Precepting/Cosignatures for Prenatal Charts at Penn Family Care:

1. When you have a new OB patient in your schedule, write your regular EPIC note as usual and send it to the precepting attending as usual.
2. IN ADDITION, look on COAST to see which OB attending is on-call for the day that you are doing this first prenatal visit.
3. Carbon-copy the patient's chart to that same OB attending for ALL prenatal visits for that entire pregnancy (in addition to the preceptor in the office that day).
4. Make a note at top of each prenatal note that: "Continuity OB Attending is Dr. X, for this patient".

In this manner, there will be one continuity OB attending following each patient during the pregnancy. We hope to improve the quality of our prenatal care in this manner and also with your panel of prenatal patients, you should hopefully have a good mix of OB attendings that are also following your patients and you can see their different practice styles.

Prenatal Care Guide:

First Trimester (conception – 12wk)

Initial OB workup is ideally performed b/w 6- 10 wks. After a positive pregnancy test assess whether this is “good news” or “bad news.” Make sure when you approach a patient who is pregnant that you wait to find out the answer to this question before saying “congratulations.” If this is bad news then you should find out if she desires to continue the pregnancy or whether she planned to terminate the pregnancy (use the words “stop” or “have an abortion” not termination as that is a culturally laden word). If she states a desire to have an induced abortion then let her know that we could help her with that in the practice or we could refer her to a site in the city. If she desire to stay with us then go to the discussion in section 9 below.

If the pregnancy is good new then go ahead with your congratulations. Most often you will be meeting the patient in a 15 minute slot/appointment and you should just say hi and order the initial labs that visit. You should then schedule the patient for a, “initial OB patient visit” with the front desk that is 45 minutes long. You need to tell the front desk to use a 30 minute and a 15 minute slot for this. If for some reason this does not occur the initial ob visit will need to be split into two visit, the first for history w/ ACOG form completed, and labs ordered, the second for a GYN exam.

1. First visit: Pregnancy test positive. Discuss pregnancy, was it desired or unexpected. Counsel on termination if appropriate. We perform termination up to 12 weeks (medical abortion up to 9 weeks , aspiration abortion up to 12), dating is imperative if desires a termination need u/s ASAP. This can be done as part of our abortion care in the procedure clinic session or you may have to call radiology Presby 349.5454, HUP 662.3000. See # 8 for management of miscarriage and medical abortion.
1. Aside - Plan B emergency contraception is not abortion and is a viable option for 5 days (120 hours) after an episode of unprotected sexual encounter. Prevents ovulation, if ovulation has occurred may prevent implantation. The sooner the better. Obviously pregnancy test will not be positive.
2. Initial OB:
1. ACOG form and template for subsequent OB visit can be found under “Orders” in EPIC (a cc of prenatal or OB visit must be entered for this to appear. You will also see a check list for labs in this section. Thorough history (pregnancy history, pastmedical/ob/menstrual/surgical/ social/family/FOB history etc. ).
2. Start a pregnancy chart whh should include date/EDC/FH/wt/BP/ctx/VB/FM/LOF/cvx, or some version thereof.
3. Screen for depression. Use the EPDS (Edinburgh Postnatal Depression Screen) instrument which is a smart text. Score of Greater than 12 requires formal evaluation for depression and treatment plan. Same treatment guidelines that are generally used apply in pregnancy. These include CBT, with or w/o medications. SSRIs other than Paxil are generally safe in pregnancy, however need to review risk/benefit, and document this. Encourage pt that are on SSRI to continue, if they rather d/c meds be aware high incidence of relapse. If pt on mood stabilizer consult Psychiatry.
4. Smoking Cessation: use 5 A’s: Ask, Advise, Assess, Assist, Arrange. If smoking document smoking status at every visit and progress on plan to quit. Also provide PA Dept of Health quitline number 1-800 QUIT NOW (1-800-784-8669) and document this.
5. If history of preterm birth: 1) offer progesterone therapy, 2) at 12-14 weeks screen for bacterial vaginosis (see below in 2nd trimester section).
6. Prenatal labs: .prenatalpanel and .prenatallab (found under the order set in “Orders tab when CC of prenatal or OB visit is created) these do not include HIV order separately. Labs include: GC/chly, RPR, HIV, HepBSAg, Rubella, T&S, CBC, UA, urine culture. Consider sickle cell screen in African America, CF in Caucasian, other genetic testing based on Family history. Consider checking Immune status for varicella and PPD.
7. Physical exam: GYN/ PAP. MUST document abnormal pap and discuss appropriate f/u.
8. Screen for BV.
3. Follow up OB:
1. Check all labs and act on abnormal labs. As an example currently 20% of positive urine cultures are not treated and 17% of women in this situation will develop pyelonephritis which increases risk of preterm birth and is always a hospitalization.
4. VBAC candidates: will need MFM consult. Need to determine type of incision (Low transverse is acceptable scar, otherwisedetermined by reviewing op report which needs to be sent with patient to consult visit. Order OB consult, in comment state MFM for evaluation for VBAC.
5. AMA (advanced maternal age): will need genetic counseling. Again dating is imperative. CVS is performed b/w 10-12wks, amnio b/w 15-18 weeks. Termination by 24 weeks in NJ or PA (cost increases as GA increases). Call 215-662-3232 for apt for genetic counseling.
6. Dating: if pt has a solid LMP, is reg periods etc LMP is appropriate for dating, this is standard practice. However some practioners routinely order a dating scan as what a pt deems a period may not actually be a period. If not and LMP is uncertain send for dating u/s. The earlier the better. If LMP is greater than two weeks form LMP use u/s for final EDC, if u/s within first trimester is days off use LMP as final EDC.
7. Documentation: Every note after the initial should include as a minimum the pregnancy chart (see#2) a copy and paste from previous to subsequent note, labs (add to it as they are obtained) and a final EDC and how this was obtained. Ultrasound date should be recorded, w/ the EDC at that time, as well as location of the placenta, i.e. Ultrasound on 10/5 w/ EDC of 6/13 @ 5weeks c/w LMP, post placenta, final EDC of 6/13. Dating is imperative, wheel pt out each visit! Each visit requires UA, FH, FHT (first appreciated @ 12 wks, if not need u/s to r/o miscarriage).
8. First trimester bleeding: ddx implantation v. threatened abortion v. Completed abortion . T/c getting an Hcg level, then repeat 2 days later. Should double, if not concerning for miscarriage. If extremely elevated t/c dating error v. molar pregnancy, need u/s.
9. Miscarriage: Up to 85% of miscarriage will spontaneously pass by 6 weeks after diagnosis of non-viable pregnancy.

