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Family Medicine Obstetrics Orientation
Department of Family Medicine special thanks to Dr. Gary Viner, Dr. Dave Millar, Dr. Kristine Whitehead, Nursing Care Facilitators & Champlain Maternal Newborn Regional Program July 2015
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FM Maternity Care - Resources
Human Labor and Birth, Oxorn - Foote, Sixth Edition – Dr. Glenn Posner et al. SOGC Clinical Practice Guidelines, sogc.org myHospital -> Policies and Procedures -> Obstetrics, Gynecology and Newborn Care Cmnrp.ca, Champlain Maternal Newborn Regional Program V-drive DFM Website Uptodate Ongoing teaching in the Units and at Academic Day
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“Low Risk” Obstetrics Session 1: Role in Obstetrical Triage & Birthing Room Technical Skills Fetal Health Surveillance Triage assessments Session 2: Management of Labor Hospital-based Postpartum Care Session 3: OBS emergencies Perineal repair: July 17, 2015 Academic Day
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Objectives Describe FM resident’s role in intrapartum maternity care
Review expected competencies and e-fieldnotes Review important skills & protocols Introduce Fetal Health Surveillance (FHS) Prepare for triage assessments NB. – this information is available on DFM website, including Mat and NB fieldnote NEW in 2014– FIRST SHIFTS ARE WITH R2, BU walk through with Care Facilitator Day 1
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Intra-partum Competencies
Diagnose SROM Perform accurate cervical assessment Manage labour / fetal surveillance Scalp electrode placement Manage amniotomy & labour augmentation Manage spontaneous vaginal delivery Manage obstetrical emergencies Participate in assisted vaginal delivery Perform uncomplicated perineal repair Communicate/collaborate effectively (patient,family, team)
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Mandatory Requirements
“Demonstrate sufficient competency on the Maternity and Newborn Field Note (FN) from across the different pregnancy stages antenatal, intra-partum and post-partum skills.” Effective : PGY1s: must demonstrate exposure to 80% of intrapartum, antenatal and postpartum competencies PGY2s: must demonstrate attainment of 80% of intrapartum, antenatal and postpartum competencies Completed FNs should be completed electronically (eFN) or faxed immediately (fax no. bottom right corner of form)
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FM Resident OB Supervisors
Maternity & Newborn Field Note - can be completed by: Family Physicians Staff Obstetrician Senior OB/Gyn Residents Obstetrical Nurses
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New DFM Evaluation Policy: when no designated/continuous preceptor
Maternity & Newborn Field notes (FNs): ≥1/day expected RN &/or Ob-Gyn residents (>PGY2) 60% of FNs must be staff MD (FMOB or OBGyn) name, role & PGY level (if resident) of evaluator MUST be clear or FN WILL BE DISCARDED Initiated by Resident or assessor
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FM Resident Role in Obstetrics
“Senior” for FM-OB but “Junior” for OB service Environment provides opportunity to work with many Special role of OB Nurse appreciate different approaches Watch, Listen, Learn and Do!! Communicate status of each patient to: Staff (OB, FM-OB) or Senior (OB resident) - on admission, prior to d/c or any significant intervention - q2-4h in labour - q1h when pushing
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At the start of each shift
Identify yourself to Care Facilitator (CF) or Team Leader (TL) Introduce yourself to RNs, staff OB, OB resident Write contact info on white board & link to your patients (white board at Nursing station and in patient room) FM Resident to FM Resident handover weekdays and 0800 on Sat/Sun/holidays – vitally important skill
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Attend interdisciplinary rounds with team in AM and PM – variable time, around 0745 and 1700
Staff OB, OB Resident Care Facilitator / Team Leader and Nursing Sometimes: med student, anesthesia, MFM Meet your patients - review history & plan prior to entering the room, introduce yourself to patient and RN Name on whiteboard If patient is Family Practice patient/low risk, ask RN to call you for ALL assessments At OGH – Interdisciplinary handover is 0745 at the CF desk Mon, Tue, Thurs and Friday on Wednesdays and 0845 on Sat. and Sun. Evening handover is 1700 Mon-Fri and 2000 Sat/Sun At OCH – Interdisciplinary handover is 0745 Mon, Tue, Friday and 0845 Wed and Thurs. Handover is 0800 on weekends. Evening handover is 1715 Mon to Thurs, 1615 on Friday and 2000 on weekends
