FMIS Obstetrics

These are guidelines. For any doubt/questions, ASK ASK ASK!!!

• Check out all decisions with upper level and/or attending.

• See the color-coded calendar at the L&D desk to determine who to call.

• Present all L&D patients to the upper level & attending.  All patients must be checked our prior to discharge!

• Fetal heart monitor (FHM) strips must be seen & signed by an upper level before patient leaves.

• For morning report or evening check-out  (7/7:30 am) include:

  ·        For laboring patients: Age, Gs & Ps, Gest. age, GBS status, FHM, Ctx freq., +/- SROM/AROM with clarity & time, +/- Pit, Dil/Effcmnt/Sta. & time.

  ·        For delivered patients include Age, Gs & Ps, Gest. age, GBS status, lacs &  repairs, problems, & time of delivery.

• High risk OB (HROB) clinic starts about 8:30-9am every Monday & Thursday on the 5th floor.  You will be paged when it starts.  Dr. Hulet or Dr. Kruse (OB) will teach.  THIS CLINIC IS A PRIORITY.  If you need to come in a bit early on Mondays and Thursdays to be ready for HROB, you should.  However, one of the upper level residents should help with the OB service if you are overloaded.

• All U/S should be done with an attending or upper level.

• Assess and write a note on a laboring patient about every 2 hours. Although the OB nurses rock, they can sometimes be so busy that decels or other things can be missed.  Remember, you are responsible to know what is going on with L&D patients.

• We like to deliver our own pts. On those pts. with a resident as their PCP, call as soon as the patient is checked in and initially evaluated (ie you find they are in active labor).  Find out if the resident is available & wants to deliver his/her own pt.  You have to have 10 PCP deliveries to graduate (have to be present only…doing baby resus or assist in Csec counts).

• For all eminent deliveries notify the upper level and the attending with enough time to arrive. A page to 5540-911 tells us to run up right away. Consider that earlier notification is required for multips.

• For PCHC patients who require an U/S or help with wet prep, FHM strips, etc. and attending is not available during the day call the upper level or SCFM attending.

• You should not get calls to help with Wendy Raso's (midwife) patients unless she's on vacation, the patient becomes high-risk, or it's a precipitous delivery & she may not make it. This last point also applies to other Dr.'s pts, too.  The babies of Wendy’s patients generally you will be following.

• Remember to record deliveries (with Pt DOB, MR#, date, and attending) for personal procedure log.

•  Drugs during labor:

• Stadol 1mg, Nubain 5-10mg, Seconal 100-200mg, Phenergan are categorized as class C & D drugs, but the Obs and FPs do order them routinely. Make sure FHM looks good. Ask if uncomfortable with ordering.

• General dosing ideas:

•         Stadol 

  o       Good for early active labor (ie. 2mg stadol with 12.5-25mg phenergan IM)

  o       Once you use stadol, it’s best to stick with it throughout labor.

• Nubain

  o       Only use in active labor (short action)

  o       General give 10mg dose (should last 1-1.5 hrs)

  o       Excellent first time med, repeat doses generally don’t work

•         Fentanyl (occasional used)

  o       Generaly use 75-100mcg

  o       Very short acting (wears off in about 30 min), use later in labor

  o       Can repeat in 1 hour or earlier if baby reactive.

•         Pudendal block

  o       Inject 10cc per side of 1% lidocaine (ask for kit).

          Thecal block

  o       Great if progressing fast

•         Epidural

  o       Can keep epidural going during delivery as long as mom is moving baby

  o       Generally have it placed when baby at 0 station and mom dilated to at least 5cm  if primp (4cm if multip).

  o       Lasts about half hour after you shut it off.

• If GBS +

o       Recommended:

o       Pen G 5 million units IV initial dose, then 2.5 million units q4 hours until delivery

o       Alternate

o       Ampicillin 2g IV initial dose, then 1g IV q8 hours until delivery

o       If Pen allergic

o       If not at high anaphylaxis risk:

§        Cefazolin 2g IV then 1g IV q8 until delivery

o       If at high anaphylaxis risk:

§        Clindamycin 900mg IV q8 until delivery  (alternative   erythromycin 500mg IV q6 hours until delivery)

• Wetprep and KOH

• You need 2 slides.

• Saline slide: Look for clue cells = BV (40x) and moving trichomonas.

