Dorothy Dulko 00:08 Very good, and let me share my screen. I

Dorothy Dulko

00:08

Very good, and let me share my screen. I do expect a few others

to come along, but we can start Let me know when you can see.

are you able to see the screen?

Yes.

Unknown Speaker

00:33

okay.

Dorothy Dulko

00:37

So this the unit. 8 seminars pregnancy?

and that is a very, very broad term for a very, very specific

specialty in health care. my first bit of background, my first

Np degree with women’s health ob Gyn both.

and I subsequently back I went back to get a post-graduate certificate postmaster’s.

and in those trainings my initial masters program. I I did a fair amount of pregnancy. of

great prenatal post-partum intra pardon, anti-partum, all of those rotations. And when I, my first role as an Np.

Was in an obedience clinic in New York City, where we took care of

everyone. Teenage, pregnancy, prevention, early pregnancy, high risk ob a lot of by N obviously and

But I must say that in in frankness

it is having seeing patients from when they present, either trying to achieve a pregnancy or suspecting they’re pregnant early on or

and you begin seeing them doing all the appropriate, well pregnant testing and antenatal

work, and then they progress through their pregnancy. You get to know them, their child. They’re on more, maybe their family.

There’s something lacking in the fact that you don’t deliver those children, or you’re not part of that intra part of experience I always felt you’d come in every day and take a look at the delivery list, which at the time was still handwritten, and you’d see if any of your patients had delivered where they all okay.

And there was something anticlimactic to that, because you’ve taken them to the point of delivery, and then you don’t really know what happens from there. With that said so. Midwives, I believe, have a very important nurse. Midwives have a a very important role in the in the treatment and the care of pregnant patients.

Those are our colleagues.

So we’re going to talk a little bit today about what is normal and abnormal and pregnancy. how to identify proper management treatment. And always. you know, unless you’re in a practice that sees pregnancy

pregnant patients as a routine, a local.

a low threshold for early referral.

So we talk. I think you all have like these cases, or at least it seems so. We’ll we’ll do another one of those today. Few. Tina is grabbing a 2 par 2 2 deliveries she’s 29. She comes to the clinic. After having missed her period, she took a home pregnancy test positive

she’s had 2 months of intermittent nausea. No vomiting. She’s fatigued. She’s modly constipated. All of those symptoms are progest and related.

Pro Justin makes you fatigue. Pro Justin gives you nausea for Justin causes constipation, and all of that is to is Nature’s way of sustaining the corpus ldium, which are initially is sustained by progesting, which is why many early miscarriages are

due to progest and deficiency. And in someone who’s had repeated miscarriages, you’ll see that there’s suggestion, supplementation, or a way to keep the pro just enough to sustain that early.

So this sounds like she’s definitely she likely is pregnant. She has one child who’s 4 years old

uncomplicated pregnancy bathroom delivery 2 years prior, she delivered. a girl.

I’m sorry. 2 years ago she delivered a girl following an uncomplicated management of pregnancy and use type protection. So that was managed by reduction, sodium, and diet.

No need for medication.

Our objective data is pretty straightforward. Cheese

65 inches 130 pounds. Vm. I. 21 there, about 10 vp. Heart rate, respiratory rate, and then, too sad. All look good.

So she needs a full history and physical again going deep into her, her menstrual cycle

per more deeply into our pregnancy. History. At what week did she deliver? Were there any issues along the way other than the

hypertension which was managed conservatively. You want to talk about her family history. You want to talk about herself. You want to speak about. She doesn’t seem to have any issues with her. Vp, currently and you want to do a good physical exam looking for any edema check her lungs? Or are this the first to be visit is a very important one.

and Labs, and the this she needs a dating early dating. So now crown on plane assessment and a transactional ultrasound to accurately date pregnancy.

You do again. It’s a full exam, including breast abdomen extremities. Her whole She needs an elvic

and a speculum exam and a depression screen.

every

patient who is pregnant needs at least one, and I’ve posted. If I didn’t. I’ll post today. some information about

The recent

association of kind of logic and obstetrical providers, edict or alert to the fact that pregnancy, both during and postpartum, is a very high risk or depression state for any woman

of any age. So it’s important to take a look at her status.

The classic finding of Hagar sign and softening of the lower uterine segment and early pregnancy, even before you can calculate and enlarge a uterus is is classic.

There is this very soft lower uterine segment.

It is another sign of pregnancy on a pelvic on the by manual exam.

Chadwick sign.