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Family Practice patients – 1st priority:
responsible for all assessments management of labor attendance at deliveries & newborn assessments involve staff FM-OB, NOT OB resident in plan of care Also follow LOW RISK, term OB patients Include OB resident in plan of care (keeping them updated of changes) any concerns -> speak to OB resident first, then on-call staff Obstetrician prn
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Keep CF/TL & census (white) board up to date
‘Check In’ with your patients progress at least Q2 hourly -write note after each assessment Update the CF and supervising staff after each patient assessment. Discuss any concerns with the Family Physician or OBS resident. (i.e. slow progress, abnormal FHS, meconium etc.) PROTOCOL: Active Management of Labor Expect to be called for triage assessments – maintain a high profile around the Nursing station
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Obstetrical Areas OAU – Obstetrical Assessment Unit (Triage)
Birthing Unit (BU/Case Room) Postpartum ward – A4 OCH, 8E OGH
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1. Obstetrical Assessment Unit (OAU) = Triage
Assess outpatients Patient documentation required: History & Physical (RN supervised) Assessment Plan Review with FMOB staff/OB senior or OB staff
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All vaginal exams confirmed by RN initially
prior to OAU discharge of FM patient you must ALWAYS contact attending FM or OB resident/staff Notify FM staff or OB resident of all admissions to the Birthing Unit
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2. Birthing Unit Expectations
Attend all low risk deliveries assist with clean up (discard sharps, count instruments) Complete L & D documentation and Birth Record Complete PP orders Sign Medication Reconciliation form Complete newborn exam (& documentation) and orders for FM babies
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3. Postpartum Care Post Partum Rounds
After birthing unit rounds ~08:30 Patient lists from Ward Clerk on A4/8E – both PP and newborns See, assess & 1st call for FM moms & babies Communicate with FM-OB Staff – review concerns and before all discharges May assist with OB PP rounds Reinforce newborn need for F/U 2 days after discharge PP care review/expectations in teaching session #2 and in-unit
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Learning Opportunities!
1. Follow your patients through labor & birth (including C/S, if available) 2. Postpartum rounds/Newborn care 3. OB/gyn rounds Wednesday mornings 0730 4. Gyne (floor and ER) – sometimes, as per OB resident 5. Medical students – learn with them and teach them 6. Participate in MORE OB skills drills 7. Review TOH protocols/procedures on myHospital
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Technical Skills Clinical Assessment: ARM – amniotomy
Abdominal Exam (Leopold’s Maneuvers) Cervical Exam - confirmed by RN initially Assessment of SROM, vag/cx swabs prn, FFN prn ARM – amniotomy Induction -> Cervidil, foley catheter Scalp Electrode Attend spontaneous vaginal delivery Perform uncomplicated perineal repair Approach to assisted vaginal delivery and management of OBS emergencies
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1. Clinical assessment – every patient (triage and BU)
Introduce yourself to patient & supports Review the antenatal records Develop relationship, project secure/safe environment Communicate directly with patient and with RN Discuss all patients with Senior OB resident, OB staff or FM staff Never discharge a patient without reviewing with staff
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Fetal Health Surveillance - Instructor Notes
PPPESO, 2009 1. a) Leopold’s Maneuvers Second First Umbilical Grip – fetal back Fundal Grip Third Fourth Pawlick’s Grip – presenting part Pelvic Grip – fetal brow Martin, 2002 Copyright PPPESO, 2009
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1.b) Vaginal exam With RN supervision, with consent. Gently, avoid clitoris/urethra anteriorly 1) Cervix Location of cervix vs. presenting part: posterior, mid-position or anterior Consistency Effacement/Length (avoid % - use cm) Dilatation Membranes - ? bulging
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1.b) Vaginal exam 2) Presenting Part Vertex / breech / other? position
