Table of Contents



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).

IX. D. Rubella Screen Results

1. If the screen results are negative (non-immune), intermediate or indeterminate, these patients should receive a postpartum vaccination, preferably prior to discharge from the hospital, unless the patient also receives Rhogam after delivery. Then she should get her vaccination at about 3 months postpartum. If patient compliance with the three-month interval is questionable, the vaccine should be given at the six-week postpartum visit.

2. If the results are positive (immune), record on the prenatal chart.

IX. E. Venereal Disease Research Laboratory (VDRL), Serologic Test for Syphilis (STS), or Rapid Plasma Reagin (RPR) results.

1. If the screen results are negative, record on the prenatal chart.

2. If the VDRL is positive, record on the chart, contact the care provider, then confirm by drawing Fluorescent Treponemal Antibody (FTA) titer or other appropriate confirmatory testing. The Health Department should receive a report of all confirmed positive results

3. Positive VDRL and negative FTA -- These patients may be considered for other testing. Possible examples are ANA, lupus anticoagulant, and anticardiolipin IgG and IgM.

IX. F. Complete Blood Count (CBC): Record on chart and utilize the following guidelines.

1. If the white blood cell (WBC) and/or platelet counts are abnormal -- highlight results for the care provider to review.

2. In addition to the initial visit CBC, serial Hct/Hgb levels should be obtained and recorded at approximately 26-28 weeks gestation (preferably along with the glucose challenge test) and at 33-36 weeks gestation.

3. If the hematocrit (Hct) is less than 30% or hemoglobin (Hgb) is less than 10 gm/dL for nonsmokers or less than 34% or 11 gm/dL for smokers, verify compliance with iron supplementation, and notify a care provider as soon as possible.

4. If the Hct is between 30 and 34% or Hgb between 10.0 and 11.0 gm/dL for nonsmokers or Hct between 34 and 36% or Hgb between 11 and 12 gm/dL for smokers, verify compliance with iron supplementation, and notify a care provider on the next clinic day.

5. If a patient has had a Hct less than 34% or Hgb less that 11 gm/dL, verify compliance with iron supplementation, and repeat the Hct or Hgb in eight weeks or as directed by the care provider. Any Hct less than 30% or Hgb less that 10 gm/dL should be repeated in about four weeks

IX. G. Hepatitis B screen: All patients should be tested for a Hepatitis B Surface Antigen (HBsAg) at the initial visit. For hepatitis B vaccine, see section X - J.

1. If the screen is negative, record on chart.

2. If the results are positive, record in the chart and notify the care provider as soon as possible.

IX. H. Maternal Serum Quad Screen (QS) (Tetra Screen): At the initial intake visit, all patients should be given written information and offered the test to be done during the 15-20 week gestation interval. Late registrants (after 20 weeks) should be told that it is too late for the results of the Quad Screen to be valid. If the patient is unsure regarding QS, the chart should be flagged for the care provider to discuss this with the patient.

IX. I. Ultrasound (US) evaluation: An US to evaluate basic anatomy/confirm dates should be offered at 18-22 weeks gestation or as soon as possible if care is begun after 18 weeks gestation or if LMP is unknown or unsure.

1. The sonographer may schedule follow-up ultrasound studies without checking with the physician in the following circumstances: routine growth follow-up and routine anatomy screens if the initial study is less than 18 weeks or if visualization is incomplete.

IX. J. Varicella Zoster Virus (VZV) or chicken pox exposure: At the initial intake visit, all patients should be asked whether or not they have a history of chicken pox. A VZV antibody screen should be offered to patients without a prior history of chicken pox (IgG). Patients without immunity should be instructed to call as soon as possible if they are exposed to chicken pox. Varicella in pregnancy is potentially life threatening.

1. If a pregnant patient is exposed to chicken pox:

a. Prior history of chicken pox, patient is probably immune, reassure her.

b. No history of chicken pox, contact the care provider and draw VZV serology (IgG), if not previously done.

i. IgG positive, patient is immune, reassure her.

ii. IgG negative, patient is at risk. Isolate the potentially infected patient from other pregnant patients at the office or hospital. We must consider antiviral medication if maternal Varicella develops. This can be given IV or PO. Consider referral to MFM for follow-up.

c. For susceptible (non-immune) exposed patients, avoid delivery if possible during a 7-day window: 2 days prior to onset of rash and 5 days after onset of rash (mean time from exposure to rash is 15 days, range 11-21 days).

