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Frequently Encountered Situations on Labor and Delivery

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Frequently Encountered Situations on Labor and Delivery Powered By Docstoc
					Developed by Wendy Beyer, MD and Susanna Magee, MD, MPH
Portions have been adapted from “SCVMC Pocket Guide to the OB Rotation”
Contents
Overview of the Rotation                         4
Attending Floor Coverage/Who’s on Call           5
Eval Patients                                    6
Antepartum Testing                               6
Labor Patients                                   7
Medical Records/Computer/Dictation               8
Frequently Encountered Situations on L&D
    Fetal heart monitor strips                   9
    HTN in Pregnancy                             10
    Gestational Diabetes                         13
    Hyperemesis                                  14
    Preterm Contractions/Labor                   15
    Tubal Ligation                               16
    Induction of Labor                           16
    Group B Strep                                17
    Pain Control                                 18
    Internalizing Patient Monitors               18
    Prolonged Decel                              18
    Amnioinfusion                                19
    Chorioamnionitis                             19
    Endomyometritis                              19
    Your Delivery Table                          20
    Neonatal Resuscitation Algorithm             21
    Shoulder Dystocia                            22
    Postpartum Hemorrhage                        22
    Postpartum Fever                             24
    Postpartum Perineal Wound Care               25
How to Consent /Counsel for Certain Situations

                                2
     Cesarean Section                                 26
     Vaginal Birth After Cesarean (VBAC)              26
     Macrosomia                                       26
     History of Shoulder Dystocia in Prior Delivery   27
     Herpes                                           27
     Breastfeeding                                    28
     Circumcision                                     29
     Postpartum Contraception                         30
Getting Patient Ready for PPTL                        31
Documentation                                         32
Example Vaginal Delivery Note                         33
Neonatal Resuscitation Note                           34
Example Eval Note                                     35
Example Postpartum Daily Progress Note                36
Example Daily Baby Progress Note                      37
Example Labor Admit Orders                            38
Example Postpartum Orders-NSVD                        39
Example Postpartum Orders-LTCS                        40
Example Antepartum Discharge Form                     41
Example Postpartum Discharge Form                     42
Example Newborn Initial and Discharge Form            43
Glossary of Acronyms/Abbreviations                    44
MCH Medical Spanish                                   46
Commonly Used Medications on L&D                      52




                                  3
Overview of the Maternal Child Health Rotation

Welcome to the MCH rotation at MHRI. We are happy to have you here. We think you will enjoy
your time here and gain valuable experience for your maternal child health training. The following
information is essential for you to review and follow while you are here on the MCH service.


Learning Objectives:
       1. Triage of term patients with appropriate evaluation for admission or discharge; to
          recognize problems which would require additional medical attention e.g. post-dates,
          decreased AFI, PIH, GDM, VBAC counseling.
       2. Evaluation and management of preterm contractions, preterm labor and PPROM.
       3. Demonstrate adequate knowledge of labor management including labor dystocia and
          accurate interpretation of fetal heart monitoring.
       4. Learn how to manage more complicated intrapartum conditions as well as appropriate
          post-partum care for these conditions:
              a. PIH/pre-eclampsia
              b. Gestational Diabetes
              c. Post-partum Hemorrhage
              d. Shoulder dystocia
       5. To feel comfortable in the delivery room setting with term spontaneous vaginal deliveries
          under the supervision of senior resident and faculty providers.
       6. Learn how to repair second degree vaginal lacerations with competence; and be able to
          recognize 3rd and 4th degree lacerations requiring OB consult.
       7. Learn the principles for operative vaginal delivery e.g. vacuum assistance.
       8. Post-partum care of both complicated and uncomplicated patients.


Schedule:
       1. Weekday rounds start at 7:30am sharp in the Wood 2 conference room. All post-partum
          mom/baby pairs and any Level II babies need to be seen and have notes finished and in
          the chart prior to rounds. You and your co-intern should divide up the patients. Try to see
          the same patients daily until their discharge. On days the OB R2 is post-call he/she will
          help with notes. The post-call person should also make sure all laboring/eval patients “in
          the back” have notes and are up to date on plan of care for presentation at rounds.
          Generally only one intern is covering the floor at a time, therefore sign-out times are key
          to providing quality patient care; thorough resident to resident sign-out of all labor/eval
          and post-partum patients must take place at morning rounds, at lunch time and at 5pm. It
          is helpful to keep the whiteboard in the conference room updated to be sure nothing is
          missed at sign-out.
       2. Weekend and holiday rounds start at 8am, outgoing post-call and incoming on call
          residents should split the notes on weekends and holidays.




                                                  4
General Daily Attending Floor Coverage: (subject to change, changes posted in
conference room on a weekly basis)

       Monday – Dr. John Morton (OB)
       Tuesday – Dr. Emily Harrison (Family Med)
       Wednesday – Dr. Sue Magee (Family Med) and MCH Fellow
       Thursday – am Dr. David Harrington (OB)/ pm Dr. Sue Magee
       Friday – am Dr. Heidi Peterson or Dr. Pepi (Family Med)/ pm Dr. Mimi Koehm


Who’s On Call? – all schedules posted behind nursing desk in L&D
       MCH – there is always a Family Doc or midwife on call for FCC patients or patients who
       show up from an outside hospital or do not have a doctor
       Senior Surgeon – one of the OB-GYNs is always on call as back-up
       Neonatology – Pediatrician on call for delivery of high risk newborns
       Anesthesiology – an attending is available in house 24/7
       FCC (FM inpatient service) – attending and FMR3 on call for FCC babies
       Other providers on call for their own patients:
              Morton/Harrington/Pepi
              Peterson
              Koehm
              Harrison
              Mumford-Haley/MCH Fellow
              Nothnagle/Magee/Anthony/Taylor/Duarte/Rubeor


On your first day of the rotation, if you have not already done so, grab your senior, or pedi resident
or an L&D nurse and go into a delivery room. Have them show you, and familiarize yourself with the
layout of the room, where things are kept, how to find emergency equipment and how to turn on and
set up the baby warmer/suction/O2. As you read through the following commonly encountered
situations, stand in the room and find the equipment you would need in a given situation.


Labor/Eval Patients:

        New patients will arrive from several sources: being sent in by their PCP (PCP should call
and let the floor know patient is coming and question to be addressed, they may give this info to the
nurse or the resident), from the ER (anyone over 20 weeks will generally be sent up upon presenting
to ER, note: trauma patients must be cleared from a trauma standpoint (e.g. c-spine) in the ER before
being sent to Wood 2), ambulance transport or “walk-in.”
        Generally patients are from: (call the individual office for their own patient evals)
        FCC – residents or attendings
        Drs. Harrington/Morton/Pepi – Women‟s Health Associates, Pawtucket
        Dr. Harrison – Women‟s Care Pawtucket
        Dr. Peterson – Attleboro Family Medicine
        Dr. Mimi Koehm – PCC Quality Hill/Plainville
        CNM Mary Mumford-Haley/MCH Fellow – East Bay Family Health
        also walk-ins or evals may be patients at Women and Infants Hospital/BVCHC
                                                  5
Eval Patients:

      1. Patient will be placed in a room and on the monitor by nurse, nurse will gather initial
         vitals, EDD and chief complaint and enter on top of eval form.
      2. Resident will then gather further history and PE data as needed depending on complaint.
         For the first month all speculum and vaginal exams must be witnessed and verified by
         senior resident. Discuss data including toco/FHR and plan with senior resident then call
         attending before implementing plan unless emergent issue (e.g. baby crowning) in which
         case ask the nurse to call the senior resident and attending immediately. In general it is
         always better to call in your help (senior, attending) sooner if you think you may need
         them.
      3. Resident will write orders and go over plan with nurse and patient as discussed with
         attending. Charts on eval patients can get scattered so be sure to tell the nurse personally
         of any intervention, lab or medication you are ordering.
      4. Resident will write a full note on each eval – for FCC patient this note should be in
         Logician and flagged to the PCP, for all other patients this note should be on the back of
         the Eval Form. Please see section on forms for what should be included in this note.
      5. Resident will gather data including exam, labs or studies and review case with attending
         before discharging or admitting a patient.
      6. Upon discharge of eval patient resident will fill out and go over Antepartum Discharge
         Instruction form with patient including reasons to call PCP and follow-up appointment
         plan. Resident should note in the bottom of the eval form which attending the patient was
         discussed with, the time of discharge and sign the bottom of the form.




Antepartum Testing:

      1. Patients with risk factors will be scheduled for weekly (or biweekly) NST/AFI in the 3rd
         trimester. Each time you see one be sure to book the next NST/AFI and write it in the
         Antepartum book on the nurse‟s desk. Try to space these prebooks out in the day if you
         see there are already several patients coming in.
      2. These patients are often coming in frequently, please try to see them in an efficient
         manner so they are not stuck on Wood 2 for too long every week.
      3. Nurse will put patient on monitor, get vitals and reason for testing. Resident should review
         patient‟s chart and get brief interval history (for instance glucose log if diabetic,
         contraction hx if preterm labor etc.). Review NST, check AFI (your senior must watch
         you the first couple times to verify your competence).
      4. When you have all the data, call the patient‟s primary attending (or floor coverage
         attending for FCC patients), present the case including follow-up plan. Once cleared by
         the attending, fill out and go over discharge paper with patient including all medications,
         follow-up appointment with PCP, next NST/AFI and phone number for her doctor‟s
         office. Tell the nurse when you send the patient home.




                                                 6
Labor Patients:

     1. Any patient being admitted needs an H&P in the chart. For scheduled c-sections the
         surgeon will generally have dictated this in advance, for all others it is the resident‟s
         responsibility to write the H&P.
     2. Fill out Admission orders (pre-set order form see form section of booklet).
     3. Keep the conference room whiteboard updated on laboring patients including mom‟s age,
         EGA, Gs and Ps, PCP, ROM, GBS status, pertinent history, most recent exam and any
         interventions (pitocin, epidural, magnesium, FSE, IUPC)
     4. Check the admission labs in CASI and document in chart – every admitted patient should
         get CBC and Type and Screen
     5. Complete antepartum section of resident patient summary sheet (see example in forms
         section).
     6. Progress notes should be written (see Sample SOAP Note on Laboring Patient for content)
             a. in latent phase – minimum every 4 hrs
             b. in active phase – minimum every 2 hrs
             c. whenever there is any intervention – document necessity of intervention, e.g.
                 induction medication, pitocin, epidural, AROM, antibiotics, FSE, IUPC, etc.
     7. After delivery the attending will write brief delivery note in paper chart, resident will
         dictate full Vaginal Delivery Summary. Resident will also fill out post-partum orders and
         enter birth certificate in computer.
     8. After a c-section it is nice to ask the surgeon if you can help with any of the paperwork,
         such as orders or birth certificate.
     9. All newborns, section or vaginal, need a full Initial Exam done and documented by the
         resident, ideally between 6-12 hrs of life, in no circumstance should this be delayed
         beyond 24hrs of life.
     10. Other paperwork to be filled out for newborns includes newborn orders, HepB vaccine
         consent, hearing screen questionnaire, circumcision consent if desired




                                               7
Medical Records (tel#2230)
       1. You are expected to sign back charts once per week at Medical Records office, 2nd floor
          near lobby atrium.
       2. For current inpatient charts please be sure to review and sign all verbal orders each
          morning, you may sign verbal orders given by one of your co-residents on the same
          service (please do so to avoid huge stacks when you go back later).
       3. Birth certificates are vital, please enter them in the computer system ASAP and be sure
          that you certify it (not just save it). See your senior resident or Gail Goes for help with this
          system.




