Traditionally, low risk women have been followed every four weeks from initial appointment to 28 weeks, every two weeks from 28-36 weeks, and then weekly through delivery. If patient is LOW RISK (ie completely pregnancy this time, and if a multip had a completely normal pregnancy last time), can follow an alternative schedule which is:
G1: 12, 20, 25, 28, 31, 34, 36, 38, 40, 41
Multip: 12, 20, 28, 34, 36, 38, 40, 41
These alternative schedules have shown equivalent outcomes and allow less frequent appointments for reliable patients without concerns.Â
Check fundal height, fetal heart tones (after 12-14 weeks; if in second trimester, MUST attempt), blood pressure, weight gain
Are they taking prenatal vitamins? Any other medications?
Vaginal bleeding, abnormal urinary symptoms, abnormal discharge or vaginal symptoms, frequent cramping, loss of fluid?
(After 18-22 weeks) Fetal movements, contractions?
Plans for postpartum contraception/family planning?
Up to date with labs and immunizations?
Make sure you edit the Listrunner if they are on it!!!
Full history and physical: important to make sure you get the details on their previous pregnancies - did they have any complications? If they had a primary cesarean, why? If they had a miscarriage was it spontaneous, or did they need a D&C, and how far along were they? If they had preeclampsia, were they on magnesium (ask "were you on a medicine that made you feel really hot and really terrible?"), or did they need blood pressure meds after delivery? If they had a preterm delivery, was it spontaneous or induced, PPROM or preterm delivery? If they had a shoulder dystocia, how big was that baby? Any major (3rd/4th degree tears)? Was a vacuum or forceps used? How big was their biggest baby? etc, etc, etc
Any surgeries, gynecologic complications, medical problems, medications (including prior to pregnancy since many patients will stop medications when they got pregnant
Where do you live? Who do you live with? Is the father of the baby involved? Is he the same father as other children? Any h/o abuse with him?
Make sure patient has been screened with the 5Ps screening tool, and if any positives needs counselling and referral (depending on what positive)
Screen for domestic violence
Get routine prenatal labs - Type and screen, CBC, HIV, HBsAg, RPR, GC/CT, Rubella, A1C, UDS, UCx. No longer includes TSH!
Get baseline PIH labs (AST/ALT/Cr and urine p/c) in ALL patients at high risk for preeclampsia (history of, DM2, cHTN, lupus, renal disease, twins)
Get a dating ultrasound if their period is not sure AND reliable (meaning regular periods, and no pregnancies or hormones in the 3 months prior to conception)
If 12+ weeks, start on ASA 81mg daily if indicated (see quick reference materials)
Do some first trimester counselling (see separate page)
Refer to MFM if indicated
Make sure if patient qualifies for the high-risk list, she has been added to the high risk list
Order an anatomy ultrasound (must be 18 weeks at least, ideally done between 18-22 weeks)
Order Quad screen if patient desires (best done 16-18 weeks, can do from 15-22 weeks)
If prior spontaneous preterm delivery, start cervical length screening (Q2W through 28 weeks) and weekly progesterone injections at 16 weeks (through 36 weeks)
Make sure has had all labs done
If still having nausea/vomiting, likely GERD and not HCG induced
Give a flu shot if the right time of year and not done yet
See if feeling baby move
Do some second trimester counselling (see separate page)
Start discussing plans for postpartum birth control or family planning
Counsel about HTN precautions and if blood pressure at ALL above normal (including in the 130s), ask about preeclampsia symptoms (HA, vision changes, CP, SOB, RUQ pain, etc)
Order the GTT, RPR and CBC (and Antibody screen for any Rh negative patients); make sure they know not to fast (should eat a meal with some protein in it about 2-4 hours prior for the most accurate results. Do at 24 weeks for higher risk patient (if obese, prior GDM, baseline A1C>5.5%)
Give Tdap to all women at or after 27 weeks
Give Rhogam to all Rh negative women around 28 weeks
Start Q3-4 week growth scans at 24 weeks for twins or patients with significant growth concern at the 20 week ultrasounds
Start Q3-4 week growth scans at 28 weeks for GDM/DM2 on meds, cHTN on meds, morbid obesity, etc
Sign tubal consent sheet
Offer birth classes (only in English) or hospital tours (can schedule by calling L&D, or by going online - google "lutheran hospital birth classes" and the first link will take you to a page where they can sign up for classes, book a tour, preregister, etc)
Make sure has done 28 week labs, has had Tdap, and has signed tubal if desiring
Start twice weekly antenatal testing on GDMA2, cHTN on medications
Do some third trimester counselling (see separate page)
Assess fetal position with leopold's maneuver - if you suspect breech, confirm with an attending. If definitely breech, have patient check out spinningbabies.com and do the exercises a bunch through the day
Last chance to sign tubal paperwork, so make sure if even remotely on the patient's radar, that it's signed and in the chart
Counsel on signs of labor
Collect GBS swab (between 36+0 and 37+6)
Start weekly antenatal testing for advanced maternal age (Can do NST one week, BPP the next week)
Start discussing plans for delivery (birth plan, who will cut cord, skin to skin, etc)
Make sure if a cesarean section, that surgery is scheduled
Review labor precautions
Induce women with cholestasis of pregnancy
Start acyclovir in patients with h/o HSV and has had a outbreak in the last year
Confirm if vertex or breech - if unsure get an attending, and if still unsure can get an ultrasound at this point (NO NEED TO GET ULTRASOUNDS FOR POSITION PRIOR TO THIS). If they are breech, can discuss version.
Induce women with preeclampsia w/o severe features, gestational hypertension
Consider doing external cephalic version on breech patients
Can start discussing plans for labor induction for low-risk patients if patient is interested
Should be inducing women >40, GDMA2, cHTN on meds
Doing scheduled cesarean sections on women
Needs NST twice weekly if still pregnant
Have plan for induction so delivery is by 42 weeks
Contraception?
Have they had a period?
Are they still breastfeeing?
Have they had intercourse? If so, any pain/discomfort? Note that if breastfeeding, may need lubrication during intercourse because of hormones
Still taking prenatals? Iron if applicable?
How is there mood? Is everyone/family adjusting to everything?