Some women do not feel comfortable waiting to pass a fetus once they are aware of the loss. A loss, no mater how early, can be traumatic to the pt as well as her family. Counsel her; bring her back to check on her. Her options include a waiting for the fetus to pass v. medical management v. aspiration aka D&C, we use the manual vacuum aspiration device for these).

1. Induced Abortion: If a pt desires a termination MUST review critical counseling followed by a 24 hr waiting period. Counseling entails:
1. There are alternatives to abortion including adoption
2. There is medical insurance available in pregnancy to cover prenatal care then pediatric care.
3. The Father of the baby (FOB) can be forced to help support.
4. There are photographs available that review the stages of pregnancy, you can view them if you desire to, but are not obligated to do so. After this discussion, the pt MUST be allowed 24 hr to change her mind. During this time a CBC and Rh should be performed, also contact Dr. Bennett via e-mail to inform him of a termination, and schedule pt for first available procedure clinic. If interested in an aspiration procedure advise the pt to take 800 mg Motrin prior to the procedure.

Medical abortion is as effective as a D&C and can be performed up to 9 weeks. This is performed by administering 800 micrograms (4 tablets) of misoprostol intravaginally, pt may experience cramping followed by passage of fetus. If this does not occur may repeat once after 24 hr. There are rare instances that require a D&C if abortion is not complete or pt has excessive bleeding.

Aspiration abortion (often referred to as surgical)is performed in our office up to 12 weeks. The above counseling and labs should be obtained 24 hr prior to procedure. An u/s will be performed by Dr. Bennett to assess dates. If <12 weeks he will perform procedure, If > 12 week refer to Planned Parenthood at 215-531-5560.

Abortion is legal in this state up to 24 weeks, it becomes more difficult to

Locate a provider to perform procedure later as well as becomes more costly and more dangerous.

1. Hyperemesis: Onset 5-6 wk peaks @ 9 wks, abate by 16-18 wks. Initial evaluation includes wt, orthostatic BP, TFT (including free T4), BMP, and urine ketones. If urine indicates ketones hydrate w/ LR, until clear ketones. Importance placed on avoidance of triggers, hydration and small frequent bland meals. If these fail t/c pharmacologic tx, none approved by FDA. Start w/ nerve stimulation over volar aspect of wrist (pressure point braclets found in local pharmacy) w/ or w/o antihistamine such as benadryl 25mg po q 4-6 hr or doxylamine succinate 10mg BID in conjunction w/ pyridoxine (vit B6) 10- 25mg TID. If these fail t/c antiemetics: ondansetron (zofran) 8mg q 12h, promethazine (phenergan) 12.5-25mg q 4 prn, metoclopramide (reglan) 5-10 mg po q8, prochlorperazine 5-10mg q4 or 25mg BID prn.
2. Asymptomatic Bacteruria: Defined as persistent infection of pregnant lower urinary tract. This results in preterm delivery as well as LBW. Every pt should be screened w/ a urine cx, then have a UA at every visit. If it is positive (+leuk, + nitritites, + blood etc it should be sent for Urine culture. Greater than 100,000 CFU/cc is indicative of infectio and should be treated w/ ampicillin 500mg TID, 1st generation cephalosporin (keflex 250mg QID), or macrodantin 100mg BID. Sensitivities should guide treatment. DO NOT us bactrim in 1st or 3rd trimester. Treatment should extend for 3 days for uncomplicated UTI (asymptomatic UTI is uncomplicated)10d in a complicated UTI. TOC within one month of treatment. Recurrent or persistent infection should be treated prophalactically w/ Macrodantin 100mg qhs.
3. Follow up: If history and exam are performed at first visit then the pt should f/u in 4 weeks. If not bring pt back in 1-2 weeks, complete H&P then f/u in 4 weeks until 30wks then every 2 wks until 36 weeks, 36 wks on every week.

