classification: internal use only internal use only classification: internal use only 3 this...

Classification: Internal Use Only

Classification: Internal Use Only 1

Protocol Title: Normal Interval OB Care

Effective Date: 09/30/15 Version: 1.0 (Revised: XX/XX/XXXX)

Approval By: CCC Clinical Steering Group at 8/26/2015 meeting

Planned Review Date: 8/26/2016

1 Purpose & Objective This normal interval OB care protocol provides evidence-based care recommendations in the care of

pregnant patients in the primary care setting.

2 Scope of Protocol

2.1 Target Population This protocol was derived from clinical guidelines for individuals in the CCC population diagnosed with

pregnancy who are 18 years of age or older.

2.2 Target Users

This protocol is developed for use in primary care settings.

2.3 Excluded Topics

This protocol does not address the clinical management of patients with complications of pregnancy.

2.4 Related Guidelines

Guidelines for perinatal care / American Academy of Pediatrics and the American College of Obstetrician and

Gynecologists.-7th ed.



3 Protocol Development & Approval Process

CCC Women's Health Workgroup

CCC Clinical Delivery System Steering Group

CCC Advisory Committee

CCC Board of Directors

Guidelines ProtocolsProcess

Outcomes & Measures

At minimum, will be

reviewed annually

At minimum, will be

reviewed annually

Tracked and reported on a

regular, consistent basis



This protocol originated in a subcommittee of the CCC Women’s Health Workgroup. The work of the

subcommittee included clinical experts and operations staff from Dell Medical School at UT Austin, Seton

Healthcare Family, CommUnityCare, and Community Care Collaborative; these organizations met weekly for

three months to design a pilot project for referring patients between inpatient and outpatient settings to

improve quality of care and health outcomes. Members converged initially to develop the pilot project, but

saw implications for the broader delivery system. In these sessions, members engaged in the process to

extract evidence-based elements to adequately care for pregnant patients in the CCC population.

The above depiction describes the approval and subsequent review process for this protocol.

Group Name Approval Date

CCC Women’s Health Subcommittee 07/14/2015

CCC Clinical Delivery System Steering Group 08/26/2015

CCC Advisory Committee TBD

CCC Board of Directors TBD

4 Entry to Care

4.1 Patient Access to Prenatal Care

Walk-in positive urine pregnancy tests or patient call to PNC

Patient is given appointment within one week for screening or to see provider for IOB at appropriate

intermediate care clinic depending on geographic location.

If possible, patient is to be screened prior to appointment with OB provider. This screening would include:

Pregnancy options counseling

WIC referral

Trimester appropriate packet to be given to the patient

Education reviewed

Appropriate labs ordered and drawn

Appointment to see OB provider at that time or within one week

Schedule ultrasound to coincide with OB provider visit

If a patient presents late to care or lapses care, all appropriate screening tests and education should be

completed upon presentation or re-entry to care.

5 Obstetric Care by Estimated Gestational Age 6-9 Weeks EGA



Clinical Elements

Review complete history including complete pregnancy history, medications/supplements, family or personal history of genetic disorders (ACOG)

Physical exam, including breast and pelvic exam

Height, Weight, Blood Pressure, BMI

Dating ultrasound performed if first trimester

Screening o Edinburg Postnatal Depression Scale o Domestic Violence screen o Intense Nutrition screen

Screen for TB risk factors o Order PPD if indicated per guidelines/risk factors

Known HIV infection Close contact with individuals known or suspected to have TB Medical risk factors known to increase the risk of disease if infected (diabetes, lupus, cancer,

alcoholism, and drug addiction) Birth in or emigration from high-prevalent countries Being medically underserved Homelessness Living or working in long-term care facilities, such as correctional institutions, mental health

institutions, and nursing homes

Screen for immunizations o Offer influenza vaccine September through May

Prescribe prenatal vitamins

Counsel regarding aneuploidy screening or genetics referral as appropriate per guidelines. This should include counseling regarding Cystic Fibrosis carrier screening. Patients of Eastern European Jewish descent should be offered additional carrier screening that includes carrier screening for Tay-Sachs disease, Canavan disease, cystic fibrosis and familial dysautonomia. Patients of French Canadian or Cajun descent should be offered carrier screening for Tay-Sachs disease.

