OB+Rotation+info

quick summary of OB thanks to Sarah McNeil, 8/09.


 * __OB ORIENTATION__ **

(See OB-GYN page as well) toc

**Shadows**:
 * First years have a shadow for every call and second years have shadows for the first half of the year.
 * Shadows function to support the resident. Feel free to discuss any patient care issues with either the shadow or the attending.

Review the chart to see if the Family Practice doctor wanted to be paged to the delivery. Bhatt & Madrigal routinely request to be paged and all residents come to deliver their patients.
 * Continuity Deliveries:**

On-Call OB Resident
At 6:30am each weekday (8am Saturday and Sunday) everyone convenes at the board to go through sign-out. Do not just read the board. The resident post call will review each patient using the SBAR format:
 * L&D board sign-out:**
 * Present age, G_P_
 * **S**ituation (diagnosis)
 * **B**ackground (previous hx, labs)
 * **A**ssessment (vaginal exam, ROM, FHT, etc)
 * **R**ecommendations (expectant managment, start pitocin, rupture membranes, etc)

Some residents find it helpful to keep a hand written list of the patients using the SBAR format; if you do, please write any updates on the board so that others are aware of any chagnes.


 * Gyn board sign-out:** Immediately following L&D sign out.
 * The patients, room number, CC, and brief plan are written on the board in the back room
 * Gyn resident and attending of the day area also written on this board
 * Discuss which residents are going to scrub into any OR cases that day.


 * Postpartum rounding:** Link to Postpartum Guidelines on Wiki.
 * During the week, an outpatient attending helps with postpartum rounds.
 * Post-call resident rounds and usually leaves around 10am. As the post-call resident priortize rounding on patient you delivered or managed.
 * All other residents should assist with rounding depending on their morning scedule.

L&D Triage:
All patient >20wks with acute complaints are seen in triage. This can include non labor related complaints from the ER. You will see 3-4 triage patients for every one that you deliver. All residents (even R3's) must present triages to Attendings.

> - Write orders, “d/c to home,” “d/c” IV, and sign.
 * When patients arrive, a nurse puts them on a monitor in an eval bed, places their name on the white board with a brief CC
 * Always be aware of a patients dates. **Dating the patient** is really important and sometimes can quite difficult – figuring it out early, though, will really save you a lot of time. All patient less than 24 weeks are considered non-viable. Patients that are stable between 24-34 weeks are tranferred to a higher level of care (JMMC or ABMC).
 * **Relevant history**: bleeding, contractions, headache, right upper quadrant pain, other abdominal pain (some of this can be obtained from the nurse)
 * **Focused PE:** heart, lungs, fundal height, Leopold’s/Sono, reflexes, edema, +/- cervical exam (depending on the history, gestation and rupture of membranes!!)
 * **Discharge**: **You must sign out all triage patients to an attending before discharge**.
 * **Admission**: if you’re admitting a patient, you just have to write “admit” in the orders and sign
 * ** Worrisome presentations: **(ask for help quickly!): non-reassuring FHT, unstable maternal vital signs, excessive vaginal bleeding, peritoneal signs on exam, and fever of unknown source.


 * 1) **Pre-term labor**: <37weeks (but be cautious <38wks)
 * **Sterile speculum exam BEFORE digital exam!**
 * FFN (fetal fibronectin) from 24-34wks (nothing in the vaginal in the past 24hrs)
 * **Needs to stay in posterior fornix for 15-20 seconds, no lube.**
 * GC, Chlamydia: Sample OS and Posterior Fornix
 * Cath urine and utox
 * pH à Saline Prep or KOH
 * **PPROM** (premature preterm rupture of membranes): look for Pooling, Nitrazine, Ferning
 * check GBS
 * 1) **Leaking fluid:** SROM (spontaneous rupture of membranes)
 * PROM: premature rupture of membranes (>1hr before onset of labor); consider induction with pitocin
 * Speculum exam: “pooling,” amniotic fluid is nitrazine +, and dried on a slide, creates ferning
 * Consider risk of infection when doing multiple digital exam, you may want to defer an exam until patient is contracting
 * check GBS status
 * 1) **Bleeding**: normal to life threatening; **check MediTech for an ultrasound of the placenta before a digital exam!**
 * Call for help
 * Previa – **painless** bleeding; abruption – **painful** bleeding
 * **Labs:** CBC, type and cross, coag test, Pre-eclampsia labs, urine drug screen
 * 1) **Decreased fetal movement**: consider gestational age and risk factors; reactive NST often alleviates the anxiety (and families love to see fetal movement on the ultrasound)
 * 2) **Pain**: all that hurts isn’t labor; think about appendicitis, pyelonephritis, cholescystitis, adnexal torsion, UTI (consider whether a cath UA is worth the discomfort)
 * 3) **Labor at term**: regular, painful uterine contractions and cervical change
 * >4cm à usually admit directly
 * <4cm à consider the situation!