Second Trimester (13wk- 24 wks)

1. Family Planning: Discuss, recommend, and document family planning choices. Readdress 3rd trimester, on d/c from hospital, and at postpartum. If patient desires tubal ligation fill our paperwork in 3rd trimester (must sign consent 30 days prior to procedure, only valid for 60 days). Shortened inter-pregnancy interval is assoc w/ LBW and preterm delivery.
1. Depo provera: can be given at discharge from the hospital, excellent for Breast feeding mothers does not affect milk supply
2. Combined OCP (including ortho evra and Nuva ring): Should not be started for 21 days postpartum as pregnancy and immediate postpartum period is hypercoag. state. Not recommended for breast feeding as will decrease milk supply.
3. Progestin only pill (mini pill): Only for Breast feeding mothers, can start immediately postpartum.
4. IUD: Mercedes Benz of contraception with equal effectiveness to sterilization and less risk. Can be placed 3-6 weeks postpartum. Stress condoms until then.
5. Condoms
6. Diaphragm: can be placed or refitted 6-8 weeks postpartum, stress condoms until then.
2. BV: Screen for BV in the beginning of the 2nd trimester. Women w/ a h/o PTL are at greater risk of PTL if BV +. If note BV then treat w/ clindamicin 300mg BID for 7d, or flagyl 250mg TID x 7d or clindamicin gel qhs x 7d. TOC at next visit.
3. Multiple Marker Screen at 16-18 weeks. These results come to Boomey as a paper result. She places them in your mailbox. Must act on a positive test promptly as window for termination is small. Recheck dates, and repeat u/s.
4. GTT: Can be ordered as a future test toward the end of this trimester, can order as a future order and pt take the test at next appropriate visit. If value greater than 130 then f/u w/ 3 hr glucose tolerance test. If this is positive t/c

MFM consult. ***

1. Anatomy ultrasound Scan: Performed at 24-26 weeks ***

Third Trimester ( 25 wks - 40 wks)

1. Tubal ligation papers: If pt expresses desire to have a tubal consider scanning a consent form in her chart so in the event she needs a c-sct she can get a tubal. Timing of consent depends on insurance. Private insurance can be signed anytime, even day of procedure, Medicaid carriers (Keystone Mercy etc. the paper must be filled 30 days prior to procedure and is from date of signing until 6 months thereafter. This requires prior authorization as well as an authorization number. If a pt is serious about procedure t/c getting paper work filled out so that tubal can be performed while hospitalized or if pt has a c-sct.
2. Repeat depression screen: see First Trimester and use EPDS again with documented score.
3. Smoking screening: If was positive for smoking in first assessment see first trimester> DOCUMENT this conversation, plan for cessation, and quit-line referral. 1-800 QUIT NOW (1-800-784-8669)
4. Family Planning: See second trimester
5. Birthing classes: patient can contact Darcy Penrod
6. Breast-feeding: address and encourage this prior to delivery. Discuss what to be expected, women stop breast-feeding because of false or unrealistic expectation. Take a few min to discuss time course of milk coming in to decrease chance of quitting prior to milk coming in.
7. Post dates: bi weekly NST start at 41.0 weeks. Call PEC 662.7033 to schedule. With NST an AFI is also performed. If both normal pt is to return in 3-4 days. If NST is no reactive then a BPP is performed, if 8/10 then pt d/c to f/u in 3-4 days for repeat, if BPP< 8/10 then CST v. IOL.
8. IOL: Can be done at 38 weeks, should always be done after 41.6 weeks. Call Labor floor to schedule. Cervidil IOL occurs at 9pm, a resident must be in house, be polite and page the resident on call to let them know. Also let the attg on call know. Cytotec IOL starts at 0700. If cervix is favorable and decide on pit attg must be in house. Exam pt in the office, consider stripping the membranes.
9. Birthing plan: discuss pain control in labor. Discuss when to call (ctx > 4 hr, VB, decreased FM)

Post Partum

1. Depression screening using EPDS with documented score. If >12 then formal evaluation for current major depression is needed, screening for suicidality/homicidality, with treatment plan and close follow up.
2. PAP
3. Family Planning (see if you can get them to use the IUDs), Plan B w/ 6 refills
4. Smoking Cessation – 5A’s and referral to quit line (1-800 QUIT NOW 1-800-784-8669) as well as pharmacological intervention