UBC Objectives: Maternity Care, Priority Topic: Gender Specific Issues & Priority Topic: Pregnancy1/12/2018 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 2: As part of caring for women with health concerns, assess the possible contribution of domestic violence. Skill: Clinical Reasoning Phase: Hypothesis generation, History Pregnancy Key Feature 4a: In a patient presenting with a confirmed pregnancy for the first encounter: Assess maternal risk factors (medical and social). Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, History Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Establish accurate dates. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Advise the patient about ongoing care. Skill: Clinical Reasoning Phase: Treatment So my 42 year old confirmed primp (confirmed with the handy dandy urine beta-hCG dipstick in office) wanted to go ahead with growing this baby. What next? I certainly didn't have a half hour available to go through a complete first prenatal visit at this time, but knowing well that there was now a developing embryo (or fetus) inside of this patient - one that may be exposed to risk factors that could compromise healthy development - performing an assessment of the most important risk factors was indicated now to prevent potential harm before the more comprehensive first prenatal visit. Information I gather to assess and mitigate serious and common risk includes history of the current pregnancy, past medical history, medication and substance review, and social history, detailed below.
After the above historical information is gathered and you have provided guidance to reduce risk as indicated, you want to establish the EDD and gestational age (GA) as accurately as possible, which in this day and age is by dating ultrasound, to be done straight away (sonography is most accurate at establishing EDD and GA if obtained between 7 and 10 weeks of gestation, although it continues to remain more accurate to establish EDD than using LMP in a woman with regular menstrual cycles until 22 weeks of gestation (UpToDate, 2017). This is important in planning the rest of the prenatal care throughout pregnancy as many interventions need to be timed according to gestational age, and accurate establishment of dates reduces morbidity and mortality for the mom and the infant. The mom can then be advised to return for her first prenatal appointment once the results of the dating ultrasound are back. She will continue to be seen monthly after the first prenatal appointment, eventually returning for followup every two weeks (generally in the second trimester) and afterward, every week (in the third trimester). Every visit should include some routine and some unique assessments that depend on the gestational age at the time of assessment. It is always important to screen for complications and provide anticipatory guidance including what symptoms should prompt the women to seek urgent medical attention. (Prenatal care recommendations vary regionally. For BC, see Perinatal Services BC, including this prenatal checklist for primary care providers that includes a list of the screening maneuvers and options for genetic testing to offer/provide to women according to gestational age.) If you are not providing obstetrical care, then the patient will need to be referred to an obstetrical care provider. The rest of her prenatal care then can either be with the obstetrical care provider or may consist of a dual relationship (for example, a primary care physician who does not deliver babies may assume the majority of care and only arrange transfer of routine prenatal visits after 20 weeks of gestation or so). *Note that while pregnancy is a risk factor for domestic abuse, many women (and men) who are not pregnant live in abusive circumstances, so it is important to screen for this opportunistically when gathering a social history.
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