Computer
          There are 3 systems you will need to use on this rotation:
                   CASI – web based on every hospital computer, type „webcasi‟ in location bar in your
web-browser, this shows all labs done at MHRI, results of imaging studies and dictated notes. Please
note that Blood Type and screen does not show up in this system, you must call the Blood Bank at
x2404 for this information. You should have received a username and password for CASI at the
beginning of internship.
                   Logician – FCC EMR, this will have prenatal records and full charts on all Family
Care patients, eval notes should be entered here and flagged to the PCP to ensure continuity of care.
The only computer on Wood 2 with Logician is in the conference room. This username and password
is distinct from CASI and should also have been provided at the start of internship.
                   BirthCertificate – software on dedicated computer on the central desk in “the back”
(labor area). Instructions are posted on the wall behind this computer, your username for this system
is first initial last name (JSMITH) and your password is your 5 digit hospital dictation number.




How to Dictate:
       All vaginal delivery summaries, level II infant discharge summaries and c-section patient
discharge summaries must be dictated by the resident. dial x3710 and follow prompts, work type
code for vaginal deliveries is 06, cheat sheet for dictation available from medical records, have a pen
ready at the end to write down job # as it is not repeated.




                                                    8
      Frequently Encountered Situations on Labor and Delivery

Reading and interpretation of fetal heart monitor strips




                                   9
Hypertension in pregnancy:
Chronic Hypertension:
       BP ≥ 140/90 mmHg before pregnancy or diagnosed before 10 weeks gestation OR,
       Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks
       postpartum.

Gestational Hypertension: A diagnosis of exclusion generally made postpartum. It is dangerous not
to treat if patient has presentation consistent with preeclampsia.
         BP ≥ 140/90 mm/Hg for 1st time during pregnancy.
         No proteinuria.
         BP return to normal <12 weeks postpartum
         Final diagnosis made only postpartum
         May have other signs of preeclampsia, for example, epigastric discomfort or
         thrombocytopenia.

Mild pre-eclampsia: (Management of this is Attending dependent. Some wait to start MgSO4 in the
active phase. Others start MgSO4 immediately).
        BP ≥ 140/90mmHg after 20 weeks gestation.
        Proteinuria ≥ 300mg/24h or ≥1 + dipstick.

Severe preeclampsia: (These patients should be followed with the senior resident. Start these patient
on MgSO4 for seizure prophylaxis immediately). Criteria for severe preeclampsia:
       SBP ≥ 160, DPB ≥ 110, recorded on at least 2 occasions at least 6 hours apart with patient
       on bedrest.
       Proteinuria ≥ 5g/24h (3+ or 4+ on qualitative exam). (Proteinuria may fluctuate widely over
       any 24h period even in severe cases).
       Oliguria (≤400cc in 24h)
       Cerebral or visual disturbances. (Convulsions are usually preceded by unrelenting severe
       headache or visual disturbances. Thus, these sx are considered ominous.)
       Epigastric/RUQ pain. (Due to hepatocellular necrosis, ischemia, & edema that stretches
       Glisson‟s capsule. This pain presages hepatic infarction & hemorrhage as well as catastrophic
       rupture of a subcapsular hematoma).
       Pulmonary edema or cyanosis.
       Impaired liver function of unclear etiology.
       Thrombocytopenia (<100,000/mm3). (Due to platelet activation, aggregation, &
       microangiopathic hemolysis induced by severe vasospasm. Evidence for gross hemolysis is
       indicative of severe disease: ie. Hemoglobinemia, hemoglobinuria, hyperbilirubinemia,
       elevated LDH, schistocytes on peripheral smear).
       IUGR. Also check for oligohydramnios.

Eclampsia: Seizures. 10% develop before overt proteinuria.

Superimposed Preeclampsia (on chronic hypertension):
       New-onset proteinuria ≥ 300mg/24h in hypertensive women but no proteinuria before 20
       weeks gestation.
       A sudden increase in proteinuria or blood pressure, or platelet count <100,000/mm3 in
       women with hypertension & proteinuria before 20 weeks gestation.


                                                 10
HELLP:
     Hemolysis, Elevated Liver function, Low Platelets.

If a patient has BP elevation on admission (>140/90):
Hx: Headache? Blurry Vision? Scotomata Epigastric/RUQ pain? Face/hand edema? Recent rapid
weight gain?
Physical: Edema, DTR‟s, clonus
Labs:
Cath UA for protein
BUN/Cr
CBC (for hemoconcentration (compare to her last hematocrit in prenatal care) & thrombocytopenia.)
Uric acid.
AST.
If considering HELLP, you can also order an LDH and a peripheral smear to look for schistocytes-to
check for hemolysis.

Document all labs with date/time drawn in the chart immediately when available. If serial labs are
being drawn, document the results on a flow sheet.

Pre-eclampsia orders to write:
Magnesium Sulfate 4 g IV loading dose over 20 minutes, then 2g/h IV. (MgSO4 appears to prevent
eclampsia in part by selectively dilating the cerebral vasculature and relieving the cerebral vasospasm
associated with preeclampsia).
Strict I/O‟s.
Check Mg level q6hrs after bolus.
DTR check q 1 h. (b/c toxic level of Mg can decrease DTR
Foley to gravity.
Check RA POx q shift. Call HO for POx <96%.
Total IV and PO intake no greater than: 125cc/h for mild preeclampsia; 100cc/h for severe
preeclampsia.

Every progress note on these preeclamptic patients should include:
S: Preeclampsia symptoms (HA, blurry vision, scotomata, epigastric/RUQ pain) difficulty
breathing? Pain control?
O:     VS range, pulse, RR,
       I/O‟s: Total for the shift & current urine output (watch out for oliguria <30cc/h)
       O2 sat: (watch out for pulmonary edema). (and last O2Sat on RA)
       FHT:
       Toco:
       CV:
       Lungs:
       DTR‟s: patella 2+
       SVE if done (or re-order the date/time/last exam).
       Mg rate:
       Pitocin rate:
       Last labs w/date & time drawn, if not already documented.

Goal is to maintain serum Mg levels between 4-7 mEq/L (4.8-8.4mg/dl or 2.0-3.5 mmol/L)


                                                  11
Be vigilant of Mg toxicity when renal functions is decreased (creatinine high or urine output low).


            MgSO4 Toxicity:
            Loss of patellar reflex         8-10 mEq/L
            Respiratory depression          >10mEq/L
            Respiratory paralysis           >12mEq/L
            Cardiac arrest                  20-25mEq/L

            Treat with:
            Calcium Gluconate 1 gram slow IV push over 3 minutes (1g=1amp
            (10cc of 10% solution)).

            Prompt tracheal intubation and mechanical ventilation.


Antihypertensive treatment is indicated when BP‟s are sustained over 160/110.
      - Do not give if DBP lower than 105; uteroplacental perfusion may be compromised if the
      blood pressure is lowered below this range.
      - Labetalol (alpha and beta selective Beta blocker) – 20mg IV over 2 minutes x1: followed by
      40 mg if not effective within 10 minutes; then, 80 mg every 10 minutes prn; but not to exceed
      a maximum total dose of 220 mg IV.
      - Hydralazine (vasodilator)-5 mg doses slow IV push q 15-20 minutes until desired response
      is achieved. May go up to 10 mg dose, but start at 5 mg.

Eclampsia:
      - Convulsion usually lasts for 60-75 seconds.
      - ABC (Airway, Breathing, Circulation).
      - Prevent maternal injury during the convulsion:
      - Oral airway to prevent tongue-biting. (You can find one taped to the wall above the head of
      the bed or in the crash cart)
      - Guardrails up.
      - Maintain oxygenation:
         - Administer O2 by face mask.
         - Auscultate lungs-consider CXR if suspicious for aspiration pneumonia.
      - Minimize aspiration risk (turn her on her side).
      - Give adequate MgSO4 as your first line agent: If not on Magnesium yet give MgSO4 6 mg
      IV push over 15 minutes. An alternative dose/route is MgSO4 5 g IM into each buttock;
      however, the onset of a therapeutic effect will be slower. If seizure while on IV magnesium
      give 2g additional bolus x1.
      - If not responsive to magnesium may give Diazepam 5 mg IV push, repeated as needed to a
      maximum cumulative dose of 20 mg. IV Diazepam rapidly enters the CNS where it achieves
      anticonvulsant levels within 1 minute, and will control seizures in >80% of patients within 5
      minutes. However, benzodiazepines should be used with caution because of the risk of losing
      control of the mother‟s airway, and the potentially profound depressant effect on the fetus.
      This effect becomes clinically significant when the total maternal dose exceeds 30 mg.
      - Correct Maternal Acidemia: If she has had repeated convulsions, she may be acidotic. If
      she is hypoxemic, then r/o aspiration pneumonitis.

Postpartum Pre-eclamspia Orders:
       - There are pre-printed orders for postpartum preeclampsia patients.
                                                  12
Gestational DM:
       Intrapartum management:
        The goal in labor is to prevent ketonuria while maintaining adequate fluid replacement and
       normal glucose values, and to prevent fetal hyperinsulinemia (& thus, postnatal
       hypoglycemia) near delivery (ie. Keep maternal glucose levels <130 in labor).

For all diabetics:
        - Check a chem7 with admission labs (to correlate the glucometer with a lab-determined
        glucose at least once in labor).
        - Review the patient‟s glucose control during pregnancy; document in your history:
                 -Fasting & 2hr postprandial levels for all diabetics
                 -Her last HbA1C.
                 -Last Growth scan results.
                 -Glucose finger sticks: Goal is <95 for fastings, <120 for 2hr post-prandial.
        - Check finger stick glucose:
                 -q4h if in latent phase & last result in normal range.
                 -q2h if in active phase.
                 -q1h if on insulin drip or prior result >130.
        - IVF‟s:
                 - Early labor: can be managed with NS or with D5NS/D5LR @ 125cc/hour.
                 - Check urine for ketones at each void. If ketones are present, place her on D5LR and
                 increase the infusion rate until resolution of ketonuria.
        - If finger stick glucose >130 consistently, then start an insulin drip.
                 - Insulin drip: Start at 1unit/hr and check CBG q1h. Increase or decrease by 1 unit/hr
                 to keep BG<130. Please read nursing policy for ordering details.

Low-dose continuous Insulin infusion for the Diabetic Woman in the Intrapartum Period
     Blood glucose                      Insulin                       Fluids
         (mg/dl)                         (U/hr)                     (125cc/h)

            <80                          Call MD                          D5LR
           80-140                            0                            D5LR
          141-160                       1.0 = 10ml                         NS
          161-180                       1.5 = 15ml                         NS
          181-240                       2.0 = 20ml                         NS
          241-300                       2.5 = 25ml                         NS
            >301                         Call MD                           NS

*Dilution is 50U of regular insulin in 500cc of normal saline administered IV.

       - Postpartum management:
              - GDM-A1:
                     May resume regular diet.
                     In am, check FSBG x1. Call HO for BG≥200.

               - GDM-A2 & pre-gestational DM: It is not unusual for the patient to require virtually
               no insulin for the 1st 24 hours or so and then for insulin requirements to fluctuate
               markedly in the next few days.
                                                    13
                      Check FBG‟s, 1h postprandial BG‟s, call HO for BG>200
                      1800-2200 KCal ADA diet
                      Return to pre-pregnancy insulin regimen vs 50% of last insulin dose.

