1. 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

2. 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

3. “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

4. 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

5. 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)

6. 6

7. 7

8. 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)

9. FM Resident OB Supervisors
Maternity & Newborn Field Note - can be completed by:
Family Physicians
Staff Obstetrician
Senior OB/Gyn Residents
Obstetrical Nurses

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Obstetrical Areas OAU – Obstetrical Assessment Unit (Triage)
Birthing Unit (BU/Case Room)
Postpartum ward – A4 OCH, 8E OGH

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 1.b) Vaginal exam
2) Presenting Part
Vertex / breech / other?
position

27. 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

28. Occiput posterior position
1.b) Vaginal exam
Occiput posterior position

29. Occiput transverse positions
1.b) Vaginal exam
Occiput transverse positions
ROT
LOT

30. 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)

31. Assessing descent by vaginal examination
-2 station: - leading bony edge of presenting part is 2cm above ischial spines
0 station: - head is engaged

32. 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?

33. 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.

34. 1.b) Vaginal exam
Preferred test
Ferning

35. 2. Technical Skills - ARM
practice
Amniohook

36. 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)

37. 5.Technical skills – Perineal Repair
Academic Day July 17, 2015
Foam model simulation

38. 6. Technical Skills - AVD Assisted vaginal delivery
In hands-on workshops: session 3 (OBS emergencies)

40. FETAL HEALTH SURVEILLANCE Fundamentals Workshop 2009
Fetal Health Surveillance - Instructor Notes
PPPESO, 2009
FETAL HEALTH SURVEILLANCE Fundamentals Workshop 2009
Copyright PPPESO, 2009

41. 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
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42. Paper speed - 3 cm/min © PPPESO 42 2009
Fetal Health Surveillance - Instructor Notes
PPPESO, 2009
Paper speed - 3 cm/min 42
© PPPESO
2009
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43. 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
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44. 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
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45. 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
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46. 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
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2009
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47. 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
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48. 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
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49. 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
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2009
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50. 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
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51. 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
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2009 51
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52. Variable Deceleration
Fetal Health Surveillance - Instructor Notes
PPPESO, 2009
Variable Deceleration
“Shoulders”
“Overshoots”
NORMAL (REASSURING)
ABNORMAL (NON-REASSURING) 52
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2009
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53. 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
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54. 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
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55. 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
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56. 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
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2009
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57. Intermittent Auscultation (IA)
Appropriate for low risk labor

58. Classification of NON STRESS TEST (NST)58

59. Classification of EFM tracings

60. 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
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2009
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61. 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
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2009
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62. 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
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2009
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63. 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
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2009
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64. 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
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2009
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