Admissions
**Complete H&P** with orange stripe for Labor Admit
 * Check in with patient and nurse (is patient about to delivery immiently?)
 * Look on meditech for labs, # of patient visits, and ultrasound results, obtain labs from Quest if not done in our system.
 * Important for billing to include # of prenatal visits!
 * Sort through pre-natal records, check the files for recently faxed pages.
 * Talk to patient
 * Present to attending
 * Fill out orders/Medication Reconcilliation form (see below)
 * Important to include meds for the pediatricians (this is often all they see)
 * Complete VTOL checklist and consent if trying to deliver vaginally after 1 prior c-section
 * Complete Surgical consent form for elective c-section.
 * Order labs if patient **hasn’t had 3rd trimester labs** (in the last 8 weeks), stat HIV (f/u within the hr), RPR, & CBC, Type and Screen if patient is high risk for bleeding during c-section or is anemic to being with.
 * Swab for GBS if not done yet.
 * TB Screening:
 * No testing needed if low risk: not out of country for >1mo in last 5yrs; not homeless, no jail, do street drugs in last two years
 * Negative QFT à no CXR needed (regardless of prior TST/PPD)
 * High risk and no result à order QFT on L&
 * If +PPD (TST) and no QFT à CXR and consider checking a QFT
 * UPDATE the sign out border: You need to write then estimated fetal weight, fundal height, GBS status, position (sono and/or feeling sutures are best!) and any other relevant details.

**Admit orders** Pain Medication: Some providers do not like stadol since it lasts longer. Fentanyl is the other option. It is ok to check both boxes and discuss with nursing. Some providers like all patients to be NPO while in labor, consider feeding patient before placing induction agent or starting pitcoin. Separate pre-printed forms/consents exist for the following:


 * VTOL (vaginal trial of labor) for VBAC (vaginal birth after cesarean): Patient need to be consented and made NPO
 * **IOL** (induction of labor): common indications include GDM, pre-eclampsia, post dates, cholestasis, etc.
 * **Antibiotics** for GBS (group B strep). GBS positive mom should get two doses of penicillin before delivery. Peripartum fever is treated with two temps > 100.4 with symptoms, or one temp > 101, usually with Unasyn.
 * **Pre-term labor**
 * **Pre-eclampsia****Fetal demise**
 * **GDM** (gestational diabetes mellitus)
 * **Med reconciliation**: tear off behind the H&P; the nurses hate when we don’t remember this one! (Also needs to be signed on postpartum d/c)
 * **C-section consents**:
 * Make an effort to put all possible surgeons in the box at the top.
 * Discuss **risks & complications: The** basics include risk of infection, bleeding, damage to other organs (especially with repeat csx), rare risk of needing blood transfusion and hysterectomy

Induction of Labor:
Before examining the patient, review bishop scores. If the patient has a favorable cervix, bishop score >6, start with pitocin. There are preset orders and the nurse will titrate it by protocol. If the patient is <=5, then consider a ripening agent, cervidil, misoprostol, or foley balloon. Discuss with your attending the dose and type of ripening agents.

Progress Notes:
Write a progress note on all women once every 24 hours. Update your notes whenever their is an event or intervention (fetal heart rate abnormality), starting pitocin, placing an epidural, or placing internal monitors.

Active Management of Labor

 * **AROM (artificial rupture of membranes)**: can expedite labor, but is also associated with higher infection rates
 * Plastic crochet hooks are in the bottom drawer below the FHTs in each room
 * Head must be engaged, so you don’t have a cord prolapse; feel for a bulging bag, hook it, and wait for liquid to come out; if you do feel something like a prolapsed cord, **do not move** and call for help! Note if the fluid is clear or meconium stained (green)
 * **Fetal scalp electrode**: used to better monitor FHT; Literally screwed into the baby’s scalp (so membranes need to be ruptured)
 * **IUPC** (intrauterine pressure catheter): to better measure the strength of contractions, often useful with obese patients and/or patients on pitocin
 * Augmentation of Labor**: When the patient's progress fall off the curve, consider adding pitocin to augment stronger contractions. This can be titrated and monitored using an IUPC. Only start pitocin if the baby is tolerating labor well.

