:
- 2x weekly NSTs
- Referral to MFM
- Deliver at 37 weeks
- Actigall 300mg tid
IVF
• Routine growth US
• NSTs at 36 weeks
HSV
• Prophylaxis treatment at 35 weeks and continue PP
- Acyclovir 400mg tid OR Valtrex 500mg bid
Sickle Cell trait
• Monthly UCs (increased risk of UTIs)
• Recommend FOB be tested
THC use
• Counsel to stop; counsel patient will have SS consult inpatient
• Referral to HS
• UDS at time of admission
Late to Care (>20wks)
• Needs follow up growth US if there is no early US for dating
• Inpatient UDS and SS consult if starting care after 28 weeks
Desires VBAC
• Allow trial of labor if they have ONE prior C/S and an operative report confirming low-transverse incision
- Recommend IOL at 40 weeks
Hypothyroidism
• If being treated, repeat testing q4 weeks the first half of pregnancy and again with 3rd trimester labs
• If treatment is initiated or dose adjusted, repeat testing in 4-6 weeks to confirm dose is appropriate
• Refer to endo if unable to find appropriate dosage
• F/u testing at 6 weeks PP
TSH Free T4
1st trimester 0.1-4.0 0.8-1.7
2nd trimester 0.2-3.0 0.6-1.4
3rd trimester 0.3-3.5 0.5-1.2
Who to screen:
- s/s of hypothyroidism
- family or personal hx of thyroid disease
- personal history of TPO antibodies
- Hx of goiter
- Hx recurrent miscarriage or PTD
- BMI > 40
- Infertility
- Hx thyroid surgery
- > 30 years
- Type 1 DM
Hyperthyroidism
• Refer to endo and transfer to MDs if treatment is needed
Office Findings
Regular Preterm Contractions
• < 34 weeks
- Do not check patient
- Send to HPMC for possible FFN and additional monitoring
o Steroids if 34-36 weeks and no GDM. Must be 3cm/70%
o Magnesium sulfate for neuro protection if prior to 32 weeks transfer to MDs
• > 34 weeks
- Check cervix
- If uncomfortable and/or dilated OBED for hydration and monitoring
- If comfortable and not dilated home with pelvic rest and hydrate with precautions
Decreased fetal movement
• NST in office and BPP if non-reactive
• Review FKC
Elevated BP readings
• If BP is mild range on 2 takes (<160/110)
- Asymptomatic and reliable
o BP log
o Outpatient labs (CBC, CMP, uric acid, fibrinogen, LDH, 24hr urine protein, protein/creatinine ratio)
o Return in 1 week (review log and labs)
- Symptomatic or unreliable
o OBED for PIH evaluation
Serial BPs
Labs
Urine protein
• If BP is severe:
- Admit to hospital
- Discuss admission and POC with MD
US Findings
Echogenic Intracardiac Focus (EIF)
• Offer cfDNA screening
• Normal finding if not seen with anything else
Choroid Plexus Cyst
• Offer genetic testing and repeat US at/after 28wks
• If isolated findings, no other testing is needed
Fetal renal pyelectasis
• < 10 (mild) monitor
• ≥ 10 (moderate to severe) refer to MFM
Breech presentation
• Confirm by US at 36wks
- Refer to MDs for C/S consult for ECV (Smith, Mora, El Masry, Harrison, Hunt, Racine, & Colina)
• Version is not typically an option for previous C/S or anterior placenta
Shortened Cervix
• Incidental cervix < 20mm vaginal progesterone
Placental/ Cord Abnormalities
• Placenta Succenturiata extra placental lobe
- Confirm accessory lobe is not a previa
- Document in problem list; increased risk for retained products after birth
• Circumvallate Placenta small chorionic plate
- Increased risk of FGR, PPROM, & PTD
- Routine growth US
• Placenta Previa placental tissue covering the cervical os
- Repeat imaging at 24 weeks, transfer to MDs if still present
- Will usually resolve before delivery, otherwise will need C/S
• Vasa Previa unprotected fetal blood vessels present in membranes covering cervical os
- Transfer to MD care
• Marginal Cord insertion normal cord inserted within 1-2cm of the edge of placenta
- Routine growth US
• Velamentous Cord insertionno wharton’s jelly protecting placental end of cord
- Growth US q4-6 weeks after 24 weeks
- NSTs starting at 36 weeks
- Delivery by 40 weeks
- Gentle traction with delivery; high risk of avulsion
• 2 vessel cord
- Refer to MFM for serial growth
- NSTs at 36 weeks
SAB vs MAB management
• Diagnostic criteria for SAB/MAB vs early pregnancy
- CRL 7mm or more with no heart beat
- MSD of 25mm or greater with no embryo
- Absence of embryo with heartbeat 2 weeks after previous scan showed a GS without a yolk sac
- Absence of embryo with heartbeat 11 days after previous scan showed a GS with a yolk sac
- HCG ≥ 3500 should see something in the uterus or be worried about ectopic
- HCG < 3500 if symptomatic, could still be ectopic
• Counsel on options expectant management and medical management (pills vs surgery)
- If expectant management f/u in 1-2 weeks with repeat US, review s/s of infection and SAB precautions
- If medical management 800mcg Cytotec buccal q12 hours x2 doses
o Provide a lot of education on bleeding and cramping expectations/warning signs to go to ED
o F/u in 1-2 weeks with repeat US to confirm all POC have passed
- If surgical management Refer to/ consult MD about D&C vs D&E
o Typically patients measuring <10wks are candidates
o Consult between 10-23 weeks; if bone is visualized, surgery is not an option
• Labs to order: GC/CT/trich, CBC, type and screen, and HCG
Transfer to MD care
• Pre-existing DM or HTN
• Maternal heart condition
• Maternal cancer/ brain tumor
• Active seizure disorder
• Lupus or connective tissue disorder
• Twins or higher multiples
• Drug use outside of marijuana
• BMI >45 prior to pregnancy
• Placenta previa after 24 weeks
• GDM requiring insulin
• Hx DVT or PE
• Fetal gastroschisis
• Fetal cardiac anomaly requiring delivery at outside facility
• Fetal anomaly and not seeing MFM
• Use of antipsychotic medications that are category D or X
• Hx of cervical incompetence, cerclage, or 2nd trimester loss
Billing
Medicaid and Healthy start LOS - New OB – H1001, OB Revisit – H1000, Postpartum – 59430
Private insurance LOS - No charge visit
**Per billing, CNMs CANNOT cosign notes. We must write a note and close the chart if a charge is being placed.
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