       - Follow-up at discharge:
              - GDM-A1:
                      Routine f/u for post-partum exam and 2hr GTT at 6 wks

              - GDM-A2 & Pregestational DM‟s:
                   Instruct patients to continue checking BG‟s at home.
                   Patient to check BG‟s at home as they did pre-delivery, and to call PCP in 1
                   week with values or if any value >200
                   Follow-up visit at 2 wks with PCP for glucose management
                   Routine post-partum visit and 2hr GTT at 6wks

Hyperemesis:
-N/V of pregnancy usually starts at 4-6 weeks GA, and is gone by 16-20 weeks
   -greater risk with young primigravidas and increased BW
   -Rx: supportive, reassurance that it is self-limited
     avoid triggers and provoking stimuli
     am water or tea and crackers 30 minutes before rising
     frequent small carbohydrate rich meals (6/day)
     accupressure - 3 fingers above volar wrist (sea bands)
     ginger tea, root, candy, tabs
     unisom (25 QID) and B6 (25 QID)
-Hyperemesis gravidarum = ketosis or loss of >10% body weight
   -hospitalize for: electrolyte replacement, IV rehydration, correction of metabolic abnormalities,
TPN
   -NPO until no N/V, then clears and advance as tolerated
   -follow Is/Os, daily weights, urine SG and ketones
   -IV 500-1000cc LR or NS bolus, then run 1L with 1amp MVI, 100mg thiamine, 2grams Mag over
four hours. Then run daily fluids (D5 1/2 NS with 20-40KCl at 125/hr with 1amp MVI and 100 mg
thiamine per day)
   -Meds: antihistamines (doxylamine/unisom, diphenhydramine/benadryl, meclizine/antivert,
hydroxyzine/vistaril)
          phenothiazines (promethazine/phenergan, prochlorperazine/compazine)
          metoclopramide/reglan
          odansetron/zofran
          can consider methylprednisolone taper: 16mg tid for three days, then taper over two weeks




                                                 14
Preterm Contractions/Labor:

Definition preterm contractions – any regular contraction pattern prior to 37 weeks
Definition preterm labor – any regular contraction pattern prior to 37 weeks THAT RESULTS IN
CERVICAL CHANGE (dilation and/or effacement)

Symptoms include: regular uterine contractions, cramping, low back pain, pelvic pressure, vaginal
bleeding, change in vaginal discharge.

Epidemiology: In 2005 12.7% of births in the US were preterm, 40-50% of all preterm births are the
result of spontaneous preterm labor, 20-30% are the result of PPROM and 20-30% are the result of
medical intervention for fetal or maternal issues. Risk factors for preterm labor include: stress, single,
low SES, depression, h/o abdominal surgery during pregnancy, multiple gestation, polyhydramnios,
fibroids, h/o 2nd trimester abortion, h/o cervical surgery, h/o preterm labor in previous pregnancy,
STDs, severe systemic infection such as pyelo, placenta previa, substance abuse, smoking, maternal
age <18 or >40, low BMI, African-American, poor prenatal care, anemia, fetal effects (congenital
anomaly or growth restriction.

In evaluation of possible preterm labor, time is of the essence, move quickly through this evaluation
and treatment plan.

Evaluation of any preterm woman complaining of abdominal pain and/or showing contractions on
tocometry (believe the patient not the monitor)–
       Confirm patient‟s gestational age
       NST/AFI
       Sterile speculum exam to r/o rupture, gather FFN, GC/Chlam swab, wet mount, KOH,
       visualize cervix
       Labs – UA, Urine culture, urine tox screen
       IV fluid bolus
       If unruptured and placenta previa ruled out, do digital cervical exam

If you suspect true preterm labor please involve your senior/pedi back-up and attending sooner than
later – don‟t wait for all labs to come back before calling for help!

FFN, or fetal fibronectin, is used between 22-35wks gestation, must confirm no cervical manipulation
in past 24 hrs (e.g. intercourse, cervical exam), no gross bleeding, intact membranes and dilation less
than 3cm
         – if FFN negative 99.2% of women will not deliver in the next 14 days, educate patient, have
patient f/u with PCP in 1 week
         - if FFN positive this does not mean delivery is imminent, 16% of women with positive FFN
will deliver in the next 14 days, a cervical length U/S should be performed.
                 - cervical length >2.5 cm is reassuring
                 - cervical length <2.5 cm or funneling is considered high risk for delivery, consider IM
                 steroids for fetal lung maturity, place on modified bed rest , admit for monitoring
                 consider MFM consult

IF MAKING CERVICAL CHANGE AND LESS THAN 34-35 WEEKS PATIENT NEEDS
TOCOLYSIS, ANTIBIOTICS, STEROIDS AND TRANSFER TO NICU EQUIPPED FACILITY
IF DELIVERY NOT IMMINENT
                                                   15
Tocolysis:
        Current best evidence is in favor of nifedipine, 10mg PO q20 minutes up to 4 doses.
(Alternative regimen: loading dose 30mg PO x1 followed by 20mg PO x1 after 90 minutes – higher
risk of hypotension). Side effects include flushing, nausea, HA, dizziness and palpitations. Caution in
patients with LV dysfunction or CHF. Cannot use at same time as magnesium (severe respiratory
depression).
        Second line if nifedipine contraindicated, may use indomethacin 50-100mg PO/PR followed
by 25mg PO q4-6hrs
        Magnesium sulfate IV is no longer first or second line for tocolysis.


Tubal Ligation:

On presentation to L&D, ask every patient if she intends to have a bilateral tubal ligation and note
this on your H&P as well as the date she signed her papers. Check to see that correct form was signed
and is in L&D chart. You never know when a stat C-section might be necessary, and we want to
avoid missing a desired Tubal Ligation because we rushed back for an emergent C-section without
knowing she wanted it or having the necessary Medicaid papers/consent. Note that the state
sterilization form must be signed no less than 30 days prior to procedure, no more than 180 prior and
cannot be signed in the hospital. The only exception to the 30 day rule is if the woman delivers prior
to 37 weeks EGA. Of note, no one age 21 or younger in Rhode Island can have a tubal ligation if on
state insurance (RIte Care). Studies have shown high rates of regret and enquiries into reversal when
tubal ligation is done on patients under age 27. Remember to counsel patients that reversal is
successful in achieving pregnancy only 20-40% of the time and is not covered by insurance (cost
approx. $10,000).

Induction of Labor:
Bishop Scoring for Cervical Ripening
                   0                      1                    2                    3
Dilation (cm)      Closed                 1-2                  3-4                  5+
Effacement (%)     0-30                   40-50                60-70                80+
Station            -3                     -2                   -1                   0+
Consistency        Firm                   Moderate             Soft                 -
Cervix Position    Posterior              Mid                  Anterior             -

Predictive value of Bishop score for successful induction without ripening:
        0-4    50-55% success
        5-9    90% success
        10-13 100% success
Misoprostol (Cytotec): If the cervix is closed/long/high (ie Bishop‟s Score <6) and the patient is
contracting less than 3 in 10 minutes, then you may use Misoprostol. It may be given vaginally.
Contraindications: Nonreassuring fetal heart rate pattern, uterine scar, cervical dilation >4 cm,
uterine contractions ≥3 in 10 minutes, significant maternal cardiac/renal/hepatic disease, maternal
glaucoma.
Vaginal: Misoprostol 25 mcg PV may be given q4h (for a maximum of 24 hours or 6 doses; wait 4
hours from last dose before starting pitocin) if she is not contracting. The pharmacy will cut the 100
mcg tablets into quarters. The Misoprostol quarter fragment is hard to keep on your fingertips,
lubricate your glove with water (NOT Surgilube), hold the pill fragment between your 2nd & 3rd
                                                  16
fingers, HOLD ON TO IT until you get to the fornix, then leave the pill fragment there without
pulling it out with your glove.
DO NOT GIVE TO ANYONE WITH PREVIOUS UTERINE SURGERY (Ie, c-sections,
myomectomies, cornual ectopics).

Foley Bulb: Ask your Senior Resident to supervise you while you do it. Do this if the cervix is 1 cm.
Can start pitocin at the same time.
Under direct visualization w/sterile speculum, clean cervix/vagina with Betadine x 3. Or have
someone squirt Betadine into the vagina and swab away the excess.
Foley bulb can also be inserted blindly with one‟s hand.
Grasp foley near the bulb w/ring forceps & insert tip of foley beyond the internal os.
Fill balloon with 30cc sterile water.
Apply gentle traction and tape to patient‟s thigh.
Foley will fall out when cervix has dilated in response to pressure applied.
Contraindications to foley bulb – ruptured membranes

Pitocin: Go right to Pitocin if the Bishop‟s score is >5.
Dilute pitocin 15 units in 250 ml NS:
Begin Pitocin 2 milliunits/min IV. May increase by 2 milliunits/min Q20 minutes to titrate RUC‟s to
q3 min or 150-250 Montevideo units (with IUPC)



Group B Strep: GBS

Patient should have their vaginal-rectal GBS culture checked in their prenatal care between 35-37
weeks EGA.
The culture result is good for 5 weeks.
If positive, then the patient should receive Penicillin G 5 million units IV loading dose, then 2.5
million units IV q4h once in active labor or sooner if situation indicates (e.g. PROM).
If negative, then no antibiotics are indicated.
If penicillin-allergic: mild allergy give Ancef, if severe allergy (eg SOB/anaphylaxis) give
Clindamycin 900 mg IVPB q8h or Vancomycin (depending on GBS sensitivities that should have
been sent for that patient given high risk allergy status)
If she has had GBS grown in urine culture (any colony count) this pregnancy, then treat as GBS
positive – a 35 week swab for GBS is not needed in this patient.
If the culture is >5 weeks old or GBS status is unknown, then initiate penicillin IV only if the patient
has one or more of the following risk factors:
         Preterm (<37 weeks EGA)
         H/o GBS affected infant
         H/o GBS UTI this pregnancy
         Prolonged rupture of membranes >18h
         Maternal temp >100.4




                                                   17
Pain Control:
If the patient requests re-dosing of pain meds at less than 2 hour intervals, please consult the senior
resident or attending.

If patient is not close to delivery
Stadol (butorphanol) 1-2 mg IV; or 1mg IV and 1mg IM; may repeat q 3-4 h prn pain; evaluate FHT
and make sure it still looks reassuring. (Stadol 1-2 mg compares favorably with 40-80 mg Demerol).

Epidurals: Usually we wait until the patient has entered active phase (eg. 4 cm dilation) prior to
offering her an epidural; however any patient who is in extreme discomfort can be offered an epidural
on her request. Patients must have admission CBC results back (for platelet count) and an IV fluid
bolus of at least 500ml prior to procedure. Please tell the nurse first prior to calling anesthesia to
ensure adequate nursing coverage during the procedure.



Internalizing Patient Monitors:
Do not AROM unless they are vertex and engaged (eg.-2 station).
If you are placing an IUPC & FSE, place the IUPC in first, followed by the FSE. If you place the
FSE first, you may dislodge it with the subsequent IUPC placement.
Wear sterile gloves on both hands when you internalize. Sometimes amniotic fluid will track up the
introducer and onto your external hand.
Avoid internalizing patients who are HIV +, HSV+, HepB+, HepC+. Discuss these cases with your
senior attending first.

Prolonged Deceleration = decel 2-10 minutes duration
Call for help, “Decel!”
Pitocin off.
IVF bolus (her main line: hit rate 1200cc/h, start).
Head of bed down.
Place patient on her side.
Get O2 Face Mask out of closet at the bedside and hook up to wall & give her O2 6-8 L/min.
Check cervix (for cord prolapse, dilation). Consider placing FSE.
Why is there prolonged deceleration?
If uterine hyperactivity is present, call for Terbutaline 0.25 mg SC x1. (Do not give if maternal pulse
>120).
Conduction anesthesia with hypotension (call anesthesia to administer ephedrine).
Supine hypotension (get her on her side).
Unrelieved cord compression/prolapse. (Cord prolapse → keep your fingers there to hold up the
head to keep pressure off the cord, and call for stat c-section).
Maternal respiratory arrest (convulsions, high spinal anesthesia, IV narcotics).
If not recovering, call anesthesia, senior surgeon and nurse manager for emergent c-section.
If heart rate does recover to baseline, keep in mind the decel may recur. It is still appropriate to call in
your back-up and watch patient closely.