IX. K. Parvovirus B19: Patients at risk for Fifth’s disease exposure (those with children or who work with children) and without prior documented immunity may be offered screening for immunity to Parvovirus B19 (IgG). Patients exposed to Fifth’s disease and without prior documented immunity should also be tested. Obtain Parvovirus. B19 IgG and IgM.

IX. L. Human Immunodeficiency Virus (HIV) Testing: At the initial intake visit all patients should receive education and counseling about risk factors and preventing HIV infection. Testing with patient’s consent is recommended. A note should be made in the chart documenting that counseling was performed and the patient’s agreement or disagreement with the testing. HIV results should be treated according to the policies of the Network and the state of Ohio or other pertinent governmental agencies.

IX. M. Gonorrhea testing (GC): All patients should have testing done at the initial care provider visit.

1. If any result is negative, record on the chart.

2. If any result is positive, record in the chart and contact the care provider for an order for the treatment. Notify the Health Department. Patients should then have repeat testing performed 2-4 weeks after treatment and again at approximately 36 weeks gestation. An attempt should be made to contact the patient regarding the sexual partner (or partners) to have him or them treated. The nursing staff member should attempt to obtain the medication allergy history of the partner(s).

3. If the patient remains at increased risk for sexually transmitted diseases (STD’s) (i.e. women under 25 years of age and women with a new or more than one sex partner) she should also be considered for testing during the third trimester to prevent maternal and neonatal infection.

IX. N. Chlamydia testing: All patients should have testing done at the initial care provider visit.

1. If any result is negative, record on the chart.

2. If the result is indeterminate, record in the chart and testing should be repeated at the next visit.

3. If any result is positive, record in the chart and contact the care provider for an order for the treatment. Notify the Health Department. Patients should then have repeat testing performed 2-4 weeks after treatment and again at 36 weeks gestation. An attempt should be made to contact the patient regarding the sexual partner (or partners) to have him or them treated. The nursing staff member should attempt to obtain the medication allergy history of the partner(s).

4. If the patient remains at increased risk for sexually transmitted diseases (STD’s) (i.e. women under 25 years of age and women with a new or more than one sex partner) she should also be considered for testing during the third trimester to prevent maternal and neonatal infection.

IX. O. Urine Cultures: Every patient should submit a urine specimen for culture at her initial visit. If the patient has a history of PCN allergy, the lab requisitions should be marked to include sensitivity to erythromycin and clindamycin if the culture is positive for GBS.

1. If the result is negative, record in the chart.

2. If the result is positive, record on the chart and do the following:

a. The nursing staff member should call the care provider for any positive Group B strep and other bacterial colony counts 50,000 or greater for treatment orders.

b. If the colony counts are less then 50,000 and not Group B Strep, the patient has no significant symptoms, the results should be shown to the care provider on the next clinic day. Treatment may be considered for colony counts over 20,000, especially in high-risk patients (e.g. sickle cell carrier/disease, kidney stones, stents in place, or recurrent UTI’s. These results should be brought to the attention of a provider ASAP.

c. If the colony counts are less than 50,000 and the patient has significant urinary tract infection (UTI) symptoms, the care provider should be called.

3. All patients who receive treatment for positive urine cultures should have repeat clean catch urine culture to document a “test of cure.” This should be done approximately 10 days or more after completion of therapy.

4. A urine culture may be obtained for each patient complaining of significantly increased urinary frequency, dysuria, or bloody urine, or having positive nitrites or leukocytes on urine dipstick.

5. Copies of positive, treated urine culture and sensitivity reports should be sent to the hospital to facilitate treatment of patients with subsequent problems (e.g. pyelonephritis, drug reactions).

IX. P. Papanicolaou smear results: A Pap smear should be obtained for all patients at the initial care-provider visit unless deemed unnecessary by the care provider. Results should be recorded on prenatal chart.

1. If the result is normal, and the patient is low risk, follow-up post-partum.

2. If Pap smear reveals ASCUS (“atypical squamous cells of uncertain significance”), HPV typing should be done routinely by the reference laboratory.

a. If the HPV (high risk) is negative, the patient should have a Pap smear at the postpartum visit per routine.

b. If the HPV typing is positive for HPV high-risk types, the patient should be scheduled for colposcopy.

