1. Common ob triage complaints
Jaleh Akhavan and Quinn Jackson
Family Medicine Resident School
August 14, 2019

2. Objectives
Describe the proper work up for term labor, SROM rule out and preterm labor rule out
Identify candidates for MAT
Determine if a patient is more appropriate for buprenorphine vs methadone treatment
Apply these skills on MCH!

4. Term Labor Records!!! Prenatal care, labs, ultrasounds, GBS status
Term = > 37wga
Ultrasound for presentation
NST
Cervical exam
Typically admit if >/= 6 cm or not tolerating pain of contractions
If no GBS status, get RAPID GBS swab (in drawer at HUC station)
Admit orders: OB Admit to L&D powerplan +/- OB Induction Augmentation Module (this has miso, Cooks, and pit orders)
If not in labor: discharge order and MSE

5. Term Labor Records! Ultrasound for presentation Cervical exam GBS
Admit to L&D powerplan
+/- OB Induction Augmentation powerplan

7. SROM Rule Out Records!!! Prenatal care, labs, ultrasounds, GBS status
Sterile speculum exam- pooling? Is os open or closed?
Nitrizine paper (little box on HUC desk)
Ferning (microscope in “dirty” room in the back)
If >35 weeks and no GBS collected yet, get one
NST
If negative = discharge home order and MSE
If SROM = admit for induction
Then, ultrasound for position
Don’t do SVE before staffing with attending, some want to check and some don’t
Admit order: OB Admit to L&D powerplan + OB Induction Augmentation Module
Can’t use a cook

8. SROM Rule Out Records! Sterile speculum exam
Pooling, nitrizine, ferning
No cervical exam

9. Preterm Labor Rule Out
Records!!! Prenatal care, labs, ultrasounds, maybe GBS status
Preterm = less than 37 weeks
NST- are there contractions?
Sterile speculum exam first
FFN swab first, as long as nothing in vagina for 24 hrs, DON’T send before staffing
SROM exam- is os open or closed? Pooling, ferning, nitrizine
CT/GC/trich and Vagpath swabs, urine culture
If no GBS status, collect REGULAR GBS swab (in triage rooms)
SVE- if >2cm or making change with time; after staffing, may leave her in triage for 2-4 hours and recheck to assess change
Ultrasound for position
If admitting: OB Preterm Labor powerplan
When staffing discuss things like steroids and magnesium

10. Preterm Labor Rule Out Records! NST Sterile speculum exam, FFN
Infectious workup

11. Subutex Start
Records!!! Prenatal care, labs, ultrasounds. Also documented substance history and prior treatments/rx’s if in system.
Detailed substance history- what, how much, how long, last use, prior MAT
NST if >24 weeks
NOT a good bup candidate if: primary addiction is to something else (esp benzos), active hepatitis ( >3x limit), can’t or won’t come to prenatal
appointments sometimes weekly, prefer methadone after talking about it
If starting bup:
Labs: prenatal labs + LFTs, Hep C antibodies, Urine drug screen- UDATR, rapid buprenorphine in MCH work room before sending urine to lab
Sign consent form
COWS (MD calc)
If less than 22 weeks, may be able to do outpatient induction- discuss with attending
If admitting: OB IUP Admit powerplan + three doses of buprenorphine “ON CALL”
If more appropriate for methadone after staffing, call MCH fellows

12. Subutex Start Records! Substance use history
Prenatal labs + LFTs, HepC, UDATR, Urine Bup
Consent form
COWS
Admit IUP Powerplan
Order subutex “ON CALL”

13. Questions???

14. To Summarize
Write your prenatal notes same day and put them in powerchart
Put the MCH guidelines on your phone