                                                    18
Amnioinfusion:
Indication: repetitive variable decelerations.
Place IUPC.
Begin Amnioinfusion: bolus 500cc NS through IUPC then infuse at 100cc/hr.

Chorioamnionitis:

       Diagnosis:
       - Maternal fever >100.4 (38.0C) plus one of the following:
              - Fetal tachycardia.
              - Maternal tachycardia.
              - Uterine tenderness.
       Treatment during labor:
       - Ampicillin 2 gm IV q 6 hrs, and
       - Gentamycin 120 mg IV loading dose then 80 mg IV q8hrs.
       - Tylenol (especially if fetal tachycardia is present) 650 mg PO or suppository PR q4h prn.

Endomyometritis:

       Suspect if maternal temp >100.4 degrees more than 8hrs after delivery and fundal tenderness
       on exam
       Treatment if s/p vaginal delivery:
       - Ampicillin 2 gm IV q 6 hrs, and
       - Gentamycin 5 mg/kg q24h (usually 300 mg IV q24h).
       - Treat until 24-48 hrs afebrile and clinically improved.
       Treatment if post-op C-section:
       - Ampicillin 2 gm IV q 6 hrs, and
       - Gentamycin 5 mg/kg q24/h, and
       - Clindamycin 900 mg IVPB q 8 h.
       - Treat until 24-48 hrs afebrile and clinically improved.




                                                 19
Your Delivery Table & Delivery:
See Williams Textbook for Conduct of the Vaginal Delivery.
Tell the RN, “Please call Drs. ______ (the senior resident and attending) to come for the delivery”.
An attending must supervise all your deliveries and repairs.
Make sure you put on an eyeshield.
Once patient is at +3 or +4 station, do not turn your back or go far from the perineum. Some babies
(especially in multiparas) can come out very fast!
When you gown, keep your hands inside the sleeves (no skin sticking out) until your 1st glove is on
(ie. don‟t pick up the first glove with your bare skin).
Ensure that your glove covers the white cuff of your sleeve (the white cuff is not a fluid barrier and
neither you nor your patient is protected).
Always ask when‟s the last time she urinated and if it‟s been >3h, then ask for a straight cath kit to
cath her.
Where to put your instruments….
        Lay out just what you need (bulb suction, 2 Kelly clamps, scissors) on an area of table closest
        to your dominant hand.
        Or, you can clip a hemostat on your gown and slide your 2 kelly‟s & scissors through it.
After the baby‟s out:
        Don‟t avulse the umbilical cord! That is, be conscientious of the tension on the cord & don‟t
        pull the baby too far from the perineum.
        Hold the head lower than the butt (so the secretions can run out the baby‟s mouth (instead of
        being aspirated) and the baby lower than the level of the placenta.
        Don‟t clamp the cord too close to the umbilicus-leave room in case you need to place an
        umbilical vein/artery line.
For deep repairs, ask for 3-0 Polysorb on a large needle. For more superficial repairs, ask for a 4-0
Polysorb on a small needle.
Keep all your sharps in 1 distal area of your table. Put all your own sharps (sutures needles &
Lidocaine needle) in the wall sharps box yourself when you‟re done with everything.




                                                  20
      Neonatal
     Resuscitation
      Algorithm




21
Shoulder Dystocia:
(See Gabbe or Williams‟ section on Shoulder Dystocia for diagrams).
1/2 of shoulder dystocias occur in neonates <4000g. Any delivery could be complicated by shoulder
dystocia, so know the steps!
Risk factors: macrosomia, maternal obesity, previous infant weighing over 4000g, diabetes mellitus,
prolonged 2nd stage of labor, prolonged decelaration phase (8-10cm), instrumented midpelvic
delivery. You may see the “Turtle Sign” (recoil of head on perineum)
Potential complications:
        Erb‟s Palsy: brachial plexus injury to spinal nerves C6-C7 (hanging upper arm)
        Klumpke‟s Paralysis: brachial plexus injury to spinal nerves C7-T1 (claw hand).

Call “Shoulder Dystocia!”
       - Call for help early & DO NOT PANIC. – ask nurse to get additional nurses, senior resident
       and attending in room STAT.
       - Look at the clock! Delivery of the baby should occur within 5 minutes.
       - Gentle downward traction to deliver anterior shoulder (don‟t pull too hard or you may injure
       the brachial plexus. If gentle downward (not outward, but toward the floor) traction isn‟t
       working, move on to the next step, don‟t pull harder. Drain the bladder if it‟s distended.
       - Suprapubic Pressure applied by the RN (Never give fundal pressure-may result in further
       impaction).
       - McRobert‟s Maneuver (hyperflex her knees toward her ears).
       - Rotate Anterior Shoulder forward (toward the chest). To get the bisacromial diameter in an
       oblique direction & dislodge the anterior shoulder.
       - Rotate the posterior shoulder forward (toward the chest). This is called the “Woodscrew”
       maneuver.
       - Put patient in hands and knees position and redo maneuvers.
       - Deliver the posterior arm. Carefully sweep the posterior arm of the fetus across the chest,
       then deliver the arm.
       - Consider episiotomy to make room posteriorly.
       - Fracture clavicle. By pressing the anterior clavicle against pubic ramus (less serious than
       brachia nerve injury or asphyxia)
       - If no one in the room is able to perform a c-section, then Zavanelli‟s maneuver (replacing
       the fetal head into the vaginal canal in preparation for c-section) is NOT indicated. One
       should instead repeat the above maneuvers to facilitate vaginal delivery.



Postpartum Hemorrhage:
Definition: EBL ≥500cc after 3rd stage of labor. (or >1000ml for c-section)
Know the hematocrits on all patients who you deliver. Document them in the chart and on the L&D
Board. Anyone can have a postpartum hemorrhage.
Risk Factors:
        Uterine Atony: “Big, Sick, Tired uterus”
               High parity
               Uterine overdistention (macrosomia, polyhydramnios, multiple gestation)
               Meds: High dose or prolonged pitocin administration; or MgSO4 for preeclampsia
               seizure prophylaxis.
               Choriomnionitis.
               General anesthesia.
               Rapid labor.
                                                  22
       Delayed postpartum hemorrhage:
              Retained placental tissue.
              Placenta accreta (especially with previous c-section and anterior placenta).
              Preterm delivery
              Succenturiate lobe.
              Cord avulsion.
       Genital Tract Laceration:
              Precipitous labor & delivery.
              Operative vaginal delivery.
              Compound presentation or macrosomia.
       Uterine inversion. Never pull on the cord without giving suprapubic pressure.

Managing post-partum bleeding: Call for help as early as you need to:
      - Do bimanual massage.
      - Ensure placenta delivered intact (ie. no retained placental fragments requiring manual
      exploration of uterus or uterine curettage).
      - Ensure bladder is empty. (An overdistended bladder will prevent the uterus from
      contracting down effectively).
      - If + uterine atony, call for meds (see below).
      - If not responding to meds & bimanual massage, CALL FOR HELP!
      - Check for lacerations (vulvar, vaginal, cervical (especially @3 & 9 o‟clock where the blood
      vessels/supply are)) especially if it was a precipitous birth, macrosomia, or instrumented
      (forceps/vacuum) vaginal delivery. Get adequate exposure: The right angle, wide Jackson
      retractor; a gooseneck lamp (the ceiling lights are only adequate for the vulva, to see into the
      vagina you need a gooseneck); Yankauer wall suction.
      - Do manual exploration of uterine cavity for retained placental fragments or laceration. (if
      you do manual exploration of uterus, douse your gloved hand with betadine before and and
      give cefazolin 1-2 grams IV and continue q8h for 24 h).
      - Call for blood! cross matched or O negative
      - 2nd large bore IV access (to keep IV pitocin & blood going at same time).
      - Place pulse ox to continuously monitor pulse.
      - Place Foley catheter to monitor urine output.

Pitocin: Ask for 40 units in her IVF bag (instead of the usual 20 units). (Never give Pitocin
undiluted IV push-can cause serious hypotension or cardiac arrhythmias)
Methergine (methylergonovine an ergot alkaloid derivative) 0.2mg IM q 15 min prn x2-3 doses.
Contraindicated in HTN/preeclamptics.
Misoprostol (PGE1, aka cytotec) 400-800mg per rectum. (our L&D stocks the 200 mcg pills, so
that‟s 2-4 pills per rectum).
Hemabate (PGF2 or Carboprost) 0.25 mg IM q 15 min prn (8 doses maximum). Avoid in asthmatics.
20% have side effects in decreasing order of frequency, diarrhea, hypertension, vomiting, fever,
flushing, tachycardia. Use only if necessary as the diarrhea is very unpleasant for the patient. May
want to give lomotil 2 tabs po at same time due to diarrhea. Hemabate is kept in the refrigerator, so if
you want it, call for it ahead of time.




                                                  23
Postpartum Fever

- Definition:
        2 temperature elevations ≥ 380C (100.40F) (outside the 1st 24h after delivery).
        or
        a temp of ≥ 38.70C (101.50F) any time.
- Differential Diagnosis:
        Womb: endomyometritis.
        Weaning: breast engorgement, mastititis, breast abscess.
        Wind: atelectasis, pneumonia
        Water: UTI or pyelonephritis.
        Walk: DVT or pulmonary embolism.
        Wound: wound or episiotomy infection.
        Wonder drug: drug fever.
        Whoops!: ureteral injury.
- Work-up:
Physical exam: CV, lungs, CVAT, abd, Ext (asymmetric edema, cords, erythema, Homan‟s sign), &
Uterine tenderness?
Pelvic exam to r/o hematoma or retained membranes/placenta.
Breast exam.
Labs: CBC w/diff, cath UA c&s, blood cultures x2 prn.
Radiologic: CXR, pelvic US prn.
Treatment : If endomyometritis
                 Clindamycin 900mg IV q8h, and
                 Gentamycin 5mg/kg q24h.
                 If spikes on these add Ampicillin 2 gm IV q 6 hrs
                 Treat until 24-48 hrs afebrile and clinically improved.
              If endomyometritis post-op C-section:
                 Ampicillin 2 gm IV q 6 hrs, and
                 Gentamycin 5 mg/kg q24h, and
                 Clindamycin 900 mg IV q 8h
                 Treat until 24-48 hrs afebrile and clinically improved.
If unresponsive after 48 hours of IV antibiotics, re-examine the patient & consider:
Pelvic abscess,
Septic pelvic thrombophlebitis,
Drug fever.




                                             24
Postpartum Perineal Wound Care

All patient with a 3rd or 4th degree perineal tear should be evaluated by a surgeon if the delivering
provider is not experienced with these tears.
        - Postpartum orders should routinely include stool softeners, sitz baths, Dermoplast and
        perineal care.
        - Prior to discharge resident needs to inspect the wound for signs of early
        infection/breakdown.
        - Patients need to be instructed on the importance of…
                 Avoiding constipation, and
                 Good perineal care (ie, sitz baths TID; no sex, no douching, nothing in vagina until 6
                 week postpartum evaluation).
        -Discharge orders should include sitz baths, stool softeners, instruction on perineal hygiene,
        donut to sit on, and a phone number to call if they have any problems/questions.
        - Postpartum follow-up for patients with 3rd or 4th degree lacerations should include a 1-2
        week clinic visit in addition to the 6 week postpartum check.




