Begin to establish relationship with woman

Comprehensive health history: primary care, medical and surgical, family history, family and personal genetic history for both partners, menstrual, obstetric and gyn histories, sexual history, history of contraceptive use and safety. 

Depression screening and intimate partner violence screeening, immunization screening

Risk history- substance abuse, environmental exposures, other potential harms

Also: symptoms of pregnancy, women's concerns, acceptance of pregnancy 

Topics- stopping all harmful substances (tobacco, alcohol, drugs, teratogens such as medications and occupational exposures)

Seatbelt use, travel, dental care, employment or education plans, appropriate exercise and activity, hot tub/sauna use, nutrition, vaccines, over-the-counter meds.

Anticipatory guidance: fetal growth, common discomforts, pregnancy related changes with related appropriate treatments, mood changes. 

Orientation to midwifery care, schedule of visits, when to call midwife, food safety, options for genetic/chromosomal anomaly screening, toxoplasmosis, sexuality, myths/superstitions, breast support, establishing EDD, weight gain guidelines, pica, perineal and vaginal care 

Height and weight

Vital signs

Complete physical with pelvic exam and clinical pelvimetry

Assessent of uterine size/gestational age/compare with LMP

Labs: Review results for initial visit (blood type, antibody screen, RH. hbg/hct or CBC to include PLC, HepBsAg, chlamydia with or without gonorrhea, syphilis (rpr/vdrl), rubella titer, pap, UA and culture, offer cystic fibrosis testing-- possibly lead level, hemoglobin electrophoresis, diabetes screening, free beta hCG).

?nuchal tranlucency, PAPP-A, free beta hCG, CVS

Physical: weight, blood pressure, fhr with doppler after 8 weeks, assess uterine size and change from previous visit

Screenings: Interval history, risk assessment, woman's concerns. Review medications, any symptoms, travel... 

Labs: Follow-up on previous results, amniocentesis after 15 weeks if indicated, Quad screening or multiple markers (15-20weeks), Anatomy US (18-20weeks). 

Physical: weight, blood pressure, Abdominal exam (fundus halfway to umbilicus at 16 weeks, 2 fungerbreaths below umbilicus at 18 weeks, immediately below umbilicus at 20 weeks, over 20 weeks fundaus should equal weeks gestation +/- 2-3cm). FHR with doppler.

Screenings: Risk assessment, woman's symptoms and concerns need to add specifics re:risk assesment for each trimester

Labs: Gest diabetes screening (24-28weeks), hbg/hct 28weeks, ?repeat antibody screen if Rh negative- prepare to give Rhogam. Follow up on prev. results. ? repeat STI testing as per state law or history. Group B test at 35-37weeks unless unnessary based on history). 

Physical: Weight, blood pressure, OB Abd. exam (fundal height), fetal lie and presentation, Leopolds 35-40 weeks for fetal lie, presentation, position, variety, and EFW. FHR. SVE for bishop score if over 40 weeks. AFI, nonstress test, BPP over 40weeks if indicated

Screenings: Risk, woman's concerns. Fetal kick counts if high-risk at 28 weeks/start at 35 weeks for all/ Depression screen, intimate partner violence screen. 

increased energy

Improved sleep

help with weight control

increased strength and endurance

greater sense of wellbeing

fewer back aches

decreased risk of pre-e

possible decreased risk for gest diabetes

Contradictary evidence re: exercise and vag vs csection and exercise effect on prenatal weight gain

Anticipatory Guidence:Exercise in Pregnancy

Women may start or maintain exercise programs at moderate or vigorous intensities in preg without adverse fetal effects. Use talk test to determine intensityp>

Women who are sedentary will benefit from adding exercise to their routines. Advising an increase in activity via daily walking, pregnancy exercise class etc is part of optimal prenatal care. Pregnancy can be a major motivator to make positive health changes 

Women will feel short of breath sooner in pregnancy- due to progesterone effects. Reassure that this is normal 

Advise warm up and cool down periods with each exercise session-- musculoskeletal changes may predipose women to injury

N/V- antihistamines (Benadryl, doxylamine (unisom), doxylamine/pyridoxine (Diclegis). Phenothiazines (compazine, phenergan). Benzamides (Metoclopramide- Reglan), Serotonin agonists (Ondansetron). 

Acid reflux- antacids- Aluminum/mag hydroxide (rolaids, maalox) and calcium carb (tums). These agents are preferred.