This cervix has this bluish, purplish tint.

there is cervical mucus. There is vascularity in the vagina and service. All of this is in preparation for the growing baby.

the the you know, the pelvis, the entire pelvic area becomes inundated with all of this glorious blood flow and velvety consistency of an engorged area of with with this nutrition being already brought forward to

to nourish the growing.

And we all see this. This is a very excellent picture.

an early pregnant cervix, or even a later, will look look like this. And that new coast is normal.

I mean as a first pregnancy visit, as a as someone who comes in and is pregnant. You do want to make sure that person’s at

is up to date. You’re going to draw. You’re going to have Tc. Comedian cultures. You want to do both of those things as well as HP. Testing

in terms of specimens that you obtain on you

while you’re doing the second exam. If you see something abnormal in terms of discharge, always a wet mount or other testing is is appropriate to see something in the Volvo, the vagina, the external genitalia that looks unusual always have a low threshold to culture.

So these are

a breakdown of what to do in terms of labs and diagnostics. You definitely want to confirm the pregnancy, obtain urine specimen. If that specimen is negative, which it likely would not be, she has enough signs, and she’s for missed enough of. She’s far away from enough for her last period to have a positive pregnancy test. If any doubt you can draw a Beta, Hcg, just to be sure, you want to calculate the due date based on her last menstrual cycle and ultrasound.

The latter is more accurate. If this is a very early pregnancy in the first 8 weeks, unless she has clockwise every single month, every single month is 28 days.

Ever since the day she had her first period, and she knows when she became pregnant. She knows the day and the time. Then you can kind of also rely upon the last menstrual period. But it’s a general rule of This early in pregnancy a trans factual ultrasound will reveal a crown rump link

that will give you a very accurate dating of the.

You want to have an a typed, an orh, she will likely know her Rh status based on the fact that she’s been pregnant before. She doesn’t mention that she needed program or other than she likely is not, or it’s negative, but testing everyone gets tested again. You want a hemoglobin in Mada grid as a baseline. She won’t have a dilutional anemia yet.

because the blood volume and the fluid volume of the of the pregnant state is not in full swing, but you want to know where she is at. Baseline.

hepatitis B HIV rouvella syphilis. All of those tests along with the cultures that you’ve obtained.

perform the complete physical, including a pelvic. As for gonorrhea, for media, and a pack to best, if she is due for one, or doesn’t remember when she has her last. You also want to get her Hpv. Vaccine status

and any abnormal testing that she may have had related to pap smears with HP.

she needs an obstetric ultrasound

and based on anything she mentions to you in the complete history you’re taking.

You can offer her genetic counseling. And then the genetic counselor can determine if she needs screening.

if there’s any family history, cystic fibrosis, or any other issues that might

cause you to be concerned

about her.

Unknown Speaker

11:38

Oh.

Dorothy Dulko

11:39

need for genetic

Nagel’s rule. First day of the A. This is calculating an estimated date of delivery.

First date of the last period, first day, plus 7 days minus 3 months plus one year. Get yourself a wheel, or use the one that’s online it. It’s such that you can really determine easily

entering the last mental period, what the estimated data delivery is.

And again.

unless someone is clockwise, regular, and you have an ultrasound early on. You’re going to use the date

that is confirmed, and we early from

so what is this? What does she need? She needs prenatal vitamins

with folic acid. She’s talked about a little bit of nausea. She can really just receive supportive care for that

ginger, ginger. Choose

some salt teens by the bedside. They these things actually do out

little little pretzels, or something dry, and fill the stomach before you get out of bed she has to notify. She’s unable to drink. These are all very

straightforward. You will know these. you will know these small pieces of advice, but they’re important. If she’s not tolerating fluids. If she’s not

able to eat adequately, she needs to come back or tell you

constipation she can have call if

the other increasing in fluid water, water, water, fiber.

But

childbirth classes, even if you’ve had other children. Every I can see it’s different. Shopper classes give patients an opportunity to meet with other people, with other women, families and fathers and partners. It’s a great thing to do.

start talking about how she wishes to deliver, she said to vaginal deliveries, but that doesn’t guarantee a third, although it’s likely it will be

How does she with? Was she satisfied with the birth experience you want to ask her about her birth experience? Did she receive anesthesia?

How? What type of anesthesia was that satisfactory to her? Did she feel that she was adequate

compared? Is there anything in the 2 prior pregnancies and deliveries that she would change

definitely, even though she denies alcohol or drug use or smoking.

You do want to ask.

This is an important time to screen for depression, as I mentioned, and also to be sure that you have at least some idea of how things are going at home.

How much support does she have for the other children that she’s?

What is her family structure at home?

Who’s working?

