o HIV and other routine tests - review what tests we get and why
o Risk factors identified by prenatal history - history of GDM/DM2? Preeclampsia/cHTN? Clotting disorders? IUGR? Fetal death? etc
o Anticipated course of prenatal care - discuss how often they will be seen, when they will get labs and ultrasounds, etc
o Nutrition and weight gain in pregnancy - review what their weight gain goal is by their BMI (<18.5 = 28-40lbs, 18.5-24.9 = 25-35lbs, 25-29.9 = 15-25lbs, 30+ = 11-20lbs)
o Toxoplasmosis precautions - ask if they have a cat, and advise no kitty litter duties while pregnant
o Sexual activity - discuss that it's okay, but can cause spotting (from cervix being friable and very vascular). If spotting, cramping then stop. If bleeding, then needs to be seen.
o Exercise - is okay and is great for fetal brain development. Shouldn't change their activity level drastically. Stay well hydrated and listen to body; if something hurts or has cramping, then back off. No contact sports, sky diving, scuba diving, horseback riding (could fall) - otherwise go to town. No specific time they have to stop - again, listen to their body.
o Influenza vaccine - once an US has been done or you've heard a heartbeat, generally okay to get. Should recommend since pregnancy is a state of decreased immune system so more likely to get the flu, and to get really sick from it. Baby gets the antibodies and keeps them for 6 months.
o Smoking counselling - stop. There is a link to smoking in pregnancy and autism.
o Alcohol use - no amount can be considered safe. If they had a few drinks before they knew, they're probably fine, but cannot recommend any amount can be consumed during the pregnancy.
o Drug use - no amount can be safe. Confirm their 5Ps screening test here and refer to services as needed. Marijuana can be linked to small babies, preterm delivery, and decreased cognitive development and behavioral problems.
o Environmental hazards - are they around inhaled chemicals? Farm animals like chickens? Are they lifting heavy things frequently? Repetative motion (likely to get carpal tunnel - can give exercises)
o Travel - safe to travel, but should walk around every 2 hours to stretch legs for 10-15 minutes (even on a plane). Usually should stop travel around 36 weeks.
o Use of any medications/supplements/OTC drugs/herbs - no NSAIDs, pepto bismol; okay to use tylenol, flonase, benadryl, robitussin, nasal saline, melatonin
o Use of insect repellent - should use, and use the deet-free kind (ie. OFF FAMILY); again because of decreased immune system, are more likely to get sick, and more likely to get really sick.
o Indications for ultrasound - talk about the 20 week ultrasound only for most patients (if you know they will need growth scans for diabetes, HTN, etc, then can discuss that as well).
o Domestic violence screening - screen everyone, ideally without the partner in the room
o Seat belt use - safe to use seat-belts; lap belt should go below the belly, and chest strap between the breast. If they are concerned about the belt hurting the baby, tell them that if an accident is bad enough to hurt the baby with the seatbelt, then it's likely to seriously injure or kill them both without it.
o Childbirth classes/hospital facilities - lutheran does these (see the website page for how to get there). Do NOT ask people where they want to go, but rather discuss this with them under the assumption of them going to lutheran. Only exception is if they are planning to VBAC (again, we do not offer or plan this for them) in which case they should go to Dupont or PRMC (if they can't switch to a provider that will see them through that hospital)
o Dental care - safe to see the dentist, safe to get xrays if their belly covered, safe to get numbing medicine, and safe to get pain medicine after extractions. See the "dental letter" under quick reference materials page for a printable note template you can make for them.
o Avoidance of saunas and hot tubs - none of these, or can just put legs in the hot tub
o Breastfeeding - ask what their plans are, have they done it before, are there any concerns?