• KOH slide: Perform whiff test (+ suggests BV) & look for budding hyphae.

• UA

• They automatically dip all urine when pt gets to LD.

• If suspect UTI, send catheterized UA to lab for C & S.

• If spec gravity high hydrate ( PO or IV).

Fetal monitoring  

• Baseline:

o       Tachy (>160bpm) - maternal fever or hyperthyroidism, amnionitis,

          sympathomimetics, fetal hypovolemia or hypoxia (early fetal distress).

o        Brady (<120 bpm) - maternal hypothermia or beta blockers, paracervical block, fetal conduction defect (110-120 bpm may be normal).

o       Sinusoidal - narctotics (esp. fentanyl); usually a sign of extreme fetal jeopardy, e.g., severe fetal anemia from bleeding or Rh       isoimmunization

• Decels: (see above diagram)

o       Early: Lasts < 90 seconds, decels 10-40 bpm, not <100 bpm, coincides with ctx - head  compression with reflex brady, not worrisome

o       Late: Decrease 50-60 bpm, starts and/or persists after ctx - Worrisome for uteroplacental sufficiency, watch BTB (internal monitor) and LTV; Consider scalp fetal electrode. Turn pt on side & give O2.

o       Variable: Quick onset & return, often preceded by small accel, usually coincides with ctx but may be anywhere in cycle - cord compression, usually not a big problem but may eventually cause compromise if deep, prolonged, or slow to return to baseline ("late component"); early in labor or resting is a clue to oligohydramnios

• Reactive strip: >=2 accels to 15 bpm above baseline lasting 15 seconds within 20 minutes

• Kick count: 10 movements within 8hr or no less than usual.  Relaxing and eating or drinking helps mom notice movements.

•  R/O Rupture of Membranes (ROM)

• Perform sterile speculum exam:

o       Check for pooling, look for expressed fluid from the cervix with a cough.

o       Do nitrazine paper test (Blood, urine, & infxns can cause false +).

o       Check for ferning on a slide of dried cervical fluid.

o       Note estimated dilation/effacement/position of cervix.

• If suspect rupture, but neg. nitrazine & neg. ferning, then check amniotic fluid index (AFI). If >6 then reassure and d/c pt. If <6 will keep pt & consider induction.

• If +ROM and term note time that it occurred, admit pt, and anticipate SVD.

• If +ROM and preterm discuss with attending ASAP & consider transfer.

• R/O Term Labor

• Ctxs should be regular i.e., q3-5 minutes for >1hr

• Confirm dates, last cervical exam & date, +/- ROM

• Check UA. If Sp Gr elevated, hydrate ( PO or IV)

• Check cervix (if no h/o ROM):

o       >= 4 cm with good ctx pattern, admit & inform upper level & attending.

o       <=3 cm with good ctx pattern, walk/wait, recheck in 1hr.  If cervix changes,  admit. If no cervical change may d/c home  if reactive FHT, no ROM, normal BP. Consider AFI.

o       <3cm with poor ctx pattern, home if reactive FHT, no ROM, normal BP.

     Consider AFI.

• Always consider speed of prior labor(s), distance from hospital and social

situation in deciding to keep pt or send home.

• R/O Preterm Labor (PTL)

o       < 36—37 wks with over 4 ctxs/hr and likely/documented cervical change.

o       Do NOT do a digital SVE if possibility of ROM or bleeding; Do a sterile speculum exam.

o       If pt not bleeding & no loss of fluid (LOF), then may do digital SVE.

o       If + ctxs then check UA dip for dehydration (high Sp Gr),  Hydrate by PO/IV if needed. Consider wet prep, KOH, GC, Chlam. Monitor vitals.  Look for reason of PTL and treat the cause. Consider tocolysis (terb, MgSO4) if dilated with contractions. Repeat cervical exam in 1-2hrs. Consider Betamethasone 12mg IM q24hr x2 or dexamethasone 6mg q12hr x4 if delivery inevitable. 

• If - ctxs for 2hrs and no cervical change, d/c home. 

• Do not send pts home until no ctx for 2hrs and no cervical change. 

• Call attending ASAP if patient is truly in PTL!

• Call Peds if pt will likely delivery here and is <36weeks.

