Pregnancy on the CCFP exam

Approach

• Ask what raises risk: age, diabetes, high blood pressure, epilepsy, past losses or preterm births, and a family history of genetic disease.
• Diabetes: bring glucose control close to target before she tries. Poor control raises the risk of birth defects and another loss.
• Keep effective contraception until control is good. Then plan the attempt together.
• Review every medicine. Switch the ones that can harm a fetus before conception, not at the positive test.
• Start daily folic acid before she tries. Check immunity to rubella and chickenpox.
• Help with smoking, alcohol and drug use now. Each one harms a pregnancy.
• After a loss, no fixed wait is needed. The timing turns on her health, not the calendar.

Approach

• Ask about pregnancy plans at routine visits, with men as well as women.
• Explain the fertile window: the few days before ovulation and the day of it.
• Fertility falls with age, sooner for women. Smoking lowers it in both sexes.
• After birth, ovulation can come back before the first period.
• Breastfeeding protects only when it is exclusive, day and night. Regular formula feeds end that protection.
• Agree on contraception before she leaves hospital, not at the six-week visit.

Approach

• Ask how she feels about the pregnancy. Do not assume it is good news.
• Set out every option without judgment: continuing, adoption or abortion.
• Options depend on how far along she is. Pin down the date now, not at the routine scan.
• With no reliable period date, arrange a dating test now.
• See her alone for part of the visit. Explain what stays confidential.
• A pregnancy with a consenting, near-age partner is not, on its own, a reason to report.

Approach

• Medical risks: chronic illness, medicines, past pregnancies and births, a previous cesarean, family history.
• Social risks: housing, money, food, partner violence, substance use and mood. Ask with the partner out of the room.
• Date from the last period only if it is certain and cycles are regular. If not, arrange a dating test early.
• Send blood group and antibody screen at the first visit after 8 weeks. Testing before 8 weeks is not recommended.
• Do not dip the urine for protein and glucose at every visit when she is low risk with normal blood pressure.
• Offer prenatal screening choices early, and set out the visit schedule.

Approach

• Look for the groups at higher risk: adolescents, people facing violence, poverty or substance use, and those raising a child alone.
• Ask every patient about violence, in private. It can start or worsen in pregnancy.
• Social risk alone does not need an obstetrician. A healthy teen can stay in family practice care.
• Link supports early: social work, public health nursing, prenatal programs, food and housing help.
• Start prenatal blood work and screening choices now. Waiting for the routine scan loses weeks.
• Keep the supports going after the birth. The risk does not end at delivery.

Approach

• Never stop a needed medicine abruptly at the positive test. Review it with the specialist soon.
• Epilepsy: involve neurology early. Some seizure drugs carry more fetal risk, so the drug or dose may change.
• Diabetes: share care with a diabetes team. Aim for tight glucose control and closer watching of mother and fetus.
• Human immunodeficiency virus (HIV): involve an HIV team early. Keeping the virus suppressed protects the baby.
• Opioid use: involve addiction care early, and plan care for the newborn.

Approach

• Heavy bleeding with lost heart tones at a known date: confirm the loss, then let the weeks decide the Rh dose.
• Rh-negative and not sensitized: the weeks decide (table below). Before 8 weeks, give none.
• At 8 to 12 weeks, suggest none. Offer it if the patient wants to avoid any risk.
• After 12 weeks, suggest 300 µg. The exception is a complete molar pregnancy that is certainly diagnosed.
• Chorionic villus sampling, a placental biopsy for genetic testing, has its own advice, even early in pregnancy.
• Waters broken before term: give antenatal steroids from 24 weeks to the end of 34 weeks, only if birth within 7 days is very likely.
• New high blood pressure later in pregnancy is preeclampsia, a disorder of blood pressure and organs, until proven otherwise. Assess the same day.

Approach

• Confirm active labour before you call it slow. The early phase can last many hours.
• In active labour, check the three Ps: power (contractions), passenger (baby's size and position), passage (pelvis).
• Weak contractions with a well baby: labour can often be strengthened. Then reassess progress.
• Stalled descent in the second stage: check position and pushing. An assisted vaginal birth or a cesarean may be needed.
• Do not do a routine episiotomy, even for an assisted birth.
• Keep monitoring the fetus. A worrying heart rate changes the plan.

Approach

• Low-risk labour: listen to the fetal heart at intervals. Continuous electronic monitoring is not recommended for these patients.
• Worrying tracing: look for the cause, act on it, and call for help. If it persists, speed up the birth.
• Abruption: painful bleeding with a hard, tender uterus. It can cause a clotting problem and heavy bleeding after birth.
• Previous uterine surgery raises the risk of rupture. Watch for sudden pain, a falling fetal heart rate, or the baby moving back up.
• Shoulder dystocia: the head pulls back against the perineum. Call for help, flex her legs back hard (McRoberts), and press above the pubic bone.
• Never push on the top of the uterus in shoulder dystocia. It wedges the shoulder further.

Approach

• Measure blood loss: weigh pads, sponges and drapes. Visual estimates and normal vital signs both mislead.
• Find the cause with the four Ts (table below). A uterus that does not contract is the most common.
• First: compress the uterus with both hands, empty the bladder, and give oxytocin.
• Oxytocin: up to 10 international units (IU) into the muscle, or 3 IU as a rapid intravenous (IV) push. No response in 4 minutes: add a second-line drug.
• Second-line: ergonovine into the muscle, or carboprost into the muscle or uterus. Tranexamic acid can be added. Do not give misoprostol rectally.
• Placenta not out 30 minutes after birth: act to deliver it. Still bleeding: look for clots, retained tissue and tears of the cervix or vagina.
• Fever, a tender uterus and foul-smelling discharge point to endometritis, an infection of the womb lining. Treat it the same day.

Approach

• Ask about mood and coping at every visit, in pregnancy and the first year after birth.
• The Canadian Task Force advises against giving every patient a depression questionnaire with a cut-off score. Asking about mood is part of usual care.
• That advice does not cover patients with a past or current mental illness. Watch them closely.
• Tell the blues from depression by how long it lasts and how much it stops her coping (table below).
• Ask directly about thoughts of self-harm or of harming the baby.
• Confusion, odd beliefs or hearing voices after birth suggest postpartum psychosis. It is an emergency.
• Check for anemia. After birth, it adds to tiredness and low mood.

Approach

• Watch a full feed. Look at the latch, the baby's swallowing, and nipple shape after the feed.
• Painful, cracked nipples usually mean a shallow latch. Fix the position before anything else.
• Ask how often the baby feeds, for how long, and how many wet and dirty diapers.
• Sort the problem: latch (pain, damage), supply (little milk), or letdown (milk slow to flow).
• Supply rises with frequent, effective milk removal, not with extra fluids.
• Check for anemia after birth. It is linked to poor milk supply.
• Bring in a lactation consultant early if the baby keeps losing weight.