3. If Pap smear result is ASC-H, low-grade squamous intra-epithelial lesion (LGSIL), or high-grade (HGSIL) arrange for colposcopy as soon as reasonable. Follow-up will be determined according to current ACOG/ASCCP guidelines.

IX. Q. Glucose Challenge Test (GCT)

1. The GCT is non-fasting 50 grams oral glucose load, administered at 24-28 weeks, without regard to time of day, to all pregnant women who have not previously been identified as glucose intolerant (diabetic). A serum glucose is drawn 1 hour after ingestion of the glucose load. A value of 135 or greater indicates the need for 3 hour tolerance test (GTT). If the GCT is at or above 200, the patient is diagnosed as having gestational diabetes.

2. If a patient initiates care at 24-28 weeks or beyond, a GCT is suggested as soon as possible, i.e. at the initial intake visit (provided that the patient is not glucose intolerant).

3. Any patient with a history of glucose intolerance (not currently known to be diabetic, or receiving treatment for diabetes) should have an early GCT. This includes patients who have a history of gestational diabetes, hypoglycemia, hyperglycemia, LGA infant (over 4000 grams or 8# 13.5 oz), stillbirth, or infant with neonatal hypoglycemia, patients with obesity and patients who have a first-degree relative with diabetes. Other patients may also have an early GCT at the discretion of the care provider depending upon their risk factors. If the GCT is normal, a repeat GCT should be performed at 24-28 weeks, but no sooner than 6 weeks after initial test. If the early GCT is abnormal, but the GTT is normal, a repeat GTT should be performed at 24-28 weeks, but no sooner than 4 weeks after the previous test.

IX. R. Interpretation of the GTT (100 gm oral glucose load given to a fasting patient preceded by 72 hours of unrestricted diet and activity) results are represented by the upper limits of normal venous plasma in mg/dL:

Carpenter/Coustan

Fasting 95

1 hour 180

2 hour 155

3 hour 140

1. If the GTT is normal, continue routine prenatal care.

2. If there is one value abnormal, consider diabetic diet instruction and watch for large-for-gestational-age fetus (LGA). Repeat GTT may be ordered by the care provider.

3. If there are two or more abnormal values, this confirms the diagnosis of diabetes mellitus in pregnancy (may be gestational diabetes mellitus or pregestational diabetes mellitus)

4. If the fasting blood sugar (FBS) value is >105 mg/dL, and at least one of the other values is abnormal, the patient has overt diabetes mellitus (usually requires medication). For management see section XI - B.

IX. S. Group B Strep (GBS) screening and treatment: All patients should have a GBS culture obtained from the lower vagina and rectum at approximately 35-37 weeks gestation unless she has a previously identified risk factor as outlined below. Colonization during a previous pregnancy is not an indication for intrapartum antibiotic prophylaxis. Screening to detect GBS status in each pregnancy will determine the need for IAP (intrapartum antibiotic prophylaxis) in that pregnancy.

1. Results should be communicated as soon as possible to the labor and delivery unit, so the patient’s chart may be marked accordingly.

2. Patients with the following risk factors will be offered treatment in labor or after the amniotic membranes are ruptured (see IX.S.6.). These patients do not require further screening during pregnancy.

a. GBS bacteruria during the current pregnancy.

b. Positive GBS screen.

a. Previous infant with GBS disease.

3. Patients who did not have the above outlined risk factors and whose vaginal/rectal swab is positive for GBS are at risk for GBS in the neonate and should be offered treatment after amniotic membranes are ruptured or during labor (see IX.S.6.).

4. If the GBS status is not known at the onset of labor, intrapartum antibiotic prophylaxis (IAP) should be administered to women with any of the following risk factors:

a. Amniotic membranes ruptured greater than 18 hours.

b. Intrapartum fever of 100.4 F or greater.

c. Gestation < 37 weeks.

5. Women with known negative results from vaginal and rectal GBS screening cultures within 5 weeks of delivery do not require IAP against GBS disease even if any of the intrapartum risk factors develops. This does not eliminate the need for evaluation and possible treatment of intrapartum fevers.