o Genetic screening - should be offered to all patients. If >35yo, then MUST offer referral to MFM for cell-free DNA (if no insurance will pay for the visit and the lab...very expensive). Otherwise we do the Quad screen between 15-22 weeks (ideally 16-18 weeks)
o Signs and symptoms of preterm labor - review these
o Abnormal lab values - review their prenatal labs and discuss anything abnormal; what does it mean, what are we going to do about it
o Influenza vaccine - as above....get it
o TDaP vaccine - Every pregnant woman should get with every pregnancy....no matter when she last got it! Boosters her immunity, but more importantly it gives baby 6 months of antibodies as well. Anyone who will be around the baby a lot (FOB, other family, etc) should get a booster if they haven't had in last 5 years - most people can just ask their PCP, or if no PCP/insurance, then can get at the public health department
o Smoking counselling - as above, stop....autism
o Domestic violence - screen everyone as above
o Postpartum contraception plan - discuss their plan, and if not sure then give them handouts! Reproductive Health Access Project (see websites) has a great handout with all options, info about each, pros/cons, effectiveness etc. Comes in English and Spanish. Can get free Nexplanon from the Lafayette Medical Center if no insurance, or can see in FMC for this if they do have insurance. Can get free or cheap IUDs through NHC. If self pay (ie. emergency medicaid) then tubal isn't covered - is likely thousands if after vaginal delivery.
o Depression screening - screen everyone, and offer counselling, meds if possible. Important in moderate to severe depression to review with patients that untreated maternal depression in pregnancy can lead to behavioral problems in kids which can be permanent, while the risks of SSRIs are transient. Fluoxetine is your go-to to start in pregnancy, Sertraline in breastfeeding; potential risks of SSRIs if starting after 18-20 weeks are a withdrawal syndrome (are fussy, may not feed or sleep well), or persistent pulmonary hypertension (rare, but babies with this can need O2 for days to weeks....will eventually get off of it).
o Donating stem cells/cord blood - can discuss the program we have at Lutheran with Sean. Helps with medical research for Parkinson's, Cancer research, AIDS research etc. I usually tell people that it's all behind the scenes, and that they just take the blood left over in the cord that would otherwise be thrown away.
o Anesthesia/Analgesia plans - epidural or no epidural? Pain meds - note that they can usually only get until about 7-8cm because then can affect baby's breathing.
o Fetal movement/monitoring - baby should move 8-10 times every 2 hours. If they haven't felt baby move in that time, should sit down, put feet up, drink some juice or cold water, have a snack, lay on left side....if baby still not moving after these interventions then should go to labor and delivery.
o Labor signs - review these. Review that if having regular, painful contractions then should sit down, have some water, put feet up and relax (will stop false labor). If still having contractions with at least 4 an hour for 2 hours, then should consider coming in. Labor contractions should last ~45-60 seconds. Sometimes will have back labor instead of normal contractions, so if back pain that is coming and going, and has completely hard belly with this, consider it to be potentially back labor (and should try some hands and knees if they can). Review that ROM isn't always a big gush, but can be a slow trickle, so if feeling wet a lot, then should consider getting checked.
o VBAC counselling - we cannot recommend this. If they want then should try to transfer to a provider that does it; if no insurance then we are their only option and should be counselled on risks (uterine rupture at about 1/200ish with spontaneous labor), and that we can not/will not induce them so they must go on their own. Should not plan to labor at Lutheran, but rather Dupont or PRMC.
o PIH Precautions - review signs and symptoms of PIH, the most common being a headache (people usually call it "weird, different, unlike other headaches I've had). Other symptoms can be chest pain, SOB, vision changes (sparkles or stars while sitting still, or while up walking around for a while), persistent RUQ pain. Review that feet swelling is normal for everyone, but hand and face swelling isn't. If any concerns for these symptoms, should check BP, and if high then go to L&D.
o Post-term counselling - risks of taking pregnancy >41 weeks is placental insufficiency, and could potentially increase risk of cesarean (especially if a big baby, patient a smoker, GDM/DM2, HTN)
o Breast/Bottle Feeding - review what they want to do.
o Postpartum Depression - see if they have history of in the past. If so, were they on meds? How is their mood now? Are they worried about it again? Can sometimes plan in patients to start meds at delivery if they had it bad last time, or really worried this time.
o Influenza vaccine - get it!
o Smoking counselling - stop, as above.
o Domestic violence - screen again