• We generally transfer pts at <35 weeks who will inevitably deliver.

o       For any transfer to Memorial: Call doc first, then transport, then fill out EMTALA forms.  Memorial Hospital doc # (719) 365-2802. Transport number 1-800-763-4373 

• 1st Trimester Bleeding

• Ask about LMP, fetal heart tones, passed tissue, abdominal pain.

• Listen for fetal heart tones. 

• Pelvic exam: Os open of closed? Uterine size? Tissue for pathology?

• Consider CBC, TSH, Type and Screen, RH status, quant serum B-HCG.

• Pelvic U/S to dx IUP, ectopic, and missed, threatened, or complete Ab.

• If not ectopic, follow quant B-HCG as outpatient to 0.  Pt may need f/u U/S. 

• F/U in clinic within 48 hrs of ER visit.

• 2nd/3rd Trimester Bleeding

• NO DIGITAL EXAM until previa ruled out. Look for old U/S reports, if any.

• Ask about trauma, falls, recent intercourse.

• U/S to determine location of placenta (r/o previa and abruption). Or order

• formal U/S.

• Sterile spec exam to find source of bleed; If no previa, then digital SVE.

• Consider Kleihauer-Betke (rarely done), CBC, UA, Tox screen, type and cross. 

• Pts may go home only if no previa, no bleeding from os, no PTL or ROM and reassuring or reactive strip.

• Decreased Fetal Movement

• If >= 32 weeks or previously documented reactive strip, then look at fetal

heart rate tracing.

o       If reactive without decels, consider AFI and if not PTL, ROM, or vaginal bleeding, then give kick count instructions and f/u in clinic in 1 wk.

o       If not reactive, place pt on left side and give juice or IV fluids. If still not reactive, then do AFI and consider BPP.

• Pts 25-32 wks are not expected to have reactive strips unless previously documented as reactive.

• PIH/Pre-Eclampsia/Eclampsia

• H&P (HA, visual changes, abd pain, swelling)

• Monitor BP’s

• Check urine for protein

• Order HELLP labs (CBC, LDH, AST, ALT, Cr, Uric acid, PT, PTT)

• If high suspicion get upper level & attending involved ASAP

• Meds to consider:

o       For BP- Hydralazine, Labetolol, Nifedipine

o       For seizure prophylaxis- MgSO4

o       For actual seizure- Diazepam

• Hyperemesis

  • Check VS, UA for ketones, and FHT.

  • If + ketones then IV fluids with Phenergan 25mg IV.

  • Pt can go home when ketones clear & tolerates PO . 

  • May need to admit for obs. 

  • Consider outpatient Phenergan or Compazine.

  • If persistent hyperemesis get U/S to r/o multiple gestation or molar pregnancy and check TSH.

• Postpartum Hemorrhage

• Check VS, flow, delivery note (h/o retained or fragmented placenta, lacs)

• Perform vaginal exam.  R/O retained products, clots, etc.

• Give pitocin IV initially, then consider methergine 0.2-0.4mg IM/IV q2-4hr (up to 5 doses) or hemabate 250mcg IM (may repeat x1) if no luck.

• (Note: No methergine with high BP; No hemabate with h/o asthma)

• Abdominal/Back Pain

Differential Dx: Consider pre-eclampsia/HELLP, round ligament pain, UTI, pyelonephritis, gallbladder disease, endometritis, BV, cervicitis, trauma, fetal pressure, discomforts of pregnancy

• VBAC

• HROB eval is mandatory. Do not use cytotec.

• Must have IUPC placed if using pitocin.

• Whether or not a VBAC is allowed is up to the OB/GYN, if they show up in labor on a weekend or at night they may have a c-section. 

• C-section

• If after consulting an OB , if a C/S is decided upon it's your job to tell the patient & get consent (if you feel comfortable), call the assisting upper level, call the attending, & if necessary, call the pediatrician.

• You serve as baby-catcher & assist with resuscitation with attending.

• On weekend mornings you have no OB obligations when post-call. The OB intern coming on to call sees patients & writes notes. 

• Sample OB Notes

• Admit note   SCFM R1                                                                                                   

• (Most info is on the prenatal flow sheet. Confirm & update important info)   

HPI: 21yo G1 P0 at 39-1/7 weeks by HROB U/S done on (date) presents c/o

ctxs since (time) occurring Q5min. Denies ROM (rupture of membrane),

vag bleeding, vag d/c, PIH sxs, dysuria or urgency. Reports good FM

(fetal movts). Pregnancy complicated by (med dzs, infxns, abmnl, etc.)