6. Treatment protocol for patients with above identified risk factors:

a. Penicillin (PCN) G, 5 million units IV load, followed by 2.5 million units every 4 hours until delivery. This is the preferred treatment. (Alternatively, Ampicillin 2 gm IV load, followed by 1 gm IV every 4 hours until delivery may be given.)

b. During prenatal care, any history of PCN allergy should be assessed to determine whether a patient is at high risk for anaphylaxis, i.e. has a history of immediate hyper-sensitivity reaction to PCN (e.g. anaphylaxis, angioedema, or urticaria) or other conditions that would make anaphylaxis more dangerous (e.g. patients with asthma or who are on beta blockers). The patient’s lab results should be marked for erythromycin and clindamycin susceptibility testing.

i. Women who are not at high risk for anaphylaxis should be given cefazolin 2 g IV initial dose, then 1 g IV q 8h until delivery.

ii. For women at high risk for anaphylaxis, clindamycin and erythromycin susceptibility testing, if available, should be performed on isolates obtained during GBS prenatal carriage screening.

a’. Women with clindamycin and erythromycin susceptible isolates should be given either clindamycin 900 mg IV q 8h until delivery; or erythromycin 500 mg IV q6h until delivery.

b’. If susceptibility testing is not possible, susceptibility results are not known, or isolates are resistant to erythromycin and clindamycin, the following regimen can be used for women with immediate PCN hypersensitivity: vancomycin, 1g IV q 12h until delivery.

7. Women with threatened preterm labor ( 15%, obtain serial ultrasound every two weeks.

c. If the EFW’s reveal a difference of >20%, obtain serial ultrasounds every two weeks and a BPP every week.

d. If the EFW’s show a discordance of >25%, consider patient transfer/referral for high risk management.

4. Delivery of multifetal pregnancies:

a. Consideration should be given to having an anesthetist or anesthesiologist, surgical team, ultrasound, and an epidural during the active phase of labor.

b. Ideally a second Obstetrician and one or more pediatricians should be present for delivery.

XI. D. Preterm Labor and Delivery Management. The following policy was generated via a consensus of all practicing obstetricians and pediatricians at BCGH at the Perinatal Conference on 06/16/94 and subsequent amendments.

1. If delivery is anticipated or necessary before 36 weeks gestation, the patient should be considered for transferal to a tertiary care center.

a. If preterm labor is treated and treatment is successful, consideration should be made to continue treatment until at least 36 weeks gestation. The patient should be followed by growth ultrasounds every 4-6 weeks and serial cervical exams and/or ultrasound for cervical length.

b. If preterm delivery before 36 weeks gestation is unavoidable, the pediatrician on-call should be notified and further neonatal disposition should be in his/her purview.

c. Fetal fibronectin may be used

XI E. VBAC versus repeat cesarean delivery

1. Early in the pregnancy, operative report should be obtained (if not already in the chart) and reviewed. The type of incision(s) and reason(s) for operative delivery should be recorded on the prenatal record. The patient should be given VBAC information. The patient will then be told that BCGH and SOWH no longer offer VBAC and she may be allowed to transfer.

2. At least one physician should review with the patient the history and risks versus benefits of repeat cesarean delivery

3. At the pre-term labor class (PTLC), the patient’s plans should be reviewed and the VBAC consent reviewed and signed. The nursing staff member should ask and record if there is any patient preference for physician or date.

4. At the pre-operative visit the operating physician should review RBA (risks, benefits, and alternatives) and plan with the patient and document this discussion on the chart.

XI. F. Advanced maternal age (AMA).

1. The nurse and the physician should discuss prenatal diagnosis (PND) including multiple maternal serum markers, targeted ultrasound, nuchal lucency, chorionic villus sampling (CVS) and amniocentesis with the patient and document such discussion and the patient’s plans or declination.

2. For AMA patients, US and then physician counseling should be scheduled within 5-8 days of +UPT or nursing interview. The US is to document dates and viability of the pregnancy. At the physician counseling visit, there will be an in-depth discussion regarding risks and possible prenatal diagnosis as appropriate to gestational age.

3. For AMA patients in the first trimester, integrated testing (first trimester nuchal lucency, free beta HCG and PAPP-A followed by second trimester AFP or QS and targeted ultrasound) will be offered. The ideal gestation for first-trimester screening is determined by the referral center, generally 10-13 weeks.

