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Maternity Care Guidlines

from "Maternity Care Calendar" by Dr. Stefan Grzybbowski and Dr. Colleen Kirkham

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	<p><span style="font-size:16; font-weight:bold;">Maternity Care Guidelines (2003)</span>  <span style="font-size:12; font-weight:bold;">Name:<input type="text" name="PatientName" id="PatientName"  class="noborder" style="font-size:12; font-weight:bold; width:200px;" oscarDB=patient_name>DOB:<input type="text" name="DOB" id="DOB" class="noborder" style="font-size:12; font-weight:bold; width: 200px;"oscarDB=DOB></span></p>
	<p class="caption">(adapted, with permission, from "Maternity Care Calendar" by Dr. Stefan Grzybbowski and Dr. Colleen Kirkham (<a href="wwww.maternitycarecalendar.com" target="_new"> www.maternitycarecalendar.com</a>)</p>


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	<td class="titlebar">CLINICAL</td><td class="titlebar">INVESTIGATION</td><td class="titlebar">ISSUES FOR DISCUSSION</td>
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		<b>PRECONCEPTION VISIT:</b>
		<p><input type="checkbox" name="FolicAcid">recommend folic acid 0.4mg-0.8mg/d for primary prevention or 4mg/day if previous pregnancy with a neural tube defect (ideally 1 month before conception through first trimester)</p>
		<p><input type="checkbox" name="Herpes">ask about a history of genital/orolabial herpes in woman and partner
			<ul>
				<li>women with no history of HSV should be counselled about avoiding exposure near term (if partner is HSV-positive:advise abstinence, condom use and/or antiviral suppression of partner.  Avoidance of oral genital contact if partner has orolabial herpes)</li>
				<li>women with recurrent HSV should be counselled about the option of acyclovir at term, the role of C/S and avoiding transmission to the newborn postpartum.</li>
			</ul>
		</p>
		<p><input type="checkbox" name="ChickenPox">ask about a prior infection with chickenpox (if no prior history, check immunity with varicella zoster IgG)
			<ul>
				<li>if not immune and if not pregnant offer vaccine (delay conception 1 month after).  If pregnant: counsel re avoiding exposure and reporting exposures immediately, vaccinate postpartum</li>
			</ul>
		</p>
		<b>DIAGNOSIS:</b>
		<p><input type="checkbox" name="PrenatlDiagnosis">consider early discussion/referral for prenatal diagnosis if &ge; 35 years at EDD or risk factors</p>
		<p><input type="checkbox" name="EarlyUS">consider early ultrasound (bleeding, uncertain dates, required for CVS)</p>
		<b>FIRST ANTENATAL VISIT:</b>
		<p><input type="checkbox" name="History">complete history on prenatal form</p>
		<p><input type="checkbox" name="DomesticViolence">screen for domestic violence:
			<ul>
				<li>"Do you ever feel unsafe at home?"</li>
				<li>"Have you been hit, kicked, punched or otherwise hurt by someone within the past year?"</li>
			</ul>
		</p>
		<p><input type="checkbox" name="Physical">physical exam</p>
		<b>EARLY FOLLOW-UP VISIT:</b>
		<p><input type="checkbox" name="Prenatal4to6">regular prenatal visits every 4-6 weeks</p>
		<p><input type="checkbox" name="FHR">earliest auscultation of fetal heart with doppler (10-12 weeks)</p>
		<p><input type="checkbox" name="RhNeg">unsensitized Rh negative women should receive a dose of D Ig within 72 hours after elective abortion, amniocentesis, CVS, ectopic pregnancy termination, antepartum hemorrhage, miscarriage, abdominal trauma, external version procedures, stillbirth &plusmn; threatened abortion before 12 weeks (first trimester 50&mu;g, after 12 weeks 300&mu;g) - informed consent needed</p>
		<p><input type="checkbox" name="Influenza">offer influenza vaccine for women who will be in 2nd or 3rd trimester during flu season</p>
		<p><input type="checkbox" name="Quickening">quickening (18-20 weeks)</p>
		<p><input type="checkbox" name="Rh28Wks">Rh negative women: administer dose (300&mu;g) of D Ig if antibody negative at 28 weeks - informed consent needed (U.K. doses of 100&mu;g at 28 and 34 weeks)</p>
		<p><input type="checkbox" name="Prenatal2to3">visits every 2-3 weeks after 30 weeks</p>
		<p><input type="checkbox" name="Prenatal1to2">visits every 1-2 weeks after 36 weeks</p>
		<p><input type="checkbox" name="OfferInduction">offer induction of labour between 41-42 weeks gestation (if declined recommend serial fetal surveillance)</p>
		<b>DELIVERY/POST PARTUM:</b>
		<p><input type="checkbox" name="RhNegDelivery">Rh negative women: adminster dose of D Ig 120&mu;g (300&mu;g if test for fetomaternal hemorrhage not done) within 72 hours of delivery if a D positive infant is delivered (U.K. 100&mu;g)</p>