Diagnostics- Labs should be reviewed (labs ideally already ordered per standing delegation at time of screening, results may be available for review at time of appointment with provider)

Urine for protein and glucose

CBC

Type and Screen

HepBsAg

HIV

RPR

Varicella titer if indicated (denies history of prior infection or vaccination)

Gonorrhea and chlamydia screen

Urine culture, urine analysis

Pap as indicated per ASCCP guidelines

Urine drug screen if history of illicit drug use

Hepatitis C screening if history of IV drug use or home tattoos



Hemoglobin electrophoresis if indicated o Mediterranean, Southeast Asian or African American descent

Early screening for diabetes if risk factors present (1 hour GTT, 50-g glucose load) o Obesity (BMI > 30) o History of gestational diabetes o History of delivery of infant > 9 pounds o History of unexplained IUFD o First degree relative with diabetes o African American or Hispanic o Hypertension o HDL cholesterol < 35 o Triglycerides > 250 o Hemoglobin A1c > 5.7 o History of cardiovascular disease

Education (IOB Education Module)

Pregnancy options counseling

Provider information, emergency numbers, hospital

Hospital video tour should be provided

Anticipated course of perinatal care

Common discomforts of pregnancy

Nutrition in pregnancy

Breastfeeding education

Prenatal vitamins, folic acid, DHA

Appropriate weight gain in pregnancy

Exercise in pregnancy

Lifestyle education: work, sexual activity and travel

Medication avoidance

Precautions o Caffeine o Toxoplasmosis o Listeria o Fish o Varicella o Hot tub exposure o Environmental exposures o Occupational exposures

Substance Use, alcohol, tobacco cessation

Seatbelts, smoke detectors, gun safety in home

Review stress factors

Warning signs of miscarriage

Counseling for HIV testing

Referrals and Follow up

Referral to appropriate level of care per referral guidelines

Genetics referral as appropriate per referral guidelines

Referral to WIC



Referral for dental appointment

Referral to Case Manager if indicated

Referral to Behavior Health Counselor if indicated by EPDS or clinical concern

Follow up in 4 weeks in Intermediate or Low Risk Clinic as appropriate if not referred to High Risk Clinic

Follow and address any abnormal lab results o Treat positive urine culture, will need test of cure after treatment o Treat positive gonorrhea or chlamydia, counsel regarding treatment, will need test of

cure 4-6 weeks after treatment, offer expedited partner therapy o Refer for colposcopy as indicated by ASCCP guidelines o Treat microcytic anemia with iron supplementation o Refer per guidelines if positive for HIV, syphilis, hepatitis B, hepatitis C

10-13 Weeks EGA

Clinical Elements

Fetal heart tones

Weight, Blood Pressure

Screen for mood changes

Counsel regarding aneuploidy screening or genetics referral as appropriate per guidelines

Diagnostics


Education (Module A)


OTC medications in pregnancy





Stress management



Refer for higher level of care per guidelines if indicated by change in clinical status

Follow up in 4 weeks if not referred to higher level of care

Follow and address any abnormal lab results

Refer for first trimester aneuploidy screening if appropriate

14-17 Weeks EGA

Clinical Elements



Fetal heart tones

Weight, Blood Pressure


Screen for domestic violence


Diagnostics


Offer Quadruple screen (15-21 weeks) if not referred for Genetic Counseling

Order anatomy ultrasound to be scheduled 18-20 weeks EGA to be done in MFM ultrasound clinic








Stress management





Follow and address any abnormal lab and ultrasound results o Refer for Genetics Counseling if Quadruple screening abnormal

18-21 Weeks EGA

Clinical Elements

Fetal heart tones

Weight, blood pressure

Fundal height starting at 20 weeks


Screening o Edinburg Postnatal Depression Scale o Domestic Violence screen

Diagnostics


Order anatomy ultrasound to be scheduled 20-22 weeks EGA



Offer Quadruple screen (15-21 weeks) if not referred for Genetic Counseling








Stress management





Follow and address any abnormal lab and ultrasound results o Refer for Genetics Counseling if Quadruple screening abnormal

22-25 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Screen for preterm labor