                                                   25
How to Consent/Counsel for Certain Situations
These are guidelines on how you should counsel the patient for these situations and what you should
document in the chart.

Cesarean Section
Risks include: Bleeding w/risk of transfusion & Hep B risk 1 in 250,000, Hep C risk 1 in 1,900,000
& HIV risk 1 in 2,100,000; infection, anesthesia reaction, damage to internal organs with repair,
fistula formation, damage to fetus, DVT/PE, hysterectomy.

Vaginal Birth after Cesarean (VBAC)
ACOG practice Bulletin # 54, July 2004 states these risks of rupture for attempted VBAC after one
prior cesarean.
Low Transverse Incision                              <1%
Low Vertical Incision-just as likely for successful VBAC as a previous LTCS.
2 previous low transverse incisions                  1-3.7%
Classical                                            4-9%
T-shaped incision                                    4-9%
Prior failed VBAC with lower segment rupture         6%
Prior failed VBAC with upper segment rupture         32%
Women who attempt VBAC who have interdelivery intervals of <24 months has a 2-3 fold increased
risk of uterine rupture when compared with women who attempt VBAC >24 month after their last
delivery.
Contraindications to VBAC:
        Two prior uterine scars.
        Previous classical or T-shaped incision or extensive transfundal uterine surgery.
        Previous uterine rupture.
        Medical or obstetric complication that precludes vaginal delivery.
        Inability to perform emergency cesarean delivery b/c of unavailable surgeon, anesthesia,
        sufficient staff, or facility.
You may choose delivery of this pregnancy by elective repeat cesarean section or by attempting
VBAC.
If you attempt VBAC, there is about a 70% chance of successful VBAC, and a 30% chance of having
a repeat cesarean section anyway because of complications during labor (“failed VBAC”).
Successful VBAC has a lower risk of complications for you than an elective cesarean; while failed
VBAC has a higher risk of complications than elective cesarean.

Macrosomia
On the basis of date presented in the ACOG Practice Bulletin No. 22 November 2000,
recommendations for advising the route of delivery in suspected fetal macrosomia are revised as
follows:
       Non-diabetic EFW ≥ 5000g.
       Diabetic EFW ≥ 4500g.
Planned cesarean delivery to prevent shoulder dystocia may be considered for suspected fetal
macrosomia with estimated fetal weights exceeding 5,000 g in women without diabetes and 4,500 g
in women with diabetes.



                                                 26
History of Shoulder Dystocia at Previous Delivery
See ACOG Practice Bulleting #40 November 2002.
A history of shoulder dystocia is associated with a recurrence rate ranging from 1% to 16.7%.
Because most subsequent deliveries will not be complicated by shoulder dystocia, the benefit of
universal elective cesarean delivery is questionable is patients who have such a history of shoulder
dystocia. Other factors that may aid in the decision-making process for mode of delivery include the
present estimate of fetal weight compared with the prior pregnancy birth weight, gestational age, the
presence of maternal glucose intolerance, and the severity of the prior neonatal injury. A discussion
and review of the prior delivery events should be undertaken with the patient, preferably before the
intrapartum period. After discussion with the patient, either method of delivery is appropriate.

Herpes
See ACOG Practice Bulleting #8 October 1999.
Always document on your H&P:
1st HSV outbreak?
Frequency of outbreaks? (ie.3/year).
Last outbreak?
Does she recognize her prodrome? Is she having prodromal symptoms?
Is she on antiviral prophylaxis? (Some people will Rx acyclovir or valtrex from 36 weeks on in
patients who have frequent episodes).
On Physical Exam: Inspect the entire vulva-vaginal-cervix area & document it!
Ask her where she normally has her outbreaks & inspect there.
But also inspect and document that she has no lesions on her entire vulva, vagina, cervix.
Neonatal infections:
         HSV shedding occurs at time of delivery in .1-4% of all patients.
         Rate of infections is approximately .01-04% of all deliveries. 10% reduction over HSV
         shedding likely is a result of maternal antibodies conferring protective effect.
         70% of neonatal infections occur in women with ho history of HSV.
         Infection may occur with either HSV-1 (25%) or HSV-2 (75%).
         Rate of infection dependent on primary vs. recurrent HSV.
         Primary maternal infection at time of vaginal delivery → 50% neonatal infection rate.
         Recurrent maternal infection at time of vaginal delivery → 4% neonatal infection rate.
         60% of infants with neonatal HSV from mother with primary HSV will die.
         50% of survivors will have serious sequelae.
- It is important to recognize that primary HSV cannot be distinguished from non-primary first-
episode disease unless serology is performed. Primary infection during pregnancy constitutes a
higher risk for vertical transmission than does recurrent infection. The absence of episodes of
symptomatic genital HSV infection throughout pregnancy does not eliminate the risk of
asymptomatic shedding at delivery.
- Cesarean delivery in indicated in women with active genital lesions or symptoms of vulvar pain or
burning, which may indicate an impending outbreak. The incidence of infection in infants whose
mothers have recurrent infections is low, but cesarean delivery is warranted because of the potentially
serious nature of the disease. Cesarean delivery is not warranted in women with a history of HSV
infection but with no active genital disease during labor.
- Is cesarean delivery recommended for women with recurrent HSV lesions on areas distant from the
vulva, vagina, or cervix (eg, thigh or buttock)?
         When infection occurs among neonates on women with recurrent HSV, it is due either to
         shedding of the virus from the genital lesion itself or to shedding from the cervix. In patients
         with recurrent genital HSV and nongenital lesions at the time of labor, the only viral exposure
                                                   27
        faced by the infant during vaginal deliver is that of cervical shedding, which occurs in
        approximately 2% of such cases.
        Thus, the risk of neonatal HSV associated with vaginal delivery in a woman with recurrent
        HSV and nongenital lesions would appear to be very low. Cesarean delivery is not
        recommended for these women. Nongenital lesions should be covered with an occlusive
        dressing; the patient then can deliver vaginally.
- Remember to avoid use of FSE in these patients.
- In a patient with active HSV infection and ruptured membranes, is there any length of time at which
vaginal delivery remains appropriate?
        In patients with active HSV infection and ruptured membranes at or near term, cesarean
        delivery should be performed as soon as the necessary personnel and equipment can be
        readied. There is no evidence that there is a duration of premature rupture of membranes
        beyond which the fetus does not benefit from cesarean delivery.


Counseling Regarding Breastfeeding
Benefits of Breastfeeding:
       1- There are at least 12 antiinflammatory agents in breast milk which promote healthy
           immune system, breast milk protects against coxsackie, staph, e.coli, salmonella and
           candida
       2- Breastfeeding decreases risk of childhood cancers,asthma, bacterial infections, diarrhea,
           allergies, diabetes and SIDS
       3- Breastfeeding has been linked to improved dental hygiene and speech development
       4- Breastfeeding reduces risk of breast, ovarian and endometrial cancer in moms
       5- Breastfeeding moms return to their prepregnancy weight sooner than formula feeding
           moms

Intervention in the first 24 hours:
       1- Help moms initiate breastfeeding within the first hour of life
       2- Promote skin to skin contact and rooming in
       3- Teach feeding cues (increased activity, rooting, mouthing)
       4- Offer breast every 1-3hours depending on cues
       5- Counsel on normalcy of delayed milk production, colostrum is as important as breast milk

Infant‟s Age                      Medical indications for            Output guidelines
                                  supplementation
<24 hours                         Blood sugar <40 after adequate     One wet diaper and one
                                  opportunity to breastfeed,         meconium stool by 24 hours of
                                  Unavoidable separation,            life
                                  Maternal meds incompatible,
                                  Infant clinically unable
>24 hours                         As above,                          2nd day: 2-3 wet & 2 mec/brown
                                  Weight close to 10% decrease       3rd day: 3-4 wet & 2-3 brown
                                  from birthweight accompanied       4th day: 6-8 wet & 3-4
                                  by delayed lactogenesis,           yellow/seedy
                                  Latch score <7 for 2
                                  consecutive feeds,
                                  No audible swallowing


                                                 28
Please note: We have lactation consults available each day, and should order one for each mom that
plans to breastfeed, especially if it is their first time.

                         0                         1                        2
Latch                    Too sleepy/reluctant,     Repeated attempts,       Grasps breast, tongue
                         no latch                  hold nipple in mouth,    down, lips flanged,
                                                   stimulate to suck        rhythmic sucking
Audible Swallowing       None                      A few with stim          Spontaneous and
                                                                            intermittent if <24hrs
                                                                            old, spontaneous and
                                                                            frequent if >24hrs old
Type of Nipple          Inverted                  Flat                      Everted (after stim)
Comfort (breast/nipple) Engorged, cracked,        Filling, reddened/small   Soft, non-tender
                        bleeding, large blister   blisters/bruises,
                        or bruises, severe        mild/moderate
                        discomfort                discomfort
Hold (positioning)      Full assist (staff hold   Minimal assist (elevate   No assist from staff,
                        infant at breast)         head of bed, pillows      Mother able to position
                                                  for support)              and hold infant
                                                  Teach one side, mother
                                                  does other,
                                                  Staff holds then mother
                                                  takes over
Exerpted from Rhode Island Coalition on Breastfeeding

Circumcision

Consent needs to be reviewed and signed by mother; key points: this is a cosmetic
procedure, no medical indication by current data (some evidence that it is protective
against HIV transmission in heterosexual males in very high prevalence countries, i.e.
sub-saharan Africa), major risk factors include bleeding, infection and poor cosmetic
outcome (i.e. taking too much or too little skin). Add the statement to the bottom of
generic consent form: “Risks of procedure discussed, including but not limited to:
bleeding, infection and poor cosmetic outcome.”
      Sample Circumcision Procedure Note:
             Risks/benefits reviewed with patient’s mother, including but not limited to
      bleeding, infection and poor cosmetic outcome, mother desires to proceed,
      consent form signed and in chart. Infant ID band checked, time out performed
      with RN. 1cc 1% lidocaine without epinephrine used for dorsal penile nerve
      block. Infant prepped and draped in sterile fashion. Circumcision performed
      with _____ Gomko (or Mogen). Excellent hemostatic and cosmetic effect
      achieved. EBL minimal. Patient tolerated procedure well. Dr. _____ (attending)
      present for entire procedure.


                                                  29
Postpartum Contraception
Depo-Provera
Write, “Depo-Provera 150 mg IM x 1 prior to discharge”.
Should be given prior to discharge (not immediately postpartum) to allow normal lactation processes
to be established.
Patient can be counseled that it does not diminish breast milk production as combined OCP‟s & Patch
can; that it‟s good for 12 weeks and will cover them until they come for their 6 week check-up if they
decide to have sex before their 6 week check; failure rate .3%
Common side effects include: weight gain 5 pounds after 1 year; bleeding irregularities. Less
common side effects include: acne, alopecia, depression, headaches, abdominal/breast bloating.

Oral Contraceptive Pills
Failure rate for typical users 5%; for perfect users 0.1%.
Recommend Progestin-Only pills (POP‟s: eg. Micronor (norethindrone .35 mg) for breastfeeding
moms. If taking POP‟s, must emphasize importance of taking the pill at the same time every day; if
as much as 3 hours late, she may ovulate and so condoms should also be used for 1 month as backup.
POP can be started immediately post-partum, however consider delaying 2-4 weeks for maximum
establishment of breast milk if breastfeeding.
Combined OCP‟s (estrogen + progestin) may be taken, but should be started at least 4 weeks
postpartum due to hypercoaguable state post-partum and increased risk of DVT/PE. If she wants to
start the combined OCP at 4 weeks, inform her of the risk of decreased breastmilk production/supply
(more impact on milk supply than POP). If a combined OCP is written for a breastfeeding mom, then
a low dose of 20mcg OCP id preferable (eg, Lo-Estrin 1/20, Alesse).

