56
SOHSN OBSTETRICAL GUILDELINES
7-24-06
Table of Contents
PAGE TOPIC
3 I. Purpose
3 II. Terminology
3 III. Team Approach to Obstetric Care
3-4 IV. Intake visit including PPD interpretation
5 V. Scheduled Visits
5 VI. Transfer of SOHSN charts to the hospital of delivery
5-6 VII. Transfer of charts from secondary sites
6-7 VIII. Policy of patients transferred between sites
7 IX. Laboratory and other testing for all patients
7 A. Blood type
7 B. Rh type
8 C. Antibody screen results
8 D. Rubella screen results
8 E. VDRL or Serologic Test for Syphilis
9 F. Complete Blood Count and other hematology
9 G. Hepatitis B screen
9 H. Maternal serum screen
9 I. Ultrasound evaluation
10 J. Varicella Zoster Virus exposure
10 K. Parvovirus B19
10 L. HIV testing
11 M. Gonorrhea (GC) testing
11 N. Chlamydia testing
12 O. Urine culture
13 P. Papanicolaou smear results
13 Q. Glucose Challenge Test (GCT) and Glucose Tolerance Test
14 R. Interpretation of GTT
15-16 S. Group B Streptococcus screening
17 T. Urine drug screening
17 U. Other laboratory tests
17 V. Fetal Kick Count Instruction
18 X. Additional Individual Investigations.
18 A. History of cesarean section
18 B. History of postpartum hemorrhage
18 C. Indications for hemoglobin electrophoresis
18 D. History of thyroid disorder
18 E. History of neurologic disorders
18 F. History of cardiac disorder
18 G. At risk for congenital disorder
18 H. Non-Stress Testing
19 I. Genital herpes simplex virus (HSV)
20 J. Hepatitis B Vaccine
21 XI. Management of High Risk Pregnancies
21-23 A. Management of gestational diabetes mellitus
24-25 B. Management of patients with diabetes before pregnancy and presumed pre-gestational diabetes.
26 C. Management of Multifetal Pregnancy
27 D. Preterm Labor and Delivery Management
27 E. VBAC versus repeat cesarean delivery
27-28 F. Advanced maternal age
28 G. Abnormal maternal serum markers
29-31 H. Hypertension in pregnancy including definitions
31 I. Post dates pregnancy
32 J. Asthma in pregnancy
32-34 K. Anticoagulation and VTE in pregnancy
35 L. Thyroid disease in pregnancy.
36 M. Viral infections in pregnancy
36 N. Patients at particular risk of PTL & D.
37 O. Patients with suspected IUGR
37 P. Patients with 2 vessel umbilical cord
37 Q. Miscellaneous high-risk pregnancies (Not mentioned above)
38-40 XII. Postpartum Visits
38 A. Home
39-40 B. Office
40 XIII. Prenatal Program
41 Appendix 1 White’s Classification of Diabetes Mellitus
42 Appendix 2 BMI chart
43 Appendix 3 Management of Gestational Diabetes -- diet-controlled
44-47 Appendix 4 Management of Gestational Diabetes -- on medication
48-52 Appendix 5 Management of patients with diabetes before pregnancy
53-54 Appendix 6 Management of multifetal pregnancy
55 Appendix 7 Management of advanced maternal age
56-57 Appendix 8 Management of abnormal maternal serum markers
58-59 Appendix 9 Management of low-risk chronic hypertension
60-62 Appendix 10 Management of high-risk chronic hypertension
63 Appendix 11 Management of asthma in pregnancy
64-66 Appendix 12 Therapeutic anticoagulation
67 Appendix 13 Prophylactic anticoagulation
68 Appendix 14 Management of thyroid disease in pregnancy - hypothyroidism
69 Appendix 15 Management of thyroid disease in pregnancy – hyperthyroidism
70 Appendix 16 Viral infections in pregnancy
71 Appendix 17 Preterm labor and delivery management
72 Appendix 18a Patients at particular risk of PTL & D (HR PTL)
73 Appendix 18b Patients at particular risk of PTL & D (MR PTL)
74 Appendix 19 Patients with suspected IUGR
76 Appendix 20 Patients with 2-vessel umbilical cord
76 Appendix 21 Miscellaneous high-risk pregnancies (not mentioned elsewhere)
77 Signature page
I. Purpose: This document is intended as a supplement to Ohio state and The American College of Obstetrics and Gynecology guidelines for prenatal care. The goal is to provide all staff members with written routines for communication with patients of SOHSN.
II. Terminology: Terms such as “client” and “patient” used in this document are meant to be interchangeable. The term “care provider” represents any of the following: physician, certified nurse midwife, physician assistant, nurse practitioner, or in some circumstances a registered nurse or licensed practical nurse. MA’s may also be considered providers in some circumstances.