		<p><input type="checkbox" name="PPVaccine">rubella and varicella vaccine(s) for all non-immune women</p>
		<p><input type="checkbox" name="HBV">infants born to HBsAg positive mothers should receive HBIG 0.5mL IM within 12 hours of birth and Hepatitis B vaccine at birth, 1 and 6 months</p>
		<p><input type="checkbox" name="OcularProphylaxis">ocular prophylaxis for newborn</p>
		<p><input type="checkbox" name="HipExam">newborn hip exam</p>
		<p><input type="checkbox" name="RoomingIn">recommend rooming-in and early, frequent contact</p>
	</td>
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		<p><input type="checkbox" name="RubellaSerology">rubella serology</p>
		<p><input type="checkbox" name="HIV">offer HIV testing (with informed consent and pretest counselling including risk factors, risk of transmission to fetus and availability of therapy to reduce risk of transmission to fetus)</p>
		<p><input type="checkbox" name="HCV">offer hepatitis C antibody screening to women with risk factors (IDU, exposure to blood products - medical or occupational, HIV positive, elevated AST, prison inmates, multiple sex partners, tattoos)<p>
		<p><input type="checkbox" name="TaySachs">Tay Sachs disease testing in Ashkenazi Jews by hexosaminidase-A in serum (men, nonpregnant women) or WBCs (pregnant women)</p>
		<p><input type="checkbox" name="Canavan">offer Canavan carrier screening for Ashkenazi Jews</p>
		<p><input type="checkbox" name="Hemoglobinopathies">screen for hemoglobinopathies (sickle cell disease, beta thalassemia) by MCV &plusmn; hemoglobin electrophoresis in high risk populations (Asian, African, Mediterranean, Hispanic, middle Eastern, East Indian)</p>
		<p><input type="checkbox" name="CF">consider cystic fibrosis carrier testing (recommended routinely in USA, not routinely available in Canada unless + family history)</p>
		<p><input type="checkbox" name="HBsAg">HBsAg</p>
		<p><input type="checkbox" name="SyphilisSerology">syphilis serology</p>
		<p><input type="checkbox" name="BloodType">ABO and Rh blood type and antbody testing</p>
		<p><input type="checkbox" name="HighRiskDM">test women at high risk for diabetes (50gGTT), if neg repeat 24-28 wks</p>
		<p><input type="checkbox" name="Pap">PAP (if not done in previous 6-12 months)</p>
		<p><input type="checkbox" name="Chlamydia">screen women age &lt;25 years or at high risk for chlamydia (consider screening all women)</p>
		<p><input type="checkbox" name="Gonorrhea">screen women at high risk for gonorrhea</p>
		<p><input type="checkbox" name="BV">consider screening for bacterial vaginosis by gram stain or Amsel criteria in women at risk for preterm labour or symptomatic women</p>
		<p><input type="checkbox" name="Bacteriuria">screen for asymptomatic bacteriuria by urine culture (12-16 weeks)</p>
		<p><input type="checkbox" name="OfferPNDx">offer prenatal diagnosis to women with risk factors:
			<ul>
				<li>CVS 10&frac12;-12 weeks (f/u AFP & 18 week scan)</li>
				<li>Amniocentesis 15 weeks (can be done later if necessary)</li>
			</ul>
		</p>
		<p><input type="checkbox" name="TripleScreen">offer maternal serum triple screen to all women (15-20 weeks, optimal time between 15-17 weeks) Note: first trimester screening using nuchal translucency measurement &plusmn; serum markers may be available in some centers</p>
		<p><input type="checkbox" name="DetailedUS18">detailed ultrasound at 16-20 weeks (dates, anomalies, twins, placenta placement) - optimal time is 18 weeks</p>
		<p><input type="checkbox" name="GDMScreen">consider glucose test between 24-28 weeks unless low risk with either 2 step: 1 hour, 50g load, not fasting - if &gt;7.8mM do 3 hour GTT with 100g load (or 1 step: 2 hour, 75g GTT, fasting)</p>
		<p><input type="checkbox" name="repeatRhAb">Rh negative women: repeat Rh antibody level at 24-28 weeks</p>
		<p><input type="checkbox" name="repeatHb">consider repeat hemoglobin at 24-28 weeks</p>
		<p><input type="checkbox" name="repeatSerology">if high risk: repeat syphilis serology, HBsAg, HIV serology, screening for chlamydia and gonorrhea (repeat syphilis serology again at delivery)</p>
		<p><input type="checkbox" name="repeatUrineCS">&plusmn; repeat urine culture</p>
		<p><input type="checkbox" name="FUUS">f/u ultrasound if high risk (IUGR, placenta previa, bleeding)</p>
		<p><input type="checkbox" name="GBS">screen for group B strep (GBS) with vaginal-rectal culture (35-37 weeks) and offer treatment to all colonized women with intrapartum IV antibiotics at the time of labour or rupture of membranes.  Also offer treatment to all women with previously documented GBS bacteriuria or previous infant with GBS and women with risk factors (preterm labour &lt;37 weeks, PROM &gt; 18 hours, maternal fever &gt;38&deg;C) whose culture results are not available at time of delivery</p>
