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Frequently Encountered Situations on Labor and Delivery

By Gilbert Murphy,2014-04-26 12:32
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Frequently Encountered Situations on Labor and Delivery

    Maternal Child Health Brown Family Medicine

    MHRI

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

     Cesarean Section 26

     Vaginal Birth After Cesarean (VBAC) 26

     2

     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 rdthrecognize 3 and 4 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:

     rd1. Patients with risk factors will be scheduled for weekly (or biweekly) NST/AFI in the 3

    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)

     nd1. You are expected to sign back charts once per week at Medical Records office, 2 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. stBP ? 140/90 mm/Hg for 1 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. 3Thrombocytopenia (<100,000/mm). (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.

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