4. For AMA patients who present beyond the gestation for first-trimester screening, amniocentesis and/or QS and targeted US will be offered.

5. Biweekly NST’s and weekly AFI’s starting at 34 weeks gestation. Antepartum testing should begin at 28 weeks gestation in the presence of IUGR or other associated condition.

XI. G. Abnormal maternal serum markers (e.g. MSAFP or multiple marker screen).

1. Initial interpretation of the marker screen must be made with accurate dating of the pregnancy. This is generally done with ultrasound dating.

2. If dates are wrong, have the lab recalculate the screen.

3. If pregnancy dating shows that the test was drawn too soon to be valid, it should be redrawn at the appropriate gestation.

4. If the screen is confirmed to be abnormal, the patient should be counseled and offered referral for targeted ultrasound and/or genetic counseling and/or amniocentesis.

5. If the abnormal screen is still unexplained, biweekly NST’s and weekly AFI’s should start at 34 weeks gestation. Periodic growth ultrasounds should be considered. Antepartum testing should begin at 28 weeks gestation in the presence of IUGR or other associated condition

XI. H. Hypertension in pregnancy. All blood pressures should be taken with the patient in the sitting position and after at least 10 minutes of rest. The appropriate size cuff should be used and documented if large cuff needed and used.

1. Definitions:

a. Chronic hypertension

Mild – Systolic BP at or above 140 mmHg / Diastolic at or above 90.

Severe – Systolic BP at or above 160 mmHg / Diastolic at or above 110 or MAP above 125.

Use of antihypertensive medication before pregnancy.

Onset of hypertension before the 20th week of pregnancy.

Persistence of hypertension beyond 12 weeks postpartum.

i. Low-risk chronic hypertension - Mild hypertension in the absence of complicating factors.

ii. High-risk chronic hypertension:

Any severe hypertension

Mild hypertension in association with any of the following:

Hypertension for > 4 years

Maternal age > 40 years

Renal disease

Cardiomyopathy

Coarctation of the aorta

Retinopathy

Diabetes (classes B to F)

Collagen vascular disease

Antiphospholipid antibody syndrome with previous perinatal loss

Previous severe preeclampsia with perinatal death

b. Gestational hypertension: Hypertension in pregnancy which does not meet criteria for either chronic hypertension or preeclampsia.

i. Mild – systolic, 140-160 mmHg or diastolic, 90-110.

ii. Severe – systolic > 160 or diastolic > 110.

c. Gestational proteinuria.

i. Mild – 1+ or more on dipstick (or 300 mg/24h) and < 5 gm/24h.

ii. Severe – 5 gm/24h or more.

XI. H. 1. d. Preeclampsia – onset after 20 weeks gestation (except if molar pregnancy).

i. Mild – mild hypertension and mild proteinuria.

ii. Severe:

Severe hypertension and proteinuria.

Mild hypertension and severe proteinuria (5 gm/24h or more).

Persistently severe cerebral symptoms.

Thrombocytopenia.

Oliguria of less than 500 ml/24h.

Pulmonary edema or cyanosis.

Epigastric or right upper quadrant pain.

Impaired liver function.

Fetal growth restriction.

e. Eclampsia – new onset grand mal seizures in a woman with preeclampsia.

f. HELLP syndrome – must include all of the following

Hemolysis.

Elevated liver enzymes.

Low platelets.

g. Superimposed preeclampsia – Chronic hypertension with new-onset or worsening proteinuria. May also include women with chronic hypertension who develop headache, scotomata, or epigastric pain.

h. MAP (mean arterial pressure) calculated as (systolic BP plus 2 times diastolic BP) divided by 3.

2. Evaluation of hypertension in pregnancy

a. Baseline 24 hour urine for creatinine clearance and total protein and renal panel. Repeat each trimester or more often depending upon clinical condition.

b. Home BP monitoring is generally not indicated

XI. H. 3. Management of low-risk chronic hypertension

a. Generally no antihypertensive medications, but may be consider if MAP > 105. Oral and possibly even intravenous medication may be needed if MAP exceeds 125.

b. Serial ultrasounds every 4 weeks beginning at 28 to 32 weeks to monitor fetal growth.

c. If no treatment is indicated, bi-weekly NST’s and weekly AFI’s beginning at about 34 weeks gestation.

d. If treatment is required, antepartum testing should begin at 28 weeks gestation in the presence of IUGR or other associated condition. MFM consult may be considered.