IUD
This can be arranged at the 6 week postpartum visit by their clinic (or 8 weeks post c-section). It can
be inserted in clinic, no anesthesia is needed. Failure rate is <1%. The Mirena IUD (which has a
small dose levonorgestrel) has been shown to be more effective than tubal ligation at preventing
pregnancy and is completely reversible. Mirena can stay in for up to 5 years, Paraguard (copper IUD)
can stay in for up to 10 years.
Instruct her not to have sex before her postpartum appointment, otherwise this will delay insertion of
IUD while they make sure she isn‟t pregnant.
Is she has sex before the 6 week postpartum visit, then she must use a reliable BCM-a good plan is to
get Depo-Provera before discharge home to cover them until they get their IUD at the 6 week
postpartum check.

Interval Tubal Ligation
This is to get a laparoscopic bilateral tubal ligation (LSC-BTL) at 6 weeks postpartum
Arrange for follow-up appointment with one of the OB/GYNs as the consent form must be signed in
the outpatient setting.
Patient will have to be abstinent or have reliable BCM before the appointment.
Again, Depo-Provera prior to discharge is a combination to cover them until they get their LSC-BTL.

Condoms
Emphasize the high failure rate (14% in typical users) and the increased discomfort postpartum with
the hypoestrogenic state that leads to decreased lubrication and more easily irritated, thin, vaginal
epithelium.
If you write for condoms, then please also write for Plan B (in case of condom breakage).

                                                  30
Emergency Contraception
This should be offered to everyone who wants condoms only. They should fill the prescription so
they have it handy in the house to use ASAP after condom breakage.
It can decrease the pregnancy rate from a single act of unprotected intercourse from 8% to 1%.
You can write the Rx “Plan B: take two tabs PO together as soon as possible within 5 days of
unprotected sex. Quantity: 1. Refills 3” You can tell her it‟s most effective if you take it right after
the condom breaks.

Ortho-Evra Patch
Because the patch may be associated with higher estrogen levels that seen with combined OCP‟s, it
may be preferable to avoid using the patch in the postpartum (hypercoaguable), breastfeeding patient.
The patch is not recommended for women who weigh >190 lbs because of decreasing efficacy above
this weight. However, it may still be an option for a bottle feeding woman, <190lbs, but don‟t start
for at least 4 weeks post-partum.

Nuvaring
Same recommendations as OCP, wait 4 weeks to start due to hypercoaguability, counsel may
decrease breast milk supply if breast feeding.


Getting a patient ready for PPTL
The day before the BTL…
Make sure the day before you write her to be….
NPO after midnight.
Start D5LR @ 125cc/h when she‟s made NPO. (or whatever maintenance Dextrose IVF du jour you
want). (Never make a patient NPO & not give her a maintenance D5 IVF).
Make sure her Medicaid consent is:
In the chart.
Signed by her >30d and not >180 days from the time her TL will happen.
Make sure she has an operative/surgical consent signed.
Notify surgeon and schedule with OR (if the OR is closed leave a message regarding case and
surgeon name on OR answering machine x2435 and place PIF sheet on OR desk)
The morning of the TL….
Call OR to confirm time of case and notify surgeon of time.
Write a pre-op note documenting (& be ready to present the patient in rounds):
Her age, G‟s, P‟s PPD#____s/p_____
Risks/Benefits/Alternatives have been discussed.
That she understands PPTL is:
        - Permanent & irreversible
        - <1% failure rate, (FYI: 7.5 in 1000 failure rate (for postpartum salpingectomy), probably
        <1% for postpartum Filshie clip).
        - Increased risk of ectopic if becomes pregnant (& needs to see doctor ASAP if thinks she is
        pregnant after a TL).
Risks of surgery include but are not limited to… bleeding w/risk of transfusion & hep B risk 1 in 250,
000, Hep C risk 1 in 1,900,000 & HIV risk 1 in 2,100,000; infection, anesthesia reaction, damage to
internal organs with repair, extension of incision to laparotomy, inability to complete procedure (eg,


                                                  31
if we can‟t reach the tubes due to adhesions from previous infections/surgery-if we can‟t complete the
procedure, we can put in an IUD in clinic)
Her admission & postpartum CBC.
Whether or not she has a h/o PID, STD‟s, abdomino-pelvic surgery. (if + may increase chance of
inability to complete procedure or extension to laparotomy).


Documentation
        This is key on labor and delivery both for quality of patient care/safety and reality of practice
in a highly litigious field. If you are not sure if you should write something in a patient chart, ask
your senior or attending before you do so. It is illegal to go back to a note you have written and
change anything, if you detect an error you must write an addendum, NOT go back and cross out
what you wrote and under no circumstance can you remove a page from the medical record. On labor
and delivery in particular, if you write anything in your assessment that can be construed as non-
reassuring (decreased fetal movement, minimal variability, late decels) you must explicitly address in
your plan what you are doing to address it.
        As stated earlier:
        any eval patient needs a full note (either in logician and printed or paper) and a discharge
instruction form with all sections filled out;
        latent labor patients need SOAP note q4hrs
        active labor patients need SOAP note q2hrs
        all post partum moms and babies need a Daily Progress Note prior to am rounds (med student
notes, unfortunately, do not count)
        vaginal delivery notes need to be dictated within 24hrs of delivery
        anyone who stays more than 48 hours needs a dictated discharge summary (generally this
applies to c-sections and level II babies)

      There are many forms to become familiar with, some examples are included here, additional
examples can be found in the large blue binder entitled MCH in the Wood 2 conference room.




                                                   32
                          Sample Vaginal Delivery Dictation
Dial 3710 from any phone
Enter your ID number
Enter patient‟s medical record number
Enter work type 06 for vaginal delivery
Start talking:
         Patient delivered a ____g male/female, Apgars _ and _, at ___(time) on ___ (date).
         Baby born to a __ year old, G_, P_ at _ weeks by LMP consistent with _trimester ultrasound.
Prenatal course complicated by ___. Prenatal labs significant for: blood type, antibody screen,
Rubella, RPR, HIV, HepBSAg, GC/Chlam, QUAD screen, 1hr GDS, GBS (if positive state if
adequately treated.)
         Patient presented in active labor/ SROM/ induction (whatever the history). Electronic fetal
monitoring was ______ (reassuring throughout, early, variable or late decels). AROM/SROM with
clear fluid/meconium __ hours prior to delivery. Patient received IV stadol/epidural for pain control.
Patient fully dilated and pushing at ___(time). Delivered viable male/female over intact perineum at
___(time). Head delivered ___ (OA, ROA, OP etc). No nuchal cord (or action taken if nuchal cord
present e.g. reduced, delivered through). Body delivered easily and without incident. Cord clamped
x2 and cut. Infant mouth and nares wiped/suctioned and infant placed on maternal abdomen/handed
to Pedi Team. Any infant resus required. Cord blood/pH obtained. Placenta delivered
spontaneously/manually intact at ___(time). 3 vessel cord noted. Perineum inspected, __ laceration
found. Repair of __ laceration in standard fashion with ___ suture after __cc 1% lidocaine used for
anesthesia. Excellent hemostatic and cosmetic effect. Fundus firm. EBL ___cc.
Sponge/needle/instrument count correct. Dr ___ (attending) present for delivery.




                                                  33
                            Neonatal Resuscitation Note
Present for delivery of ____g boy/girl born via NSVD/LTCS at ___ weeks to a __year old G_P_
mother. Pregnancy complicated by __. Prenatal labs significant for: blood type, antibody screen,
HIV, GC/Chlam, RPR, HepBSAg, Rubella, QUAD screen, 1hr GDS, GBS (if positive state if
adequately treated). Labor complicated by ___. SROM/AROM with clear/meconium stained fluid _
hours prior to delivery. Mother received __ for pain control __ hours prior to delivery. Fetal heart
tracing was ___ (reassuring throughout/significant for repetitive variables during pushing/notable for
fetal braqdycardia prompting emergent LTCS etc). Viable male/female infant delivered at ___(time)
was noted to be vigorous with spontaneous cry. No nuchal cord. Infant went skin to skin/to warming
table, was dried and stimulated. Apgars _ at 1 minute (note what points off were for) and _ at 5
minutes. No further resuscitation needed. (or document resuscitation steps that were needed, such as
blow-by oxygen for 1 minute, PPV etc).
Initial vital signs
Brief exam:
         Presence of caput/molding any birth injuries
         AFOF, sutures mobile, ears normal set, palate intact, nares patent
         Clavicles intact, lungs CTA b/l
         RRR, no murmur, 2+ femoral pulses b/l, extremities warm and well perfused
         Abdomen soft, non-distended, no HSM, no masses
         Moving all extremities equally, normal tone, +grasp, +suck, +moro
         GU male/female
         Skin- no jaundice or abrasions, note any abnormalities
A/P: Newborn male/female born via NSVD/LTCS at __weeks to __y/o G_P_ mother.
         Routine newborn care
         Newborn screen, hearing screen and HepB vaccine prior to discharge home
         Mom plans to breast/bottle feed
         Circumcision desired/not desired if male
         (CBC and Blood Culture if inadequately treated GBS)
         (Heelstick glucose at 30min and 60min of life if LGA/SGA, mom diabetic or baby jittery)




                                                  34
Sample Eval Note




                   35
Sample Post-partum mom Note




            36
Sample Baby Progress Note




                            37
Sample Labor Admit Orders




                            38
Sample Postpartum Orders - NSVD




                                  39
Sample Post-partum Orders – C-section




                                        40
Sample Discharge Form – Antepartum (Eval)

Fill out all blanks on form, especially Follow-up Appointments and PCP name and office phone #




                                               41
                                      Post-Partum Discharge Form

Fill out form entirely during prerounds on am of presumed discharge.

Tailor diet, wound care and other instructions to specific patient (e.g. diabetic diet and instructions
for checking sugar if diabetic)

Under follow-up appointments be sure to write office phone number, schedule follow-up
appointments for patient prior to discharge whenever possible, at least first newborn visit and wound
check post c-section.
       Breastfed infants and infants of first time mom should be seen 2-4 days after discharge
       Formula fed infants and infants of experienced moms can be seen at 2 weeks of age for WCC
       Patients delivered by c-section should have appointment at 2 weeks for wound check
       Low risk vaginal delivery post-partum appointment is typically at 6 weeks (ok to give office
       phone number and have patient call for this appointment closer to the date)

Under medications:
        Prenatal vitamin - all breastfeeding moms and moms with any degree of anemia should
continue prenatal vitamin at least until their 6 week post-partum visit
        Iron - Moms with post-partum hemoglobin <10.0 should be given FeSO4 325 mg PO once
daily in addition to their vitamin, consider bid if hemoglobin <9.0, give enough to get through to 6
week visit = #30 or 60 with one refill
        Stool softener – any mom on iron or with history of constipation should get script for colace
100mg PO bid PRN #60 with 1 refill
        Pain medication – all moms without contraindication to NSAID should get script for
Ibuprofen 800mg PO q8hrs PRN pain #30-60 (your discretion), post c-section or sometimes post-
tubal patients may need a script for narcotic, check if they have been requiring any in the hospital,
typically give percocet 5/325mg or vicodin 5/500mg 1-2 tabs PO q4-6hrs PRN severe pain #30,
counsel breast feeding moms that the narcotic is passed to the baby in breast milk and can cause
(rarely) over-sedation in the infant, they should use ibuprofen first and narcotic only for breakthrough
and call MD if baby does not want to wake to feed/ seems lethargic. Narcotics can also cause
constipation in mom so be sure she takes colace as well.