III. Team Approach to Obstetric Care
A. Each patient is to be told at her first visit that prenatal and obstetric care will be provided / supervised by a team of care providers assigned to the office or hospital during the time that any evaluation is needed or a visit is scheduled.
B. If patients have problems with a particular care provider, the issues should be discussed with that patient in a timely fashion and a resolution reached.
C. A care provider may choose to offer to make a patient a "private" patient. This practice is generally discouraged, as that provider will be expected to be on-call for each private patient at all times.
IV. Intake visit including PPD, Influenza vaccine
A. A member of the nursing staff will interview the patient and record pertinent obstetric, medical and family history information. This information should include UTI symptoms.
B. Each patient will be given as much verbal and written information as possible regarding the pregnancy and her care.
C. Patients will be instructed to take daily prenatal vitamins for the duration of the pregnancy. Patients who cannot tolerate PNV’s may be offered an appropriate chewable (prescription or children’s chewable) or liquid substitute. Patients will generally be given daily iron supplementation (ferrous sulfate 325 mg.) at the second-trimester class (PTLC). Patients who cannot tolerate ferrous sulfate may be offered ferrous gluconate (300 mg.), Chromagen (DAW), or other appropriate iron supplement.
IV. D. Patients should be offered screening for tuberculosis, unless they have a history of a positive PPD. Protein purified derivative (PPD) tuberculin of 0.1 ml (5 Tuberculin Units) should be placed intradermally on the underside of the patient’s forearm. The patient should then return to the office in 48-72 hours for interpretation. The results should be recorded in the patient’s chart and the care provider contacted for all positive results. Positive results are as follows:
1. 5 millimeter (mm) induration and any of the following:
a. Close contact with infectious TB.
b. Chest X-ray (CXR) containing old fibrotic lesions.
c. Known or suspected HIV infection.
2. 10 mm induration and any of the following:
a. Silicosis.
b. Abnormal CXR.
c. Prolonged corticosteroid therapy.
d. Diabetes mellitus.
e. Cardiac, renal or hematologic disease.
f. Member of an ethnic or socioeconomic group with a high prevalence.
g. Intravenous drug user.
h. Resident of a long-term care facility.
i. Health-care workers.
j. Patients with previous gastrectomy, gastric bypass, or intestinal bypass surgery.
k. Chronic alcoholic patients.
3. 15 mm induration in all other patients not listed above.
E. Medical, social, and nutritional problems particular to the patient should be identified and addressed as appropriate.
F. Influenza Vaccine: All patients who will be in the second or third trimester of pregnancy during the Influenza season (winter through early spring) should be offered vaccination. The vaccine is considered safe at any stage of pregnancy.
G. All patients should be offered information and screening for cystic fibrosis (CF), unless they have a documented previous screen. If the patient tests as a CF carrier, the assumed father of the pregnancy should be offered the test. In that case, appropriate HIPPA release(s) will be signed. If both (or either of the) parents test as CF carriers, referral should be made for genetic counseling.
V. Scheduled Visits
A. Routine - Patients will be scheduled to be seen by a care provider approximately every four weeks through 28 weeks gestation, then every two to three weeks to 36 weeks, and weekly thereafter. At each routine visit the following parameters should be recorded: maternal weight; blood pressure; urine protein, glucose, ketones and nitrites; estimated gestational age; uterine size (either using AGA/LGA/SGA or measurement, or if followed by serial US’s, this may be omitted); fetal heart rate (present, absent, present by US, NE or NA if early or acute visit, reactive or rate); contractions; bleeding; leakage of fluid; and, starting at 35 weeks gestation, fetal presentation.
B. Patients will be scheduled for more frequent visits at the discretion of the care provider based upon risk factors and progress during the pregnancy.
C. Patients of any SOHSN Center may be seen at other SOHSN center staffed by their team of physicians on an emergency basis on days when no care provider is in their primary center. Appropriate record updates will be faxed to the center where the patient is being seen.
D. A strong effort will be made to have up-to-date-copies of prenatal records available to the care provider.
E. Copies of records of visits made at alternate site(s) will be transferred in a timely fashion to the primary site and those copies added to the patient's chart.
VI. Transfer of prenatal records from SOHSN centers to hospital of delivery
A. Legible copies of each patient's prenatal record, including progress notes, should be sent to hospital of delivery following the first visit with the care provider, after the "28-week" lab results are back, and after the "35 to 37-week" Hgb and group B streptococcus (GBS) studies are completed.
B. The Registered Nurse or Clinical Office Coordinator is ultimately responsible for the timely transfer of prenatal records.