4. Management of high-risk chronic hypertension:

a. Consider hospitalization to facilitate complete cardiovascular and renal evaluation. Studies may include EKG, echocardiogram, renal profile (BMP), ophthalmology exam, renal ultrasound, and 24 hour urine as noted above.

b. Initiate medical therapy as needed, such as labetalol (100 mg q8h), nifedipine (short-acting – 10 mg q8h or long acting – 30 mg/d), or methyldopa (250 mg bid).

c. Serial ultrasounds every 4 weeks beginning at 28 to 32 weeks to monitor fetal growth.

d. Home blood pressure monitoring is generally not indicated.

e. Bi-weekly NST and weekly AFI to begin at about 28 weeks gestation.

XI. I. Post-dates pregnancy.

Twice weekly NST’s and weekly AFI’s should begin one to four days after EDC.

XI. J. Asthma in pregnancy. If the patient has a history of asthma, elicit history of any medications.

1. If the patient has a history of no treatment in at least a year, obtain peak flow.

a. If 300 or higher, follow as needed for symptoms.

b. If less than 300 see XI. J. 2.

2. If the peak flow is < 300 or if the patient is on maintenance medications, the patient should do peak flow readings twice a day and bring those records to the office with each visit.

a. If the peak flow remains in the green zone, maintain routine follow-up.

b. If the peak flow is in/changes into in the red or yellow zone, the patient is considered high-risk and referral to IM or Pulmonologist should be considered.

XI. K. Anticoagulation and VTE (venous thrombo-embolic disorders) in pregnancy

1. Therapeutic anticoagulation

a. Patient categories:

Patients with history of DVT / PE in current pregnancy.

Patients with history of recurrent DVT/PE.

Patients who are homozygous for factor V (Leiden), homozygous G20210A, or ATP III deficiency (even if no prior DVT/PE).

Patients with Antiphospholipid syndrome and h/o DVT/PE.

Some patients with Antiphospholipid syndrome and no DVT/PE.

b. Heparin dosage: Over 10,000 Units bid-tid to maintain aPTT of 1.5-2.5 x normal. This should be drawn 6 hours after previous dose of heparin.

c. Heparin monitoring: CBC with platelet counts on days 5, 7, 9, and 14 of Heparin therapy. Alarm point is platelet count < 100,000 or decrease by 50%.

d. Intrapartum care: IOL (induction of labor) @ term with a favorable cervix.

Hold heparin at least 12 hours before IOL.

OR Switch to IV heparin. (half-life one hour, whereas SQ is three hours).

Epidural is safe if the aPTT is normal.

e. Postpartum: Restart heparin 6 hours after vaginal delivery and 8 hours after C/S.

If using warfarin, start it the first postpartum day and continue heparin about 5 days or until INR is 2.0-3.0.

Continue anticoagulation until 6 weeks postpartum, but if the DVT/PE was during the index pregnancy, then continue until three months postpartum (6-12 weeks if DVT only).

f. Lovenox as alternative to heparin:

Weight based dosage bid.

No need to follow platelets.

No epidural for 24 hours after last dose.

May be changed to heparin at about 36 weeks using guidelines in b and c above.

g. Additional notes:

If DVT during the current pregnancy, therapeutic for 4-6 months, then prophylactic until delivery and for 6-12 weeks postpartum.

If PE during the current pregnancy, therapeutic for 6 months, then prophylactic until delivery and for three months postpartum.

Give calcium and vitamin D supplementation to reduce heparin-induced bone loss.

XI. K. 2. Prophylactic anticoagulation

a. Patient categories:

Patients with DVT/PE in previous pregnancy.

Patients with previous DVT/PE outside the puerperium.

Some patients with Antiphospholipid syndrome and no DVT/PE.

b. Heparin dosage: 5,000 units SQ bid in the first trimester, 7,500 units SQ bid in the second trimester, and 10,000 units SQ bid in the third trimester.

c. Heparin monitoring: CBC with platelet count on days 5, 7, 9, and 14 of Heparin therapy. Alarm point is platelet count < 100,000 or decrease by 50%.

d. Intrapartum care: IOL (induction of labor) @ term with a favorable cervix.