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Occiput anterior positions
1.b) Vaginal exam ROA LOA OA Posterior fontanel: smaller fontanel - intersection of sagittal two lambdoid sutures. Anterior fontanel: larger fontanel - intersection of sagittal, frontal & two coronal sutures. Occiput anterior positions
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Occiput posterior position
1.b) Vaginal exam Occiput posterior position
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Occiput transverse positions
1.b) Vaginal exam Occiput transverse positions ROT LOT
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1.b) Vaginal exam 3) Station
Station of presenting part should be positively determined Pelvis is divided into 5ths -5 to +5 (fetal head visible at the introitus) “0”station or “spines” usually represents engagement of the fetal head ( i.e. biparietal plane of the fetal head has passed through the pelvic inlet)
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Assessing descent by vaginal examination
-2 station: - leading bony edge of presenting part is 2cm above ischial spines 0 station: - head is engaged
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1.b) Vaginal exam 4) Pelvic Architecture 5) Amniotic Fluid Assessment
Assess ischial spines, pelvic sidewalls & sacrum for adequacy 5) Amniotic Fluid Assessment Ferning Nitrazine Clear or meconium?
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1.b) Vaginal exam pH of vaginal discharge using nitrazine paper Normal
False + from blood, semen, urine, infection Normal Bacterial vaginosis Pregnant woman with premature rupture of membranes.
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1.b) Vaginal exam Preferred test Ferning
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2. Technical Skills - ARM practice Amniohook
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4. Technical skills - Scalp electrode
1) ensure continuous EFM is indicated 2) consider method of EFM: external vs. internal Fetal vs. Maternal considerations Technique … practice this to be prepared!! (see session 2)
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5.Technical skills – Perineal Repair
Academic Day July 17, 2015 Foam model simulation
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6. Technical Skills - AVD Assisted vaginal delivery
In hands-on workshops: session 3 (OBS emergencies)
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FETAL HEALTH SURVEILLANCE Fundamentals Workshop 2009
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 FETAL HEALTH SURVEILLANCE Fundamentals Workshop 2009 Copyright PPPESO, 2009
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Systematic Approach to Interpretation
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Systematic Approach to Interpretation CHECK: Tracing quality, paper speed, graph range, internal vs. external INTERPRET: Uterine Activity Pattern Baseline FHR Baseline Variability Presence of Accelerations & Decelerations Correlate findings with clinical situation: Normal, Atypical, Abnormal (Reassuring or non-reassuring?) Document Highlight importance of methodological approach to interpretation. 41 © PPPESO 2009 Copyright PPPESO, 2009 41
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Paper speed - 3 cm/min © PPPESO 42 2009
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Paper speed - 3 cm/min 42 © PPPESO 2009 Copyright PPPESO, 2009 42
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Uterine Activity Assessment (contractions)
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Uterine Activity Assessment (contractions) Frequency (in minutes) Duration (in seconds) Intensity (mild, moderate, strong) – by history and by palpation Resting tone (soft, firm) – by palpation RN can help resident learn how to palpate the uterine fundus 43 © PPPESO 2009 Copyright PPPESO, 2009 43
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Baseline FHR 110-160 normal > 160 tachycardia
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Baseline FHR Definition: approximate mean FHR rounded to 5 bpm increments in a 10-minute segment, excluding: periodic & episodic changes periods of marked FHR variability (> 25 bpm) Must be present 2 minutes or is indeterminate normal > tachycardia < bradycardia 44 © PPPESO 2009 Copyright PPPESO, 2009 44
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Fetal Health Surveillance - Instructor Notes