C. Documentation: When copies of records are transferred, a notation should be made on the prenatal record.
VII. Transfer of charts from secondary sites to the primary Center and transfers between other sites
A. A copy of each patient’s initial prenatal record should be transferred to the primary site. The copies should be transferred after the patient’s first visit with the care provider and will remain on file with the primary site at least until delivery
B. If a patient is transferred from one SOHSN site to another for continued care, sufficient copies to complete an up-to-date record should be sent to the appropriate site where she will be getting care.
VII. C. Responsibility - The secondary site RN or Clinical Office Coordinator is responsible for the timely transfer of prenatal records between sites. In the absence of the Clinical Office Coordinator, another member of the nursing staff is responsible for the transfer of records from the secondary site.
D. Documentation: When copies of records are transferred, a notation should be made on the prenatal record.
E. Care of Patient Records from Secondary Sites at SOHSN Primary Site
1. Records will be maintained in a separate binder or file until the patient has delivered unless care is transferred to the SOHSN primary site.
2. Most patients transferred to the SOHSN primary site will have a permanent chart established (except those patients transferred for post-dates).
a. Updated records of transferred patients should be forwarded to the secondary site at regular intervals, i.e. one to two weeks.
b. Once the patient delivers the original delivery summary and/or operative report will be sent to the secondary site, and a copy will be filed in the patient’s chart at the SOHSN primary site.
F. Method of prenatal record transfer: Copies of records may be transferred by courier, mail, hand-carried by personnel (site staff or care provider), or hand-carried by individual responsible patients
VIII. Policy of patients transferred between sites
A. A patient may be transferred for continued care at SOHSN primary site at the discretion of the care provider, or as recommended by other guidelines, i.e. weekly non-stress testing (NST). A notation should be made in the prenatal chart, such as “Transferred to SOHSN -Georgetown for continued care.” When possible, a copy of the patient’s prenatal record and social assessment should be forwarded to the SOHSN primary site. Additionally, in order to facilitate a smooth transition, a verbal discussion with the Clinical Office Coordinator is suggested.
B. Transferred patients may also be seen at the secondary site as needed. A copy of the note from that visit should be sent to the SOHSN primary site.
C. In some cases, patients transferred to SOHSN primary site for continued care will return to the secondary site for postpartum follow-up.
D. Patients transferred to SOHSN primary site should be informed about additional costs for which they may be responsible. Contact a SOHSN Office Manager regarding fees which may include office visit, NST, ultrasound evaluation and urine dipstick.
VIII. E. Patients who are transferred for antepartum testing will have their blood pressure, urine dipstick results, and nurse’s notes recorded on the ultrasound evaluation form. A permanent SOHSN chart will not be established. The care provider’s note may be entered on the ultrasound form or on a separate progress note sheet.
IX. Laboratory and other testing for all patients: All laboratory reports will be interpreted according to the following criteria. All reports will be initialed and dated by a care provider before they are filed permanently in the patient's chart. When the following guidelines dictate care provider notification of lab results, the person contacting the care provider shall have the patient's chart immediately available in order to give complete and current information to the care provider.
A. Blood type: Record on chart.
B. Rh type.
1. If the Rh type is positive (including D negative and Du positive), record on the prenatal chart.
2. If the Rh type is negative, record on the chart, then the patient should receive appropriate Rh information. An antibody screen (ABS) will be drawn at approximately 28 weeks gestation and any time the patient has significant vaginal bleeding. Rhogam (or equivalent) 300 micrograms (one ampule) should be administered to each patient who is not already Rh sensitized. If the patient refuses Rhogam, this should be documented in the chart, and the ABS should be repeated at approximately 32 and 36 weeks.
a. If the patient has significant vaginal bleeding or a spontaneous abortion at less than 12 weeks gestation and the ABS is negative for anti-D, then MICRhoGAM (50 micrograms) or Rhogam should be given. Rhogam administration should then be repeated every 12 weeks until delivery.
b. If the patient undergoes amniocentesis prior to receiving Rhogam at the 26-30 week interval, then an ABS will be drawn. If the result is negative, the patient should be given Rhogam. Rhogam administration should then be repeated every 12 weeks until delivery.
c. If the patient's cervix is unripe at term (i.e. 40 weeks) and it has been greater than 12 weeks after Rhogam was received, consideration should be made to repeat the administration of Rhogam.
3. Patients whose Rh type is D negative and Du positive are treated the same as D positive patients.
IX. C. Antibody Screen Results.
1. If the ABS is negative, record on the prenatal chart.
2. If the ABS is positive, record on the chart, then read the comment on report. If the antibody is non-hemolytic, i.e. anti-Lewis, no further evaluation is required. If the antibody is hemolytic, i.e. Kell, Duffy, or Kidd, then notify the care provider immediately. In cases of hemolytic antibodies, titers should be obtained, as well as the genotype of the father of the baby for that antigen (if the father’s identity can be determined with reasonable reliability).