Hold heparin at least 12 hours before IOL.

Epidural is safe if the aPTT is normal.

e. Postpartum: Restart heparin 6 hours after vaginal delivery and 8 hours after C/S.

If using coumadin, start it the first postpartum day and continue heparin until INR is 2.0-3.0 (about 5 days).

Continue anticoagulation until 6 weeks postpartum, but if the DVT/PE was during the index pregnancy, see above.

f. Lovenox: 40 mg SQ daily.

XI. L. Thyroid disease in pregnancy.

1. Patients with a history of hypothyroidism should have TSH and thyroid stimulating antibody (TSA or TSI) drawn at the initial visit. TSA or TSI can cross the placenta and lead to fetal thyroid disease.

a. If the hypothyroidism is an inactive problem such as a history, but no active treatment and normal TSH, the TSH and thyroid stimulating antibody (TSA or TSI) should be repeated each trimester.

b. If the hypothyroidism is an active problem, such as abnormal TSH or on thyroid replacement, the TSH should be tested approximately every four to six weeks and medication adjustments made as needed.

i. Antenatal testing should be begun at 34 weeks if the patient is not euthyroid.

2. If the patient reports a history of hyperthyroidism, TSH, thyroid stimulating antibody (TSA or TSI), and free T4 should be drawn at the initial visit.

a. If the patient is now hypothyroid, see above.

b. If the patient is euthyroid, TSH and free T4 should be drawn each trimester.

c. If the patient is still hyperthyroid, she should probably be jointly managed with an internist and/or endocrinologist and/or MFM.

i. TSH and free T4 drawn approximately every four weeks.

ii. Antenatal testing should be begun at 34 weeks if the patient is not euthyroid.

XI. M. Viral infections in pregnancy

1. Patients suspected of exposure and/or infection of varicella or Parvovirus B19 before 20 weeks gestation must have at least one set of virus-specific IgG and IgM levels obtained.

2. For varicella exposure in a non-immune patient, please see section IX. J. Likewise for parvovirus exposure in a non-immune patient see section IX. K.

3. Patients with documented infection of varicella or parvovirus B19 in pregnancy should be referred for MFM consultation, etc., and followed according to his/her recommendations.

4. For other viral exposures/infections, contact MFM.

5. See appendix 16.

XI. N. Patients at particular risk of PTL & D.

1. One group of these patients is those with history of or treatment in the current pregnancy for incompetent cervix. (HR PTL – high risk)

a. These patients should be followed with US for cervical length approximately every two to four weeks (or weekly if recommended by MFM) from about 14-16 to about 32-34 weeks.

b. Serial cervical exams should also be considered.

c. Cervical length of 2.5 cm or less is abnormal and these patients should begin bed rest and should be considered for antenatal steroids and possibly other treatment or testing.

d. Fetal fibronectin may be used.

2. A second group may be those who have had a cervical conization or LEEP procedure. Records review and previous OB history may eliminate this concern. (MR PTL - moderate risk)

a. A baseline cervical length (CL) should be done before 20 weeks gestation if possible.

b. Repeat CL may be done as clinical situation dictates.

c. Cervical length of 2.5 cm or less is abnormal and these patients should begin bed rest and should be considered for antenatal steroids and possibly other treatment or testing.

d. Fetal fibronectin may be used.

XI. O. Patients with suspected IUGR

1. Definition: US EFW 10th percentile, follow growth every 3-4 weeks.

XI. P. Patients with 2 vessel umbilical cord

1. Arrange Level II (targeted) US form confirmation of 2-vessel cord and checking for other anomalies.

2. Begin biweekly NST’s and weekly AFI’s at 34 weeks gestation.

3. US for growth approximately every 4-6 weeks.

XI. Q. Miscellaneous high-risk pregnancies (Not mentioned above)

1. Arrange for MFM, GC, Level II, amniocentesis, etc as appropriate.

2. Begin biweekly NST’s and weekly AFI’s at 34 weeks gestation.

3. US for growth approximately every 4-6 weeks.

4. Serial laboratory testing as appropriate.

Postpartum visits

XII. A. Postpartum Home Visits: Prior to discharge from the hospital, all new mothers will be offered a home visit by one of the staff nurses or contracted outside services. If accepted, the visit should take place 5-10 days after discharge. The purpose of the visit includes but is not limited to the following parameters:

1. Assessments:

a. The physical environment and needs of the mother and infant.

b. Knowledge pertaining to self and infant care.

c. Mother and infant bonding.

d. Mother’s emotional state.

e. Compliance and understanding of any medical instructions and/or treatments.