		<p><input type="checkbox" name="NewbornScreen">newborn screening for PKU, congenital hypothyroidism and galactosemia</p>
		<p><input type="checkbox" name="RhPosInfant">Rh negative women who deliver Rh positive infant: test (Kleihauer-Betke or rosette) for fetomaternal hemorrhage in excess of amount covered by standard dose of D Ig</p>
	</td>
	<td width="33%">
		<p><input type="checkbox" name="Meds">discuss prescription and over-the-counter medications</p>
		<p><input type="checkbox" name="PNV">discuss prenatal vitamins (including folic acid, vitamin A toxicity)</p>
		<p><input type="checkbox" name="Smoking">counsel re potentially harmful effects of smoking on fetus and recommend smoking cessation</p>
		<p><input type="checkbox" name="Drinking">screen for evidence of risk-drinking (2 drinks per day or binge drinking), counsel re potentially harmful effects of alcohol on fetus, advise abstinence or limited drinking</p>
		<p><input type="checkbox" name="Drugs">discuss potential risks to fetus of illicit drug use and encourage abstinence</p>
		<p><input type="checkbox" name="Reading">recommend reading material and Pregnancy Planning Guide (<a href="http://www.pregnancyplanningguide.com" target="_new">www.pregnancyplanningguide.com)</a></p>
		<p><input type="checkbox" name="Infection">counsel re avoiding exposure to toxoplasmosis(1), listeria(2), and CMV(3)
			<ul>
				<li>avoid raw/undercooked meat(1,2), unpasteurized milk or milk products(1,2), soft cheeses (feta, Brie, Camembert, blue-veined, Mexican queso fresco)(2), deli foods(2), p&acirc;t&eacute;(2), refrigerated smoked seafood (2)</li>
				<li>reheat leftovers, coldcuts and hotdogs until steaming hot(2)</li>
				<li>frequent handwashing (1,2,3) especially after caring for child, changing diapers(3), wash fruits and vegetables (1,2)</li>
				<li>avoid cat litter(1), wear gloves for gardening(1)</li>
			</ul>
		</p>
		<p><input type="checkbox" name="Fish">avoid eating shark, swordfish, king mackerel, tilefish, tuna steaks due to high levels of mercury (other fish, including canned tuna can be eaten in moderation: about 1-2 meals per week)</p>
		<p><input type="checkbox" name="Diet">discuss diet (including folate, calcium, iron, calories and caffeine)</p>
		<p><input type="checkbox" name="Exercise">discuss exercise (advantages, contraindications, maximum target heart rate)</p>
		<p><input type="checkbox" name="HospitalRegistration">give hospital registration form if required</p>
		<p><input type="checkbox" name="CopyCalendar">give copy of Maternity Care Calendar, highlight relevant information</p>
		<p><input type="checkbox" name="PNClasses">discuss prenatal classes</p>
		<p><input type="checkbox" name="CounselPNDx">counsel re prenatal diagnosis by CVS or amniocentesis with women with identified risk factors (age &gt; 35 years at EDD, previous affected pregnancy, known translocation</p>
		<p><input type="checkbox" name="DiscussTripleScreen">discuss maternal serum triple screening with all pregnant women (including limited sensitivity and specificity, psychological implications, risks associated with prenatal diagnosis and 2nd trimester abortion, delays inherent in process)</p>
		<p><input type="checkbox" name="Breastfeeding">discuss and recommend breastfeeding</p>
		<p><input type="checkbox" name="Circumcision">discuss circumcision</p>
		<p><input type="checkbox" name="LabourAndDelivery">discuss labour and delivery (pain relief, monitoring, episiotomy, labour support, when to call)</p>
		<p><input type="checkbox" name="CommunityResources">discuss community resources for infants & parents</p>
		<p><input type="checkbox" name="CarSeat">recommend infant car seat</p>
		<p><input type="checkbox" name="SSxBFWell">discuss signs that your baby is breastfeeding well (by day 4: breastfeeding at least 8 times, has at least 6 wet diapers and 3-4 soft, yellow stools in 24 hours)</p>
		<p><input type="checkbox" name="BreastfeedingSupport">breastfeeding information and support (early frequent contact, positioning and latching, hand expression, support groups, collection, storage and freezing)</p>
		<p><input type="checkbox" name="VitD">recommend vitamin D supplementation (200-400 IU/day)</p>
		<p><input type="checkbox" name="SIDS">recommend infants be placed on back to sleep, avoid exposure to second-hand smoke, avoid overheating and soft, loose bedding, to decrease risk of SIDS</p>
		<p><input type="checkbox" name="PPDepression">watch for signs of postpartum depression</p>
		
	
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