PPPESO, 2009 FHR Variability Definition: Fluctuations in baseline FHR 2 cycles per minute Irregular amplitude and frequency Visually quantitated as the amplitude of the peak-to-trough in bpm 120 150 180 90 Presence of variability is a crude indicator of fetal oxygenation as it reflects an intact CNS 45 © PPPESO 2009 Copyright PPPESO, 2009 45
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FHR Variability Amplitude range undetectable
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 FHR Variability Amplitude range undetectable Amplitude range detectable but 5 bpm Amplitude range bpm Amplitude range > 25 bpm ABSENT MINIMAL MODERATE MARKED 46 © PPPESO 2009 Copyright PPPESO, 2009 46
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MINIMAL VARIABILITY: 3-5 bpm
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 FHR Variability ABSENT VARIABILITY : 0-2 bpm MINIMAL VARIABILITY: 3-5 bpm No distinction is made any longer between short-term variability (or beat-to-beat or R-R wave period differences in ECG) and long-term variability 47 © PPPESO 2009 Copyright PPPESO, 2009 47
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MODERATE VARIABILITY: 6-25 bpm MARKED VARIABILITY: > 25 bpm
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 FHR Variability MODERATE VARIABILITY: 6-25 bpm MARKED VARIABILITY: > 25 bpm 48 © PPPESO 2009 Copyright PPPESO, 2009 48
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Fetal Health Surveillance - Instructor Notes
PPPESO, 2009 Acceleration Definition: Abrupt increase in FHR (onset to peak in < 30 seconds) 15 bpm above baseline lasting 15 sec. Before 32 weeks: 10 bpm for 10 sec. Prolonged acceleration is 2 minutes Acceleration 10 minutes is a baseline change NORMAL finding Accelerations are a sympathetic response indicating an intact, oxygenated CNS 49 © PPPESO 2009 Copyright PPPESO, 2009 49
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Reflex vagal response associated with
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Early Deceleration Definition: Gradual decrease in FHR (onset to peak in 30 seconds) associated with a uterine contraction Onset, nadir and recovery coincide with contraction NORMAL ie. reassuring 120 150 180 90 100 25 50 75 Remind participants that these are uncommon, despite the fact that every baby’s head obviously gets compressed coming through the pelvis. Why don’t we see these more often? Perhaps they are more common when the head is de-flexed, asynclitic or otherwise malpositioned. Not a lot of research into this No acid-base complications UNLESS associated with nonreassuring baseline features No interventions required for the early decels, however, look at the total clinical picture for lack of progress which might explain the difficulty of the head in maneuvering through the pelvis Reflex vagal response associated with head compression 50 © PPPESO 2009 Copyright PPPESO, 2009 50
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Variable Deceleration
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Variable Deceleration Definition: Abrupt decrease in FHR (onset to peak in < 30 seconds) that is 15 bpm below the baseline for 15 sec., and < 2 minutes from onset to return to baseline When periodic, their onset, depth and duration commonly vary with successive contractions Can be NORMAL, ATYPICAL or ABNORMAL 120 150 180 90 100 25 50 75 Reflex response to cord compression during or between contractions © PPPESO 2009 51 Copyright PPPESO, 2009 51
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Variable Deceleration
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Variable Deceleration “Shoulders” “Overshoots” NORMAL (REASSURING) ABNORMAL (NON-REASSURING) 52 © PPPESO 2009 Copyright PPPESO, 2009 52
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Complicated Variable Decelerations
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Complicated Variable Decelerations Deceleration <70 bpm >60 sec. Loss of variability of baseline and in the trough Biphasic deceleration Overshoot (20 bpm increase by 20 seconds Slow return to baseline Continuation of baseline rate at a lower level than prior to the deceleration Presence of tachycardia or bradycardia 53 © PPPESO 2009 Copyright PPPESO, 2009 53 53
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Fetal Health Surveillance - Instructor Notes