2. Education/Referrals:

a. Teach the mother and other care-givers about mother and infant care.

b. Provide applicable educational packets and written materials.

c. Make appropriate referrals for routine care or for identified problems.

XII. B. Postpartum Office Visits: The SOWH-Georgetown office will be notified of all deliveries. This information will be communicated to appropriate providers, offices, payers and medical records entities. The patient’s primary site will arrange postpartum appointments for patients and notify BCGH personnel of the appointments. Unless otherwise requested by the patient’s care provider, patients who had routine vaginal deliveries should be given a 6-week appointment for a postpartum assessment, preferably with the delivering care provider. Patients who had operative procedures (C/S or TL) should be given appointments for a two-week postoperative evaluation in addition to a 6-week postpartum evaluation. Prenatal charts should be reviewed for various conditions and follow-up arranged as indicated. Examples are Pap smear, colposcopy and glucose testing.

1. Follow-up of gestational diabetes – see Section XI. A. 8.

2. Patients with cervical pathology should have a Pap smear or colposcopy arranged as indicated by the prenatal chart.

3. Postpartum assessment visit: All patients should have the following information obtained and documented in the charts:

a. Weight.

b. Blood pressure.

c. Hemoglobin.

d. First day of last menstrual period (LMP).

e. Method of birth control.

f. Sexual activity since delivery (presence and/or problems).

g. Infant information:

i. Cross-check the delivery summary for accuracy of birth-date, weight, Apgar’s, and infant’s gender (infants’ genders, etc.)

ii. Infant(s) name(s).

iii. Bottle and/or breast feeding.

iv. WIC participation.

v. Infant’s age at first visit to primary care provider.

h. Physical assessment should include a breast, pelvic, and incision examination as appropriate.

i. A Pap smear should be done unless alternate evaluation is indicated.

j. Evaluation for post-partum depression and appropriate referrals.

k. Review the OB Problem list and add to the general chart problem list as appropriate.

l. Update the general problem list for Gyn issues.

4. Selected patients should be followed sooner than six weeks (e.g. HTN).

XIII. Prenatal Program

XIII. A. Certain patients at either site may be designated as patients of the Prenatal Program as necessary for statistical purposes. Testing, counseling, education and follow-up criteria may be slightly different for those patients.

APPENDIX 1. CLASSIFICATION OF DIABETES MELLITUS (WHITE’S CLASSIFICATION)

|White’s Class |Age at onset | |Duration |Complications |

|A |Any | |Any |No vascular disease |

|A1 | |Diet controlled | | |

|A2 | |Medication | | |

|B |20 yr or above | |< 10 years |No vascular disease |

|C |10-19 years |Or |10-19 years |No vascular disease |

|D |< 10 yo |Or |20 years or more |Background retinopathy only or hypertension |

|E | | | |Calcification of pelvic arteries (no longer used) |

|F | | | |Nephropathy (>500 mg/day proteinuria) |

|H | | | |Arteriosclerotic heart disease |

|R | | | |Proliferative retinopathy or vitreous hemorrhage |

|T | | | |After renal transplantation |

APPENDIX 2 - BMI CHART

APPENDIX 3 -- MANAGEMENT OF GESTATIONAL DIABETES - DIET CONTROLLED (A1)

( Diet instruction ( date and initial) and one-week follow-up as indicated ( date and initial)

Calories suggested ( date and initial).

Diabetic supplies including the following: home glucose monitor machine, glucose strips, alcohol swabs, lancets and sharps container.

GDM A1 patients should start with qid blood sugars. (FBS and 2hr PP)

( Evaluate pt BS values weekly and make consideration to reduce the frequency of testing. Goal of FBS 60-90 mg/dL; Goal of 2hr PP ................
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