Screen for fetal movement


Diagnostics

Urine protein and glucose

Diabetic screen between 24-28 weeks with 1 hour GTT (50-g glucose load)

Hemoglobin and hematocrit to be drawn with 1 hour GTT

Antibody screen drawn with 1 hour GTT if Rh negative

Education (Module B)

Birth control options education including sterilization, sign sterilization consents if appropriate

Review gestational diabetes screening process

Discuss recommendation for Tdap to be given at 27-36 weeks EGA

Trial of labor counseling if history of previous cesarean section

Review signs and symptoms of preterm labor

Review awareness of fetal movement



Review healthy weight gain in pregnancy




Follow GTT results, order 3 hour GTT if 1 hour GTT result is ≥ 140 mg/dL. Once 3 hour GTT completed, place appropriate referrals for diabetic education and management per guidelines if indicated

Follow and address any abnormal lab results o Treat microcytic anemia with iron supplementation

26-29 Weeks EGA

Clinical Elements

Confirm fetal heart tones

Fundal height





Diagnostics


Diabetic screen between 24-28 weeks with 1 hour GTT (50-g glucose load)

Hemoglobin and hematocrit to be drawn with 1 hour GTT

Antibody screen drawn with 1 hour GTT if Rh negative

Administer Rhogam if Rh negative and not sensitized

Administer Tdap at 27-36 weeks EGA

Education (Module C)


Postpartum depression education

Signs and symptoms of preterm labor

Awareness of fetal movement, teach fetal kick counts

Review signs of preeclampsia

Review postpartum birth control plan, sign sterilization consents if appropriate

Review delivery plan (TOLAC vs repeat cesarean section) if indicated

Discuss hospital registration

Review numbers to call for emergencies/labor




Follow GTT results, order 3 hour GTT if indicated. Once 3 hour GTT completed, place appropriate referrals for diabetic education and management per guidelines if indicated

Follow and address any abnormal lab results o Treat microcytic anemia with iron supplementation



30-32 Weeks EGA

Clinical Elements

Confirm fetal heart tones

Fundal height




Screening o Edinburg Postnatal Depression Scale o Domestic Violence screen

Diagnostics


Education (Module C)


Postpartum depression education

Signs and symptoms of preterm labor



Review postpartum birth control plan, sign sterilization consents if appropriate


Discuss hospital registration





33-35 Weeks EGA



Clinical Elements

Fetal heart tones

Fundal height





Begin suppression for HSV at 36 weeks if indicated by history

Diagnostics


CBC, HIV, RPR

Repeat chlamydia and gonorrhea testing if indicated by risk factors

GBS screen (35-37 weeks EGA) if indicated o Do not screen patients with history of GBS bacteriuria in this pregnancy or history of

previous infant with GBS sepsis

Education (Delivery and Newborn Education)

Signs and symptoms of active labor, explanation of Freidman curve

Review labor and delivery anesthesia options


Indications for cesarean delivery

Indications and explanation of operative vaginal deliveries

Circumcision education

Discuss plan for newborn’s healthcare provider/medical home, meet pediatrician if possible

Review need for car seat

Breastfeeding reinforcement



Review birth control plans

Review hospital registration/tour





Follow and address any abnormal lab results o Treat microcytic anemia with iron supplementation o Treat positive gonorrhea or chlamydia, counsel regarding treatment, will need test of

cure 4-6 weeks after treatment, offer expedited partner therapy

Schedule repeat cesarean section if needed



36 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Screen for labor



Diagnostics






















37 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height




Screen for labor



Diagnostics





















Follow up in 1 week if not referred to higher level of care

38 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Screen for labor



Diagnostics




CBC, HIV, RPR, if not completed previously



















39 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Screen for labor



Diagnostics






















40 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Offer vaginal exam and membrane sweeping

Review postdates pregnancy protocol and possibility for postdates induction of labor

Screen for labor



Diagnostics




















Refer for higher level of care per guidelines for postdates evaluation in Intermediate Care Clinic

If already following in Intermediate Care Clinic or High Risk Clinic and appropriate dating criteria, patient may be directly scheduled for induction of labor at 41 weeks according to patient preference