PPPESO, 2009 Late Deceleration Definition: Gradual decrease in the FHR (onset to peak in 30 seconds) associated with a contraction Onset, nadir & recovery occur after the beginning, peak & end of contraction ATYPICAL or ABNORMAL ie. Non-reassuring 120 150 180 90 100 25 50 75 Chemoreceptor & vagal response to utero-placental insufficiency , reflecting marginal fetal oxygenation Stress to participants that late decels might be either reflex (and therefore probably correctable) and occasional or related to some sort of chronic problem (poor placenta, or hypertension affecting placental blood flow) that are repetitive and not likely correctable. This doesn’t get documented, but helps care providers think about the likely success of their interventions. For example, late decelerations associated with a healthy woman who happens to be positioned on her back are probably correctable. 54 © PPPESO 2009 Copyright PPPESO, 2009 54
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Prolonged Deceleration
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Prolonged Deceleration Visually apparent decrease in FHR below baseline, > 15 bpm, lasting > 3 minutes, but < 10 minutes from onset to return to baseline Decrease calculated from the most recently determined portion of baseline Prolonged deceleration > 10 min is a baseline change ABNORMAL (Nonreassuring) Chemoreceptor, baroreceptor & CNS responses to profound changes in fetal environment 55 © PPPESO 2009 Copyright PPPESO, 2009 55
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Fetal Health Surveillance - Instructor Notes
PPPESO, 2009 Rare FHR changes Sinusoidal pattern differs from variability in that it has a smooth, sine wave-like pattern of regular frequency and amplitude, and is excluded in the definition of FHR variability Associated with fetal anemia Is classified as an ABNORMAL finding 56 © PPPESO 2009 Copyright PPPESO, 2009 56
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Intermittent Auscultation (IA)
Appropriate for low risk labor
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Classification of NON STRESS TEST (NST)
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Classification of EFM tracings
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Factors to consider when interpreting FHR characteristics
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Factors to consider when interpreting FHR characteristics Gestational age Fetal behavioral state External factors / influences Cause of decreased oxygen delivery Duration of precipitating cause The overall clinical picture! Review each of these factors: QUESTIONS: What is the reason that we should consider each of the above stated factors? 60 © PPPESO 2009 Copyright PPPESO, 2009 60
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Responses to Atypical and Abnormal FHR
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Responses to Atypical and Abnormal FHR Consider total clinical picture Further assessments to identify potential causes (maternal, fetal, placental) and to assess fetal well-being Fetal scalp stimulation Fetal scalp sampling Clinical actions to: remove aggravating condition(s) institute intrauterine resuscitation techniques 61 © PPPESO 2009 Copyright PPPESO, 2009 61
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RECOMMENDATION: Digital Fetal Scalp Stimulation
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 RECOMMENDATION: Digital Fetal Scalp Stimulation Recommended with atypical EFM Gentle digital pressure over the parietal bones Max 15 seconds between contractions and between decels Acceleration usually = pH > ( Murray, 2007) When a acceleratory response is absent: fetal scalp blood sampling where available (IIB) when unable to perform fetal scalp sampling, consider prompt delivery (IIIC) 62 © PPPESO 2009 Copyright PPPESO, 2009 62
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Intrauterine Resuscitation
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Intrauterine Resuscitation GOALS: Improve uterine blood flow Improve umbilical circulation Improve oxygen saturation Reduce uterine activity INTERVENTIONS: Change position Give O2 per mask ? Decrease/discontinue oxytocin Temporarily increase IV rate Support woman / family Communicate / Document 63 © PPPESO 2009 Copyright PPPESO, 2009 63
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Documentation content
Fetal Health Surveillance - Instructor Notes PPPESO, 2009 Documentation content Assessments, interventions, evaluations Subjective (statements/feedback from client in " ") Objective (observed/measured, actions, etc) Communication with care providers: Who was called, and time of call Information reported and request(s) made Care provider’s response Agreed-upon plans of action Outcomes Third-party information (family member, etc) Client’s non-compliant or risk-taking behaviour 64 © PPPESO 2009 Copyright PPPESO, 2009 64
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