Mucosal protectants- Sucralfate (Carafate)

H2 antagonists (Cimetidine (tagamet), famotidine (pepcid), nizatidine (axid), ranitidine (zantac). Zantac is preferred agent

PPIs-esomeprazole (nexium), omeprazole (prilosec, lansoprazole (prevacid), pantaprazole (protonix), rabeprazole (aciphex): increased risk of hypospadias has been reported

Diarrhea: Antidiarrheals: Alosetron (lotronex), diphenoxylate/atropine (lomotil), loperamide (imodium). Alosetron only for IBS-related diarrhea who have failed conventional treatment

Constipation: osmotic laxatives: lactulose (Enulose), Mag citrate (Citroma), PEG (MiraLax)

Stimulant laxatives- Bisacodyl (Correctol), Senna-- for short term use only for these agents

Stool softener- Docusate- Colace (short term also)

MEDS to AVOID in pregnancy: Caution esp in first trimester when organogenesis occurs

From Pharmacolgy for Women’s Health 1047-1048

Warfarin

Isotretinion

Valporic acid

Tetracycline

Lithium

DES

Biazin

Erythromycin estolate (Ilosom)

Ergot alkaloids (abortifacients)

Aminoglycosides

Amiodarone

Androgenis steroids

ACE Inhibitors

ARBs

Antithyroid drugs

SSRI- Paxil

Statins

Benzodiazepines

Tegretol

Aspirin- low doses (81mg/daily) appear to be ok- higher doses may cause prolonged gestation, prolonged labor, bleeding probs in neonate, IUGR, perinatal mortality

Iodine

Lindane (Kwell)

Methotrexate

Misoprostol (unless used to induce labor/ripen cervix as off label use)

Mifepristone

Dilantin

Cyclophosphamide

NSAIDs- AVOID ESP first and third trimesters

(increase risk of miscarriage, also risk of premature closure of ductus arteriosus esp third trimester, fetal renal toxicity, inhibition of labor)

Magnesium trisilicate (gaviscon): increase risk of fetal nephrolithiasis.

Sodium bicarb (Neut): metabolic acidosis and fluid overload

Bismuth subsalicylate (peptobismol, kaopectate): salicylate moiety can cause increased perinatal mortality

Thalidomide

Valproic acid

Vitamin A- over 8000IU/day. deficiencies may also cause malformations

Theorectical basis: based on feminist theory, midwifery model of care, social support theory, adult learnign theory and social cognitive theory

Comprehensive care in a group setting. melds midwifery philosophy of care with empowering women

How it works: takes advantage of fact that women in preg are open to learning and want to share concerns, reactions and experiences. involves self-care activities, faciliator leadership style, includes overall plan and core content each session, stables group composition, provides social opportunity, ongoing eval of outcomes. 10 2-hour sessions, similar due dates. includes education and prenatal care. includes focused physical assessment by provider, group size 8-12 women, meet in a circle. family involvement optional. meet monthly than every 2 weeks and then weekly as per traditional prenatal schedule

How this empowers women: shift in relationship so that women take on the decision-making power re:topics discussed and for self-care. individual contribution of each memeber is valued. self-care activities (wt, bp, self-assessment of learning needs). consumer as equal partner. Woman as expert on her own needs

Benefits: increased attendance at care, increased preg-related knowledge and increase satisfaction with care. builds community, increased birth weights for infants

Limitatons: resistance to change, need to recruit women, changes scheduling for careproviders/women

Tylenol, opiates, flexeril

analgesic creams- mentholated or capsacin

Allergies and colds: frist generation antihistamines: Chlorpheniramine (Chlortrimeton) first choice; also benadryl, triprolidine, doxylamine. Zyrtec most studied second generation. 

Oral decongestants: pseudoephedrine ok after first trimester (increase risk of gastroschisis in first tri)

Nasal decongestants: Afrin, phenylephrine, xylometazoline all ok. Saline nasal spray ok

Nasal corticosteriods- budesomide, becamethasome, and intranasal cromolyn sodium 

Antibiotics: PCN, EES, Augmentin, amox, cefizol, ceftin. Zithromax, macrobid, rocephine, third generation cephalosporin + macrolide for pneumonia

Antifungals- topical for yeast=butoconazol, clotrimazole, miconazole, terconazole, nystatin, Avoid diflucan in firt trimester. Metronidazole (flagyl) ok. 

Dental care: lidocaine and xylocaine ok, xrays ok (would need 5000 dental xrays to exceed safe radiation dose), PCN, augmentin, amox, cleocin all ok.