Prenatal Flowsheet:

1st Visit:
• CBC, Type/screen, Rubella/RPR/GC/CT/TB/HBsAg/HIV
• PHQ9
• Give FMC card
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Pregnancy Counseling
#. Rx: OTC rx list, what rx to avoid
#. Exercise:
#. Diet:
#. Safety: seatbelt use
#. When to go to hospital?

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Routine Visits:
#. age - GsPs - @ - by.
- EDD:
- PNLs:
- US results:
- FH, BP.
- OBhx:
- Issues:
- ROS: no vision change / RUQ pain / HA. no VB. no LOF.

T1: PNLs__; UA/UCx(at 12-16 wk) __; GC/CT__; PHQ-9__; Flu__

T2: Quad scrn (16-20wks)__; 1hrGTT (24-28wks)__; Anatomy US (18-20wks)__; Rhogam (if Rh-, 24-28wks)__
T3: GBS (35-37wks)__; RPR__; CBC__; TDAP__;
PP: Depression__; BCM__; Br/Bo__

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Misc
#. If previous CS: TOLAC vs R-LTCS.
#. Genetic counseling
#. Herpes screening
#. if high risk can Syphilis / GC/ CT repeat at 29-41 wk.
#. FHTs: start 11-12 wks; FM: 17-19 wks.
#. TSH only if sx; no BV screen.
#. Quad screening:
#. GDM screening: interpretation?
#. PTL screening:
#. Hep C screening:
#. Routine urine dip?

#. Hep C:
Hep C in pregnancy:
- vertical transmission is w/o effective prevention and anti-HCV regimens NOT safe in preg. c-section does not reduce risk.
- avoid etoh, screen hep panel, LFTs
- breastfeeding: don't do -- but not associated w/ inc risk HCV in newborns (need to check)
- for newborn; initial Hep C screen does NOT give dx as will catch maternal Abs crossed over. At 1yo, 95% maternal Ab is cleared out. So, need to screen regularly. Can make dx if Hep C RNA demonstrated x2
between 2-6 mo. If at 15 mo NO hep C Ab, then unlikely received. Send to peds ID.

#. Yeast Infection:
- increased in pregnancy, tx for sx improvement. 10-75% prevalence.
- Tx: miconazole 100mg vaginal suppository 7-14 days (prolonged).
- No fluconazole (craniofacial abnormalities)

#. Sickle Cell & Hemoglobinopathies :
- Everyone gets CBC – if microcytic anemia w/ nl Fe in Mediterranean, Asian, then get Hb electrophoresis.
- If African-descent, then get Hgb electrophoresis whether anemia or not.
- Sickle cell disease women have increased risk SAB, stillbirth, preterm, increased underlying hemolytic anemia and multiorgan dysfunction during pregnancy. May test partner. Folate requirement is 4mg/d instead of the normal 1mg.
. What is management of sickle cell trait in pregnancy?  
#. When to MFM referral?

#.
Text4Baby sign up.
#. cont PNVs, folate.
#. next visit? 0-28 wks q4 wks; q2-3 wks 28-36 wks q2-3 wks; weekly >36 wks
#. PNL panel: Type + screen / Rubella/RPR/GC/CT/HBsAg/HIV. CBC


Post-Partum
- Evaluate for : PP depression, PP thyroiditis
- BCM:

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 OB Panel, HIV, and Varicella titers, Urine Cx, G/C Chlamydia
2. Meds: PNV: folic acid (0.4mg/d, +/- Fe (30mg/d), +/- Ca (1000-1300 mg/d)
3. Consider Ultrasound for dating if unsure LMP or other suspicions (i.e. twins etc…)
4. Recommend No: ETOH/Drugs/Tob/Raw fish or meat or eggs/Soft or unpasteurized cheese
5. Give OTC med sheet.

OB panel includes: RPR with Reflex, Antibody Screen, Blood Group and RH type, Rubella IgG1, CBC and Platelet, HepB antigen with Reflex.


b. Ask about h/o chicken pox

2. Assess for need for genetic counseling, genetic screening tests, or other screening tests recommended if at higher risk (i.e hep C if tattoos etc..)


3. Do complete physical exam (including BMI, bimanual pelvic exam); GC/CI*; Pap (if 21 yr+ and has not had a recent pap)
4. Give yellow OB info card and discuss prenatal labs as filling in. Counsel on use of card.

3. Fundal Height
4. Weight
5. +/- urine dip for protein/glucose (*evidence is controversial)
6. +/- edema ck (*controversial usefulness)
7. Abdominal palpation for presentation only after 36+wks
8. Consider induction at 41 weeK: 

a. BiWeekly NST w/AFI recommended for monitoring starting at 41 week
b. Strong Recommendation for induction by 42 wk

Early 1 hour GTT if at risk (Hx, GDM POM1 735)
Routine kick count not recommended.


* 29-35 wks Q 2 weeks
* 36+ wks Q 1 weeks



Amenorrhea Visit 
1. Labs to order:
Initial OB visit1. Review entire OB history/Family history, Pre-Term labor risk
a. Ask about h/o herpes in pt/pt partner
Rest of visits
1. BP
2. FHT
Subsequent OB visitFrequency of Visits
* 0-28 wks Q 4 weeks