Sign the discharge form but do not write the discharge order in the chart until mom/baby pair has
been seen by the attending and cleared for discharge.




                                                    42
Newborn Initial Exam and Discharge Form




                                          43
Glossary of OB/GYN Acronyms/Abbreviations
 These are some commonly used acronyms in OB/GYN, but they may be unofficial and may not be
                       JCAHO compliant. (Take care in using them).

AMA      Advanced Maternal Age             LTCS      Low Transverse Cesarean
                                                     Section
AROM     Artificial Rupture of Membranes   LTV       Long Term Variability
B-meth   Beta-methasone                    LVCS      Low Vertical Cesarean Section
BPV      Blood per Vagina                  Mec       Meconium
BSO      Bilateral Salpingo-oophorectomy   MICC      Antepartum/Postpartum
                                                     (Mother Infant Care Center)
BUFA     Baby Up for Adoption
BV       Bacterial Vaginosis               MVU       Montevideo Units
CD       Cesarean Delivery                 NR-NST    Non-reactive NST
CS       Cesarean Section                  NST       Non-stress test
CST      Contraction Stress Test           NSVD      Normal Spontaneous Vaginal
                                                     Del.
C/w      Consistent With
D&C      Dilation & Curettage              NTZ       Nifrazine
D&E      Dilation & Evacuation             OA        Occiput Anterior
                                                     (left/right=LOA/ROA)
EAB      Elective Abortion
EBL      Estimated Blood Loss              OCP       Oral Contraceptive Pills
EFM      External Fetal Monitoring         OCT       Oxytocin Challenge Test
Elap     Exploratory Laparotomy            OP        Occiput Posterior
                                                     (left/right=LOP/ROP
EUA      Exam Under Anesthesia
FCA      Fetal Cardiac Activity            OT        Occiput Transverse
                                                     (left/right=LOT/ROT)
FH       Fundal Height
FHR      Fetal Heart Heart                 PEP lab   Prenatal Eval & Procedures Lab
FHT      Fetal Heart Tones
FM       Fetal Movement                    PID       Pelvic Inflammatory Disease
FOC      Father of Child                   PIH       Pregnancy Induced Hypertension
FSE      Fetal Scalp Electrode
FWB      Fetal Well-Being                  PNC       Prenatal Care
HSC      Hysterectomy                      PNR       Prenatal Record
HSG      Hysterosalpingogram               POC       Products of Conception
ISE      Internal Scalp Electrode          PPH       Postpartum Hemorrhage
IUFD     Intrauterine Fetal Demise         PPROM     Preterm Premature Rupture
                                                     of membrane
IUGR     Intrauterine Growth Restriction   PPS       Postpartum Sterilization
IUI      Intrauterine Insemination         PPTL      Postpartum Tubal Ligation
IUP      Intrauterine Pregnancy            PTD       Preterm Delivery
IUPC     Intrauterine Pressure Catheter    PTL       Preterm Labor
                                           R-NST     Reactive NST
IVF      In Vitro Fertilization            RSO       Right Salping-oophorectomy
L&D      Labor and Delivery                RUC‟s     Regular Uterine Contractions
LSC      Laparoscopy                       RVF       Rectovaginal Fistula
                                               44
LSO      Left Salpingo-oophorectomy          SAB         Spontaneous Abortion
SROM     Spontaneous Rupture of              TOC         Tubo-Ovarian Complex
         Membranes
                                             Toco        Tocodynamometer
SSE      Sterile Speculum Exam               TOL         Trial of Labor
STV      Short Term Variability              TVH         Total Vagina Hysterectomy
SVD      Spontaneous Vaginal Delivery        VBAC        Vaginal Birth After Cesarean
                                             UC          Uterine Contraction
SVE      Sterile Vaginal Exam                USO         Unilateral Salpingo-
                                                         oophorectomy
TAB      Therapeutic Abortion
TL       Tubal Ligation                      WF          Vesicovaginal Fistula
TOA      Tubo-Ovarian Abscess

                                       Accepted Abbreviations

JCAHO has mandated that 9 abbreviations should never be used since they have been associated with
fatal errors. Use of these error prone abbreviations noted in the table below are prohibited. They
must be completely written as indicated.

   Do Not Abbreviate               Potential Error                      Instead
         U (Units)                 Misread as 0, 4, cc               Spell out “units
  IU (International units)           Misread as IV            Spell out “international units”
   .2 (Leading decimal)               Misread as 2              Use leading zero (ie.0.2)
     2.0 (trailing zero)              Misread as 20           Do not use trailing zero (ie.2)
  QOD (every other day)           Misread as QID, QD           Spell out “every other day”
      QD (every day)             Misread as QID, QOD                 Spell out “daily”
     µg (micrograms)            Misread as mg (milligram)               Use “mcg”
  MS (morphine sulfate)          Misread as Magnesium            Write out “morphine”
                                         sulfate
 MSO4 (morphine sulfate)         Misread as Magnesium             Spell out “morphine”
                                         Sulfate
MgSO4 (magnesium sulfate)         Misread as Morphine        Spell out “magnesium sulfate”
                                         sulfate

How this will affect you and the care of your patients:
There will be a delay in your patient receiving the medication you prescribed.
You will get a telephone call asking you to clarify your orders.
You will need to return to the unit to sign the resulting verbal orders.




                                                  45
                              Maternal Child Health Medical Spanish

Quickie L&D H&P:

How old are you?                              Have you had any infections? What kind?
¿Cuántos años tiene usted?                    ¿Ha tenido alguna infección? ¿Cuál?
Gravida? (ie, how many pregnancies have       Are you in pain?
you had?                                      ¿Siente dolor?
¿Cuántos embarazos ha tenido?
Para? (how many babies borna live)            When did your contractions begin?
¿Cuántos ninos nacieron vivos?                ¿Cuándo comenzaron los dolores (las contracciones)?
Have you had other                            What time did they become regular?
pregnancies/miscarriages?                     ¿A qué hora empezaron a ser regulares (los dolores)?
¿Ha tenido malpartos/abortos/ectopicos?
When was the first day of your last period?   How often were they once they became regular?
¿Cuándo fué el primer dia de su última        ¿Con que frecuencia se presentaron los dolores una
regla (menstruación, periodo)?                vez que empezaron a venirle regularmente
What is your due date?                        How often are your pains?
¿Cuándo será su fecha de parto?               ¿Cada cuánto tiempo le dan los dolores?
Ultrasound? When first?                       How long do they last?
¿Cuándo fué su primer ultrasonido?            ¿Cuánto le duran?
Why did you come to the hospital?             What time did it break? (your water)
¿Porque ha venido al hospital?                ¿A qué hora se le reventó?
Have you been going to clinic? How many       Have you had any bleeding?
times? Which clinic?                          ¿Ha sangrado?
¿Ha estado llendo a la clinica?
¿Cuántas veces? ¿A cuál clinica?
When was the last time you went to clinic?    Was it pinkish or bright red?
What date?                                    ¿Fué de color rosado o rojo?
¿Cuándo fué la última vez que fué a la
clinica? ¿En que fecha?
In what month (of your pregnancy) did you     How much? A cupful? A tablespoonful? A
go to the doctor to begin your care?          teaspoonful?
¿En qué mes de su embarazo vió al doctor      ¿Cuánto sangre? ¿Una taza? ¿Una cucharada?
por primera vez?                              ¿Una cucharadita?
The last delivery-short or long?              Are you passing clots? Very large?
¿El ultimo parto fué corto or largo?          ¿Le salen coágulos? ¿Muy grandes?
Have you had any problems with this           Did your membranes rupture? Has your bag of waters
pregnancy?                                    broken?
¿Ha tenido algun problema con éste            ¿Se le reventó la bolsa de agua? ¿Se le reventó la
embarazo?                                     fuente?

Have you ever had an ectopic (tubal)          What time did it break?
pregnancy?                                    ¿A qué hora se le reventó?
¿Ha tenido un embarazo ectópico?
(embarazo en la trompa)?
Have you ever had a stillborn?                How much water did you lose? Down the legs?
¿Ha tenido un niño qué nació muerto?          ¿Cuánta agua perdió? ¿Le mojó las piernas?

                                                 46
Have you ever had a cesarean section?             Your cervix is dilated to 3 centimeters.
¿Ha tenido usted una operación cesarea?           Su cuello tiene tres centimetros de dilatación.
Why? What date?                                   You are in labor. Your membranes have ruptured.
¿Porqué? ¿En qué fecha?                           ¿Está en trabajo de parto. Su fuente está rota.
Your cervix is not dilated.
¿Su cuello no está dilatado (abierto)
             Obstetric History
Have you had any problems with past               Your cervix wouldn‟t open?
pregnancies?                                      ¿El cuello de la matriz no se abrió?
¿Ha tenido problemas con sus embarazos
pasados?
Bleeding? Hypertension? Toxemia?                  What was the date of your last pregnancy?
 ¿Tuvo sangrado? ¿Tuvo alta presión de            ¿En qué fecha fué su último embarazo?
         sangre? ¿Tuvo toxemia?
How many children have you had?                   What was the weight of your largest (smallest) baby?
¿Cuántos niños ha tenido?                         ¿Cuánto peso su bebé más grande (pequeño) al nacer?
Are they all living?                              After birth, any problems with the children?…like birth
¿Están todos vivos?                               defects? Mental retardation?
                                                  ¿Algun niño tuvo defectos de nacimiento? ¿Retraso
                                                  mental?
What was the cause of death? At what              Were any born early (premature)?
age?                                              ¿Ha tenido usted algun niño prematuro?
¿Cuál fue la causa de muerte? ¿A qué
edad?
Was s/he born vaginal or by cesarean?             What year were they born?
El nacimiento fue normal (por la vagina) o        ¿En que año nacieron?
por cesarean?
How much did they weigh at birth?                 Have you ever had a miscarriage?
¿Cuánto pesó el bebé al nacer?                    ¿Ha tenido usted algún malparto un aborto o perdió
                                                  algún embarazo?
On scale of 1 to 10, 1 being very mild pain
and 10 being very strong pain, how bad is
your pain?
¿Del uno al diez, el uno siendo muy leve, y
el diez muy fuerte, que número le daría a
su dolor?


   Past Medical History/Past Surgical               Social History, Meds, Allergies, Family History
                    History
Do you have any medical problems?                 Do you smoke, drink or do any drugs?
¿Tiene usted algún problema médico?               ¿Fuma cigarillos? ¿Bebe alcool? ¿Usa drogas?
Hypertension? ¿Alta presión                       With whom do you live?
Heart disease? ¿Enfermeda del corazón?            ¿Con quién vive?
Asthma/Tuberculosis?
¿Asma/tuberculosis?
Problems with your kidneys, urine,                Is there violence in your home?
infections, liver, hepatitis, diabetes, thyroid   ¿Tiene violencia en su casa?
disease, seizures, or cancer (colon, breast)?
                                                     47
¿Problemas con los riñones, infección de
orina, el higado, hepatitis, diabetes,
enfernedad de la tiroide, convulsions
(ataques) o cancer (de los intestinos,
senos/pechos)?
Have you had any operations?                  Do you take any medicines?
¿Ha tenido alguna operación (cirurgia)?       ¿Está tomando alguna medicina?

