OB Visit Workflow

*THIS WORKFLOW IS MOSTLY FOR CLINICAL STAFF - SEE GME OB PROTOCOL FOR RESIDENT INFORMATION!!!*

Standing Orders: OB Patients

To assure complete care of the OB patient, these standing orders have been adapted to be carried out by the nursing staff.

1. Complete dipstick urine and culture, and confirm urine pregnancy test will be done on the first OB visit or as indicated, nursing to pend order for provider.

2. Dipstick urines will NOT be done on each visit (only the first visit or if otherwise indicated)

3. Do serum hemoglobin at 15-20 weeks, 26-28 weeks, and 34-36 weeks.

4. Do random fingerstick blood sugar on dipstick urines positive for glucose.

5. Do urine cultures on all urine specimens post treatment for UTI.

6. Do urine cultures on all urine specimens that test positive for leukocyte estrace, nitrate or protein when complete dipstick urine ordered.

7. Do one hour glucola at 26-28 weeks

Routine Visits: 8-28 weeks every 4 weeks

28-36 weeks every 2 weeks

36-40 weeks every week

> 40 weeks twice weekly

First Visit

1. Provider to order OB Panel (blood type, Rh type, coombs ab, HIV, HepB SAg, RPR, Rubella Ab, CBC, Urine culture, UDS)

2. IO urine dipstick, complete

3. IO urine pregnancy test if not already done in Epic (previous office encounter, previous OB if transferring care, ED)

4. Provider to order Pap Smear if due (over 21 years old and not done within previous 3 years)

5. Provider to order GC, Chlamydia

6. Provider to order BS one hour after 50gm glucola (Glucose Tolerance Test):

a) obese (> 180 pounds)

b) previous infant > 9 pounds

c) unexplained fetal death

d) glucosuria

e) family history of DM (parents, sibs)

f) congenital anomalies

7. Provider to order PPD placed on high risk exposed patients without previous positive; to be read in 48-72 hours (Do not place if previously positive)

8. Nurse to record weight, height, blood pressure, pulse.

9. Provider to record FHT if applicable

10. Provider to calculate EDC using history of last menstrual period. Note gravida, para, abortion.

11. Nurse to complete Medical History: Previous pregnancies, LMP, ROS, Past history, Allergies

12. Provider to complete Prenatal Flowsheet, Prenatal Database Questionaire Systems Review and Physical Exam.

13. Provider to discuss and offer first trimester genetic screening. Refer to Maternal Fetal Medicine if desired.

14. Provider to schedule initial OB ultrasound (transvaginal OB sono at LMHS) to confirm dates – must use medical indication for order: vaginal bleeding, unsure dates, etc.

15. Education: Prenatal Care System Appropriate for Gestational Age

16. Nursing to give information on NICA, obtain signed consent, scan signed consent.

Visit(s) 15-20 weeks

1. Nurse perform and record weight, blood pressure

2. Provider complete ambulatory prenatal flowsheet.

3. Provider assess and record FHT

4. Provider Assess and record quickening

5. Discuss and offer second trimester genetic screening, refer to MFM if desired

6. Schedule anatomy Ultrasound for 16-18 weeks with LPG OB/Gyn

7. Education: Discuss topics on prenatal education sheets appropriate for gestational age.

Visit 26-28 Weeks

1. Weight, blood pressure

2. Provider to order 28 Weeks – One hour glucola, repeat HIV

3. Order antibody for RH factor.

4. Give Rhogam if Rh negative

5. FHT

6. Education: Prenatal education appropriate for gestational age

7. Discuss birth control options post delivery. Tubal ligation papers due 30 days before due date. Copy and provide one copy to patient and scan other copy to chart.

8. Discuss circumcision. If not covered by insurance, patient must pay in full prior to delivery for procedure to be done by our service in the hospital.

Visit 34-36 Weeks

1. Weight, blood pressure

2. GC, Chlamydia for high risk patients

3. GBBS at 35-37 weeks

4. FHT

4. Education: Prenatal education appropriate for gestational age

Each visit 36 weeks – 40 weeks

1. Weight, blood pressure

2. FHT

3. Cervical check if patient desires, or if medically indicated

4. Education: Prenatal education appropriate for gestational age

40 Weeks – Delivery

1. Weight, blood pressure

2. FHT

3. NST

4. Schedule post-dates induction for 41 weeks. No inductions prior to 39 weeks without clear medical indication from MFM. Must fill out induction paper orders and fax to L&D.

5. Education: Prenatal education appropriate for gestational age

Post Partum

1. Weight, blood pressure

2. Discuss birth control plans

3. Screen for post partum depression with Edinburgh scale (in Epic)

4. Pap Smear if due

5. Breast Exam, assess breastfeeding

6. Obtain Discharge Summary and Delivery Records.