41 Weeks EGA

Clinical Elements

Fetal heart tones

Fundal height


Antenatal testing (biophysical profile or non stress test), amniotic fluid assessment

Review postdates pregnancy protocol and possibility for postdates induction of labor

Screen for labor



Diagnostics
















Review family medical leave





Schedule for postdates induction of labor or postdates testing as indicated by antenatal testing, dating criteria and patient preference

Postpartum 2-week Visit Clinical Elements

o Weight, blood pressure o Screen for breastfeeding difficulties o Screening

o Edinburg Postnatal Depression Scale o Domestic Violence screen

o Screen for complications of delivery, maternal as well as perinatal o Initiate conversation with PCP regarding medical comorbidity follow up o Review contraceptive plan

Diagnostics

o Urine gonorrhea and chlamydia screening if plan for IUD or Essure placement at follow up visit. o Schedule follow up in Essure clinic as necessary. o Order 2 hour GTT to be done at 6-week postpartum visit if indicated by gestational diabetes

Education (Postpartum Education)

o Recommend exclusive breastfeeding for at least 6 months duration, address concerns o Postpartum sexual activity and birth control methods o Benefits of inter pregnancy spacing o Resume physical activity, return to work/school o Review signs and symptoms of postpartum mood disorders

Referral and Follow up

o Referral to Behavioral Health Counselor if indicated o Referral to lactation consultant or hotline if indicated o Referral to WIC or Case Management if indicated o Referral for financial screening if indicated o LARC to be placed at 6-week postpartum visit if desired

Postpartum 6-week Visit

Clinical Elements

o Physical including abdominal and pelvic exam, breast exam if not breastfeeding o Screening

o Edinburg Postnatal Depression Scale o Domestic Violence screen

o Screen for incontinence (fecal, urinary and gas) o Screen for breastfeeding difficulties o Place IUD/Nexplanon if desired or order other contraception as per patient request



o Give MMR if indicated and not received in hospital o Offer vaccines (HPV/varicella) if indicated

Diagnostics

o Pap Test if indicated by ASCCP guidelines

Education (Postpartum Education)

o Recommend exclusive breastfeeding for at least 6 months duration, address concerns o Postpartum sexual activity and birth control methods o Benefits of inter pregnancy spacing o Resume physical activity, return to work/school o Review signs and symptoms of postpartum mood disorders

Referral

o Referral to Behavioral Health Counselor if indicated o Referral to lactation consultant or hotline if indicated o Referral to WIC or Case Management if indicated o Referral to PCP/medical home for ongoing care

6 Protocol Development Team

Name Affiliation

Ted Held, MD *Associate Chief Medical Officer and Clinical Champion

Community Care Collaborative

Amy Young, MD

Chair of Department of Women’s

Health

Dell Medical School at UT Austin

John Gianopoulos, MD

VP of Women’s Health Services

Seton Healthcare Family

Deborah Morris-Harris, MD CommUnityCare



Special Liaison to Dell Medical

School; past Chief Medical Officer

David Escamilla, MD

Director of Women’s Health

CommUnityCare

Ashley Choucroun, MD

Service Line Director Women’s

Health

CommUnityCare

Mark Hernandez, MD

*CCC Chief Medical Officer; CUC

Interim Chief Medical Officer

Community Care Collaborative and

CommUnityCare

Terri Sabella, RN VP of Operations

CommUnityCare

Matt Balthazar, MHA Director of Strategic Planning and Development

CommUnityCare

Curk McFall, MSN, RN Community Care Collaborative

Andrea Guerra, MPH Community Care Collaborative

Darlene Lanham, M.P.Aff. Community Care Collaborative

7 References

8 Glossary of Abbreviations

Abbreviation Term

BMI

Body Mass Index

CBC Complete Blood Count

DHA Docosahexaenoic Acid

EGA Estimated Gestational Age

EPDS Edinburgh Postnatal Depression Scale

GBS Group B Streptococcus



GTT

Glucose Tolerance Test

IOB

Initial OB Visit

IUFD

Intrauterine Fetal Death

MFM Maternal Fetal Medicine

PPD Purified Protein Derivative

RPR Rapid Plasma Reagin

TOLAC Trial of Labor After Cesarean Section

WIC Women, Infants, and Children

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