D elivery

 * Assisted Vaginal Delivery: Vacuum and Forceps**
 * An assisted vaginal delivery can occur using either a vacuum or forceps. Be sure the let mom know what your are doing. In any distressed situation verbal consent is adequate.
 * Confirm that mom has a liklihood of a successful vaginal delivery (+2 station, discussed concerns for macrosomia, etc)
 * See section on OB dictations for details on how to document a vacuum assisted vaginal delivery.

In an otherwise uncomplicated delivery where the baby appears well at the perineum, we are encouraging babies be placed on mom's chest ‘skin to skin.’ When doing skin to skin, remove mom's monitors and lift her gown so baby is against mom's belly/chest. Resuscitate routinely with stimulation and drying. Communicate well with your staff. If anyone is concerned about the well being of the baby, go to the warmer and adequatly resuscitate before returning to skin to skin. Consider delayed clamping of the cord for 1 minute is possible (no signs of fetal distress.
 * Skin to Skin**

Post-delivery paperwork:
= =


 * 1) Ask the nurse for the delivery summary. If Peds was not at the delivery, document Apgar scores with nursing staff.
 * 2) Delivery summary **includes pieces that you must fill out**: 3 vessel cord? Intact placenta? EBL? Sex of infant? Lac? Repair? Make sure your name is legible!!
 * 3) See sample dictations to help you out. Do not take more than 15 minutes the dictate. You can correct any typos or poor grammar latter.
 * 4) Post partum orders: check all the boxes, the form was designed to give the nurses orders if needed.
 * 5) Antibiotics: Only continue if concern for chorioamnionitis, and continue until mom is afebrile x 24 hours. Don’t forget about the fever worksheet
 * 6) Complete the discharge summary (form with purple edge): diagnoses, procedures done, hospital course. You are able to quickly summarize the patients delivery and history. The postpartum rounders will have to scour the chart for this info, so take 2 minutes to complete this.
 * 7) Newborn orders: make sure to look at antenatal and intrapartum risk factors (call nursery resident/pediatrician with questions)
 * 8) If newborn is 34-37 weeks, use the late preterm newborn orders.

Post partum tubal ligations (PPTL):

 * Place the patient's name on the sign out board
 * Make sure consents are correct (ask about exceptions if necessary) and that she still desires a permanent procedure. Ask about prior surgeries, especially to the tubes and ovaries.
 * Put her on the OR schedule with case request --make sure shows up on the OR schedule and ask for help to get this correct. Do this early so that she gets an earlier spot on the schedule.
 * Make sure Attending aware. Text page Med Center supervisor 243--weekday cases done the next morning at 7am usually, and weekends at 8am --crew and anesthesiologist need to be called in at 7am on weekends.
 * Make the patient NPO after midnight, start IV then with D51/2NS with 20mEq KCL.

C-section paperwork

 * Orders: post c-section orders are a separate sheet; no need to fill out the regular post-partum orders
 * **PCA**: Morphine is standard (the first box), 2mg bolus, 1mg dose and interval of Q10min with NO BASAL! If the anesthesiologist is giving a morphine bolus through the epidural, delay onset of the PCA by 4 hours.
 * **Operative report**: Fill out findings, ask anesthesiologists about EBL, urine output, and replacement fluids
 * Anesthesiologists: Lee, Kwok, Vukalcic, Lindsay, Teung
 * **Dictation**: see the red book or sample dictations: Suture is usually #1 chromic or monocryl on the uterus and #1 vicryl on the fascia.
 * Pre-op note: there is a section for you and the attending to complete to pre-op note. The attending will mark the indication for the c-section

P ostpartum
See Postpartum Guidelines

I mportant telephone numbers
5608 – L&D 5613 – post partum (5B) 5615 – nursery 5340 – OR (2nd Floor)

Dictations:
Dial 77. Author ID: “keane ID” (given in orientation) Location: 1 (Martinez). Work type:


 * Operative (c-section) – 3
 * Discharge – 7 Delivery—22
 * OB triage – 35

To pause dictation: 1 To end dictation: 5 (get ready to write down the dictation number!!) Sample OB Dictations.