OB Risk factors: Late entry, asthma

PObHx: Date, gest age, wt, mode of delivery, & complications

Ob Labs: GBS, blood type, H/H, GC, RPR, HIV, HBV, etc. (Prenatal labs)

PMHx:                  PSHx:                   Meds:           All:              SocHx:       

PE: VS        Exam with focus on edema, DTRs, clonus & of course pelvic (SVE)          Dilation/Effacement/Station & Vertex with BOWI (bag of water intact)

Toco: Q4-5min and regular

FHM: Baseline 120s with accels to 160s. No decels. Good BTBV (beat-to-

beat variability) & LTV (long term variability).

UA: Sp Gr, etc.

A/P: 21yo G1P0 at term in active labor with BOWI. Admit & monitor. Anticipate NSVD. D/W Dr.(upper level) & Dr.(attending).

(Note: No dictation is required for L&D admits)

• APGAR Scoring

• Delivery Note               

• SCFM R1                                                                                         

This is a 21yo G1 now P1 who presented at 39-1/7 weeks. Pt  progressed to C/C/+3 with pit augmentation and started pushing. Patient was AROM'd(or had SROM) with clear fluid at (time) and was known to be GBS neg. Sterile prep achieved. A vigorous female infant with moving extremities was spontaneously delivered over intact perineum (vs. following episiotomy) at (time). Nuchal cord x1 reduced at the perineum without difficulty. Infant bulb-suctioned immediately after delivery. 3 vessel  cord clamped and cut. Infant taken immediately to the resuscitation table. Cord blood obtained. Intact placenta spontaneously delivered with trailing membranes at (time). Fundal massage was performed and good hemostasis. Achieved. EBL 300cc. Fundus firm. Insepection of perineum revealed superficial non bleeding vaginal sidewall tears (vs a 2^nd degree posterior vaginal lac…in which case…1% lidocaine placed locally without complications. The laceration was repaired with 3-0 vicryl, and hemostasis was achieved.

Baby girl with APGARs 8/9, 7# 2oz. Pt & baby stable and recovering in room. Dr.(attending) & Dr.(upper level) were present during the delivery.

• Sample Rescus Note

          Vigorous male infant delivered to a Gxnow Px mom at term via NSVD. Pregnancy complicated by maternal smoking, 1^st trimester bleeding. Labor complicated by GBS=. Received 3 doses of Pen G prior to AROm of clear fluid. After delivery infant taken to warmer for resus and received bulb suction and blow by O2. APGARs 8 at 1 min (2 off for color), 9 at %min (1off for color). Weight 7lbs 14oz. Length 21inches. 3 vessel cord.

          PE: HEENT-anterior fontanelle open and flat. Moderate caput. NECK- no masses, clavicles intact. CV HR 150s, RRR, no murmur, 2+ bilat femoral pulses CHEST- lungs clear ABD- no masses, soft BACK- no masses, sacral dimple present GU- normal male genitalia, bilateral descended testes, anus patent ORTHO- no hip clicks NEURO- good suck, nl morrow, nl grasp

          A/P: Healthy term baby boy with GBS+ mom.

          1)Routine neonatal care 2) Observe x 48hours

• Lacerations

1^st degree-involves vaginal mucosa or perineal skin but NOT the underlying muscle

2^nd degree-involves underlying lascia or muscle, but NOT the rectal sphincter or mucosa

3^rd degree- extends through the rectal sphincter, but NOT into the rectum

4^th degree-extends into the rectal mucosa

• Postpartum Rounds

• Ask each day:

• lochia, cramping, voiding, feeding (breast vs bottle), orthostatic symptoms, problems/concerns

• Discuss before discharge:

• self care, pelvic rest, diet/exercise, meds (Ibuprofen, PNV, etc), birth control, signs infection, sxs pp depression, etc. Patients need to return to clinic for 6week postpartum visit.

• At check out

Give age, GP’s, gestational age, GBS status

o       If in labor- ctx pattern, FHM, last cervical check

o       If postpartum- time of delivery, any problems with delivery, lacs, e tc