Who picks them up?

Who cooks? Is anyone hurting or in any way at all?

So it’s important because pregnancy can be on, as we’ve talked about in one of the earlier seminars a very vulnerable state for one.

Talk about environmental exposures. Should there be any. Again, the multi vitamin is important or prenatal.

have your dental care

The guns can tend to also become more sensitive. Leading comes important to counsel her on a soft toothbrush.

keeping up good dental hygiene, salt, and water rinses after brushing, just keeping the guns out, and during pregnancy is important, and have her come back

about 4 weeks.

So that is a very straightforward.

initial, prenatal visit of a healthy woman

with 2 prior pregnancies. No medical history that we know of. You know, surgical history, that we know that you want to deal deeper

for exam. It’s normal you’ve drawn the appropriate Cdc.

Chemistry and other labs

given her a calendar of the events that will occur along

journey.

that, you’ve done it ultrasound. It’s that’s available in the office transaction.

She has her vitamins couple of issues you’re concerned about. You want to keep a close eye on her.

her blood pressure. She’s having she in the past. You want to delve into that You want to be sure that you, keeping a handle on the nausea.

just to be sure that that is not

precipitating.

learn about her prior births

and culture her up, or any.

Are you doing differently? Are you following now? These are all Bgi and correct is, is there anyone who has seen or been involved in a family or primary practice for primary care practice where pregnant patients are.

are part of what is routinely seen.

No, it would be unusual. But in rural settings

the family doctor often can do many things.

Are there midwives in in any of your communities.

Okay, Chelsea. So it up there in Cape

or the midwives in private practice on their own. Or they are. and

Chelsea Johnson

17:53

yeah. So my preceptor. she’s the Obg. Why, in and there’s about I want to say 9 or 100’clock. I’ll be giants. And then there’s 4 or 5 certified nurse midwives?

Dorothy Dulko

18:06

Yes, I know I’ve spoken to the receptor, but I guess my question is

so. There are no Opg, my end nurse practitioners. All of these are certified, nurse.

Chelsea Johnson

18:16

correct?

Dorothy Dulko

18:18

So

in the area. Or I guess I would ask Deb as well, Esther, you, too.

are there any midwives who are in their own private practice, where they see

patients with a collaborating substitution. meaning that their practice is their own, they without an ob

Deb Gatliff

18:42

for me. Dev no, I I think the closest midwives

around here are up in Missouri. We don’t have any close around here, Little Rock.

I I I believe they do down there. But I whether they’re independently practice I don’t know.

Dorothy Dulko

19:07

We have. we have some actually

down here.

They have their own.

They’re on.

Okay. Well, that’s interesting. I have some additional cases, not necessarily cases, but some information to share about things that could come up in an initial ob that might flag you

to escalate

referral, referral to another practice. If you’re seeing patients environment here.

someone can come in thinking they have appendicide as someone can come in thinking they have a uti. They have a discomfort, you know, loaded feeling.

and they could actually have an all pregnancy. So you you can’t see someone early, pregnant, not suspecting you in primary care, and can also see it if someone just wants to confirm that they’re pregnant. But what happens after that visiting, and you won’t have a trans vaginal ultrasound there anything else? what you do after that visit? is important. So I have some additional information for you.

Okay? Well, I’ve I’ve caught up in core elms. And in terms of the documentation, everything looks okay.

the hours. If I haven’t reached out no one on this call. I got to do. That means that you’re looking like you’re on track to complete the appropriate number of hours of 160 to complete the the course. There are a couple of students who, I was concerned were a little bit behind on the hours, but it looks like we’re all set on that.

So we’re almost there, your preceptors likely in the next week or so we’ll begin getting their emails to complete your finally, I’ll be up. I’ll have to be on the lookout for those, because I can find those in for elms. But part of what you need to do in the upcoming weeks

is both download your preceptors. Evaluation But you need to be sure that you also are evaluating your preceptors. If you have more than one evaluation for

for both

and those get uploaded to the class as well. Of course it’s important to know how how the experience has gone from your perspective as well.

And we do have a we do have a seminar like next week.

so we’ll talk more about closing up the loops for the last couple of weeks. It’s gone really fast. It always does

But it’s it’s

you both on really good work

there is.

The assignment don’t do the pregnancy you can choose

the the case. Some of you have submitted that.

but I will be looking over those on on the weekend. I’m not there any concerns. I don’t think so based on what I’ve seen so far.

and good conversation and discussion

on breastfeeding so far this week.

and I look forward to the continuing conversation. I’m here if you need me.

Thanks. Everyone.

Okay.