F etal Monitoring
= = Variability**: Minimal < 5bpm; moderate 6-25bpm; marked > 25bpm** Loss of variability: sleep cycles (20-30min), narcotics, MgSO4, prematurity (<32wks) **Accels**: 15bpm above baseline for > 15 seconds (<2min) Sinusoidal pattern: think about fetal anemia (stadol, fentanyl) **Decels**: Variables: < 30sec to get to nadir; all different shapes (cord compression) Late: >30sec to get to nadir; rounded in shape Early: 30sec to get to nadir; rounded in shape (head compression, vagal) **Baseline heart rate**: 110 < normal < 160; brady or tachy is > 10min **Uterine contractions**: tachysystole is > 5 contractions in 10 minutes Sinusoidal pattern: think about maternal meth/cocaine use

Absent and/or minimal variability, accompanied by recurrent decels and/or sustain bradycardia (<60bpm) are associated with acidosis in the fetus è Intrauterine resuscitation: left lateral position, O2 facemask, IV fluid bolus, d/c cervidil or pitocin, cervical exam

** BP in Pregnancy **
**Gestational HTN**: BP >140/90 **after 20wks gestation**; no proteinuria Risk à pre-eclampsia **Pre-eclampsia**: BP > 140/90 after 20wks gestation; proteinuria **(>1+ or >300mg/24hrs on 2 diff occ)** Edema is supportive of dx, but not in criteria 1/3 of cases are postpartum Management: weekly/biweekly **labs** (hgb, plts, urine protein, creatinine, uric acid, AST, ALT), Delivery at 37-39 weeks **Severe pre-eclampsia**: BP **> 160/110**, h/a, visual Δs, pulmonary edema (caution w/ fluids), elevated creatinine, hepatic dysfx (RUQ or epigastric pain), oliguria, proteinuria **(>5g/24hr),** thrombocytopenia/hemolysis Management: vital signs, neuro checks and DTRs Q15-60min; foley cateter for Is/Os **Labs**:pre-eclampsia + LDH, peripheral blood smear, coagulation profile, albumin Lower BP to prevent cerebral hemorrhage, delivery **HELLP** (one presentation of severe pre-eclampsia): hemolysis (abnl smear, LDH > 600), elevated liver enzymes (AST or ALT > 100), low platelets (<100K) **Medications:** Magnesium (anti-convulsant; does NOT affect BP), labetalol, hydralazine
 * Chronic HTN ** : BP > 140/90 **before 20wks gestation**; no proteinuria; elevated BP > 12wks postpartum

** Vaginal bleeding in latter half of pregnancy: **
**Placeta previa**: painless bleeding in 2nd or 3rd trimester; often after intercourse Complete, marginal, low-lying (seen in 50% of 16-20wk U/S; 90% resolve) Risk factors: prior c-section/ instrumentation, high parity, AMA, smoking, multiple gestations **Placental abruption**: painful bleeding Risk factors: HTN, smoking, cocaine, trauma, overdistention of uterus
 * Worrisome ** : placenta previa, abruption, ruptured vasia previa, uterine scar disruption/rupture

** Treatment of preterm labor: **
Bed rest and hydration not proven beneficial **Cortisteroids** for 48hrs: betamethasone or dexamethasone **Tocolytics**: terbutaline (SE: pulmonary edema), magnesium (SE: flushing, warmth, facial edema, respiratory arrest), or CEB

** Assisted vaginal deliveries: **
Pneumonic for vacuums: ABCDEFGHIJ **A**sk for help, address the patient, adequate anesthesia **B**ladder empty? **C**ervix fully dilated? **D**etermine position (anterior fontanelle has three sutures), think about possible dystocia **E**quipment and extractor ready **F**ontanel – 3cm in front of posterior fontanel at the flexion point **G**entle traction during contractions **H**alt traction after contraction, half procedure with > 3pop offs, no progress in three pulls **I**ncision – evaluate for episiotomy **J**aw – remove vacuum when jaw is reachable

** Shoulder dystocia: **
pH decreases by 0.4 for every minute the baby is not getting oxygen **HELPERR** pneumonic: **H**elp **E**valuate for episiotomy **L**egs (McRobert’s maneuver) **P**ressure (suprapubic) **E**nter vagina **R**oll the patient (to hands and knees) **R**emove the posterior arm

** Postpartum hemorrhage (PPH): **
**Resuscitation**: call for help, ABCs, two large bore IVs, oxygen, stat labs (type & cross, hgb, coags) Rx: oxytocin, 10-40 units in 1L at 250cc/hr; methergine (contraindicated in HTN), hemabate (SE: diarrhea, n/v)
 * Causes ** (4 T’s): tone (70%; atony, atony, atony!), trauma (20%), tissue – retained) (10%), thrombin (10%)



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