Past Gynecological History                    Do you have any allergies?
                                              ¿Tiene usted alguna alergia?
What do you use for birth control?            Has anyone your family had…?
¿Qué typo de anticonceptivo usa?              ¿Alguien en su familia ha tenido…?
                                              See above for conditions.
Have you ever had a sexually transmitted
infection?                                                         Return OB Visit
¿Ha tenido alguna enfermedad transmitido
sexualmente?
Have you ever had an abnormal pap smear?      Have you had any problems with this pregnancy?
¿Ha tenido un papanicolao anormal             ¿Ha tenido algún problema con éste embarazo?
(malo)?
When was your last pap?                       Have you been vomiting?
¿Cuando fué su ultimo papanicolao?            ¿Ha estado vomitando?
Are your periods regular? Are they light,     Have you had any infections? Of what?
medium, or heavy?                             ¿Ha tenido alguna infección? De qué?
¿Le viene la regla normal cada mes?
¿Leve, normal, o abundante?
Do you get cramps with your period?                                 Instructions
¿Le da cólico con su regla?
Have you felt the baby move yet?              You are going to stay in the hospital
¿Ha sentido que su bebe se mueve?             Se va a quedar en el hospital
Has the baby been moving normally?            You may go home
¿Se ha movido bastante su niño?               Se puede ir a casa
Have you had painful urination? burns?        You are in early labor
¿Ha tenido dolor al orinar? le arde?          Está en la primera parte del parto
Have you had the urge to urinate often?       Stay at the hospital and walk for two hours
¿Tiene ganas de orinar muy a menudo?          Quédese aquí en el hospital y camine por dos horas
Have you spots/stars in front of your eyes?   The heart rate of the baby is normal
¿Ha notado manchas enfrente de los ojos?      El corazón del niño está normal.
Have you had severe headaches?                Take off your clothes
¿Ha tenido dolores de cabeza fuertes?         Quitese la ropa
How many time a week?                         Take off your panties, please
¿Cuántas veces en una semana?                 Quitese su ropa interior (panteletas) por favor
Have you had swelling of both hands, face,    I am going to examine you
legs?                                         Voy a examinarte
¿Se le has hinchado las manos, la cara, las
piernas?
Can you use/wear your rings?                  Bend your knees
¿Puede ponerse sus anillos?                   Doble las rodillas

                                                 48
Go to L&D if: you have vaginal bleeding;        Put your feet together.
your water breaks; (if preterm) you have        Juntese los pies
>6 contractions per hour; you are having
regular contractions every 5 minutes (if full
term); or if the baby isn‟t moving for >8h
even though you ate something.
Vaya al hospital se tiene sangrado vaginal,
si se rompe su fuente, se tiene más de seis
contracciones en una hora, si tiene
contracciones regulares cada cinco
minutes, si el bebé no se mueve por más de
ocho horas, aunque ha ya comido.
Lie down on your back                           Relax your body
Acuéstese en su espalda. (Acuéstese boca        Descanse (relaje) el cuerpo
arriba)
Lie down on your right (left) side              Move down on the table. (a little bit)
Acuéstese de lado derecho (izquierdo)           Bájese (un poquito)

Other
Move                                            Severe
Muévase                                         Severo/Fuerte
Don‟t push                                      Mild
No empuje                                       Leve
Breath through your mouth, more slowly          Medium
Respire por la boca, mas despacio               Mediano
Push with your pains                            Heavy
Empuje cuando sienta dolor                      Abundante
Do you understand?
¿Comprende?
Congratulations. You have a baby girl
(boy)
Felicitaciones. Es una niña (un niño)
                 Anatomy
Abdomen                                         Butt
El abdomen/vientre, la barriga                  Las sentaderas
Appendix                                        Rectum
El apéndice                                     El recto
Ruptured                                        Bladder
Reventada/roto                                  La vejiga
Head                                            Vagina
La cabeza                                       La vagina
Breasts                                         Cervix
Los senos                                       El cervix, el cuello de la matriz
Uterus                                          Cyst
El útero, la matriz                             El quiste
Fallopian tubes                                 Ovaries
Las trompas (los tubos)                         Los ovaries
Nipple
El Pezón
                                                   49
Postpartum/Post-Operative
How do you feel?                               Have you passed gas?
¿Como se siente?                               ¿Ha pasado gas por detras?
Have you had a bowel movement?                 Are you dizzy when you stand up?
¿Ha pasado excremento?                         ¿Tiene mareas cuando levanta?
Do you feel pain? Nausea? Vomiting?            You had the king of c-section that you should not try to
¿Siente dolor? Tiene nausea? Vomito?           have vaginal birth again. You need to have c-sections
                                               for all your future deliveries.
                                               Ha tenido el typo the cesarean despues de que is
                                               importante que no trata de tener bebes por la vagina.
                                               Necesita tener cesareas por todo sus embarazos en el
                                               futuro.
Are you having vaginal bleeding? Is it         You had the kind of c-section that you can try to have
heavy? It‟s normal to have a bloody            your next baby vaginally, if you want.
vaginal discharge for up to 6 weeks            Ha tenido el typo de cesarea despues de que puede
postpartum.                                    tener su proximo bebe por la vagina, si quiere/
¿Tiene sangre por la vagina? ¿Sangra
demasiado? Es normal a tener flujo con
sangre por la vagina hasta seis semanas
despues del nascimiento.
When the baby delivered, your anal             What do you want to use for birth control?
sphincter tore. You must be careful not to     ¿que quiere usar para anticonceptivo?
strain too much or have constipation so that
you don‟t tear out your stitches.
Cuando el bebe salio, a roto su ano.
Necesita cuidarse para no hacer
demasiado fuerza o a tener estrenimiento
para no romper los puntos en su ano.
Your stitches will dissolve.                   Condoms? Birth Control Pills? Three month shot?
Sus puntos van a dissolver naturalmente.       IUD? Patch?
                                               Condones? Pastillas anticonceptivas? La inyecion de
                                               tres meses? El dispositivo (la T)? El parche?
We recommend that you not have sex until       If you use condoms, you must have lubrication by the
after your 6 week checkup.                     bedside because it is very common after having a baby
Recommendamos que no tenga relaciones          to have more vaginal dryness. If you have sex without
por las seis semanas hasta su cita en la       enough lubrication, you may get vaginal irritation.
clinica.                                       Si usa condones, necesita tener lubrication al lado de
                                               la cama porque es muy commun despues de un
                                               nascimiento estar seco en la vagina. Si tiene
                                               relaciones sin bastanta lubrication, puede tener
                                               irritacion en la vagina.
If you use Birth Control Pills or Patch, you   If you have the 3-month shot, you can get it before you
should wait until the 3rd Sunday after you     leave the hospital.
had the baby to start them.                    Si quiere la inyeccion, puede recibirlo antes de salir
Si usa las pastillas anticonceptivas o el      del hospital.
parche, necesita esperar hasta el tercer
Domingo despues del nacimiento para
empezarlos.


                                                  50
If you want the IUD, you should not have    The regular pill and the patch can decrease your milk
sex until your doctor can put it in, after  supply. You can start with the 3-month shot and switch
your 6 week checkup.                        over at your 6 week checkup when you know your milk
Si quiere el dispositivo (la T), es         supply is well-established.
importante que no tenga relaciones antes    Las pastillas anticonceptiva regular y el parche pueden
de su cita a las seis semanas cuando su     disminuir la leche. La inyeccion de tres meses y el
doctor puede ponertelo.                     dispositivo no affectan la leche. Puede empezar con la
                                            inyeccion, y a su cita de seis semanas, puede cambiar a
                                            otro metodo cuando esta segura que su leche viene
                                            bien.
With the patch, 1 patch is for 1 week. Each If you are breastfeeding and want oral contraceptives,
Sunday you put on a new patch. You wear we usually give the progestin-only pill to not decrease
it 3 weeks on, 1 week off. You should       your breastmilk. This pill is “weaker” than the regular
have your period the week you have it off. pill and you cannot be late in taking it. You must take
You must remember to start it the next      it the same time everyday or you may get pregnant. If
Sunday after your patch-free week           you miss it, you should use condoms.
Con el parche, un parche is por una         Si el bebe come por el pecho y quiere pastillas
semana. Cada Domingo, ponga un parche anticonceptivas, damos las pastilla con solamente
nuevo. Tiene tres semanas con parche, y     progestin (no estrogen) para no disminuir la leche.
despues una semana sin parche, va a tener Esta pastilla es mas leve que la pastilla regular, y no
la regla durante la cuarta semana cuando    puede tomarla tarde. Necesita tomarla al mismo
no ponga un parche. Necesita recordar a     tiempo cada dia o puede embarasarse. Si olvida su
empezar el parche otra vez despues de la    pastilla, necesita usar condones por un mes en
semana sin parche.                          addicion a las pastillas.
Breastfeeding is very good for the baby.    You can get the 3-month shot once, to cover you until
Breastfeeding is easier and cheaper than    you can get your IUD.
bottle-feeding. Breastfed babies have less  Puede recibir la inyeccion de tres meses una vez para
infections that formula-fed babies.         cubrir usted hasta puede recibir el dispositivo.
A comer por el pecho es muy bien por el
bebe. Comer por el pecho es mas facil y
mas barato que tomar botella. Bebes
quienes comen por el pecho tienen menos
infecciones que bebes quienes toman
botella.
You have anemia. You must take iron to      I‟m giving you a prescription for stool softener. It‟s
build your blood supply up. You will feel   also important to drink a lot of water and eat fruits &
stronger (less weak) if you do.             vegetables so you have soft poop (no constipation)
Tiene anemia. Necesita tomar hierro para that‟s easy to pass.
hacer su sangre mas fuerte. Va a sentir     Te voy a dar una receta por medicina para hacer su
mas fuerte (menos debil) si toma su hierro. excremento mas suave. Es importante tomar much
                                            agua y comer muchas frutas y verduras para tener
                                            excremento suave (para evitar estrenimiento) que es
                                            facil pasar.




                                                51
Commonly Used Medications on Labor and Delivery
Antibiotics:
   Ampicillin 2g IV q6h (for chorio while in labor, or endometritis failing
    gent/clinda post-partum)
   Clindamycin 900mg IV q8h (for endometritis post-partum)
   Gentamycin 120mg IV x1 then 80mg IV q8h (for chorio while in labor)
   Gentamycin 300mg (5mg/kg) IV q24h (for endometritis post-partum)

GBS +:
   PCN 5million units IV loading dose then 2.5million units IV q4h
   Ancef 2g IV q6h – if low risk PCN allergy
   Vancomycin 1g IV q12h/Clindamycin 900mg IV q8h – if high risk PCN allergy

Induction:
   Cervidil – 10mg vaginal insert (remove at onset of labor or after 12hrs)
   Cytotec (misoprostol) – 25micrograms per vagina q4h
   Pitocin – 15units in 250ml NS start gtt at 2 milliunits/min and increase by 1-2
    milliunits q20minutes per protocol until adequate contraction pattern

Pain:
   Stadol 1mg IV and 1mg IM x1

Pre-eclampsia:
       Magnesium sulfate 4g IV loading then 2g/h (check level q6h)
       Hydralazine 5mg slow IV push x1
       Labetalol 20mg IV over 2 minutes x1
       Calcium gluconate 1 amp= 1g slow IV push over 3 minutes

Pre-term contractions:
   Terbutaline 0.25mg SC q20minutes x3 (hold for HR>120)
   Nifedipine 10mg PO q20min x4 doses
   Betamethasone 12mg IM q24hr x2 doses

Uterine Atony/PP hemorrhage:
   Pitocin 10-20 units IM x1 or 20-40 units in IV fluids (at least 250ml)
   Methergine 0.2mg IM q15min x3 doses or 0.2mg PO q6hrs x 4 doses
    (contraindicated in HTN/pre-eclampsia
   Cytotec (misoprostol) – 400-800micrograms per rectum x1
   Hemabate 0.25mg IM q15min up to 8 doses (avoid in asthmatics)
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