Common OB Triage problems

For all patients presenting to PEC for triage:

Determine EDC

• review chart notes for LMP, ask patient to confirm
• Naegle's rule for dating:¸=LMP - 3mos + 7days
• add to this date # of days that the menstrual cycle exceeds 28d
• pre-requisites for naegle use: Regular spontaneous menses
• Quickening 16-20wks
• Doptone FHT's 10-12wks
• 1st TM exam c/w dates
• 20cm fundal height at 20wks GA
• look at all US reports and recalculate YOURSELF
• Remember 1st TM US +/- 1 wk, 2nd TM +/- 2 wks, 3rd TM +/- 3 wks.
• Determine Parity (G P Florida Power And Light)

RULE OUT LABOR

AT TERM

1. Confirm dates!
2. Check VS-BP up? See pre-eclampsia
3. Vag bleeding? See vag bleeding
4. ROM? See ROM below
5. Good fetal mvmt? If no
6. Serial Digital exam (not if vag bleeding-U/S first); if no change- walk after reactive strip x 1hr. If change, admit
7. FHT-need reactive NST prior to ambulation or discharge. If non-reactive, consider giving juice or BPP

PRE-TERM LABOR/CONTRACTIONS

1. Confirm dates!
2. Check 2-5 above
3. Consider causes:
1. STD (GC/Chlam cx)
2. BV (wet prep)
3. UTI (U/A, C&S)
4. Drug abuse (ask, urine screen w/permission)
5. Recent intercourse
6. Dehydration
4. Exam- if any question of ROM, STERILE SPEC & ROM Protocol before any exam
1. if cervical change; tocolysis
2. if none, consider PO/IV hydration to stop Ctx's
3. FHT-need reactive NST if >32wks; if <32 wks, then appropriate for EGA

PRE_ECLAMPSIA vs. PIH/Other¸

• pre-eclampsia=onset of HTN, proteinuria, and/or edema after 20wks GA
• eclampsia= generalized seizures not the result of neurologic disease occuring in a patient who otherwise manifests si/sx consistent w/ pre-eclampsia
• chronic HTN= HTN w/onset <20 wks or persisting beyond 6wks pust-partum.
• Transient (gestational) HTN= mild elevations in BP occurring after 20wks GA which is not assoclated w/other si/sx of pre-eclampsia

• Any diagnosis of pre-eclampsia requires non-dependent edema(>5lb wt gain/wk)
• requires signs of organ injury: oliguria (>400cc/d),HELLP, creat>2, HA, visual change, RUQ pain, pulmonary edema, cyanosis, retinal bleed, CVA, IUGR

1. Pre-eclampsia labs/mgmt¸
1. Hx: ?HA, BV. Epigastric pain, non-dependent edema, or recent large weight gain?
2. Exam: BP, U/A, reflexes
3. Labs: LFT's,Plt cnt, CBC, BUN/Cr, uric acid (>5), fibrinogen, PT/PTT, consider 24hr urine protein
4. Classify: normal, PIH, Pre-eclampsia, eclampsia (see pre-eclampsia vs. other)
1. monitor sx's:clonus, edema, hypereflexia, HA, scotomata
2. daily kick counts, daily wts, 2x/wk nst, serial U/S for interval growth q3-4 wks
2. Criteria for outpatient mgmt of PE (all must be met):
1. Immature fetus (<34wks)
2. Reliable patient
3. No evid of fetal jeopardy (nl growth & surveillance)
4. BP perisistently >150/100
5. Urine protein <2+ on dip, 1gm/d
6. NL Creat, LFT'S, PLT's
3. For seizure prevention:
1. MagSo4 6mg load 2mg/hr for sz prev
2. check for hypotonia=high levels
4. For BP control:
1. hydralazine 10mg IV (5-25mg) q20 min until bp controlled then q3-6 hr or
2. labetolol 20mg IV q10 min, then q3-6

ROM/PROM/PPROM

(Rup of membranes/ Prolonged ROM/Pre-term Prolonged ROM)

1. TERM: (>36-37 wks)
1. Sterile spec - check pH & fern. See if you can determine dilation by visualization.
2. If contracting, digital exam. If not, +/- exam.
3. Consider AFI regardless of exam, findings if good story for ROM
2. PRETERM (24- 36 wks)
1. Same as #1 above
1. Is patient contracting?
2. no – do not perform digital cervical exam as risk of chorio is related to length of time from initial digital exam. Do sterile spec and try to estimate dilation visually
3. contracting – may examine if uncomfortable; otherwise may consider holding off on exam.

##For all patients (preterm and term) patient should be scanned for AFI regardless of fern/nitrazine/pool), especially if she has a good story for ROM.

VAGINAL BLEEDING

1. Quantify (how many pads? More than 2 per hour for three hours = evaluation)
2. Common causes:
1. Bloody show at or just prior to term
2. Previa – check ultrasounds! If none scan prior to digital exam
3. Abruption
1. is abdomen/fundus firm or tender?
2. check abruption labs: CBC, plts, PT/PTT, Fibrinogen,
3. perform spec exam to quant. bleeding, bld in vault? OK to perform gentle dig exam if not previa
4. CERVICITIS - a common cause of spotting, check gc/chlam, wet mount
5. LABOR - Cervical ripening causes spotting (bloody show at term), but may cause frank bleeding if a cervical venous sinus ruptures

DECREASED FETAL MOVEMENT

1. Place patient on monitor
2. Reactive NST (2 accelerations of FHT 15 bpm above baseline for 15 sec in a 10 minute period when monitored at least 20 minutes) d/c home
3. Non-reactive NST
4. consider giving juice
5. BPP+AFI (BPP = NST+ AFI+ Tone+ Movement+ Breathing) If 8 or more, home, 6 or less consider admission
6. Modified BPP= NST+AFI

From the UIowa FP Handbook

Intrapartum Monitoring and Management

Electronic fetal heart rate monitoring may be performed by means of external Doppler, or direct scalp lead when membranes are ruptured.

• Indications.

**Meconium staining, use of oxytocin; delivery of an anticipated premature, postmature, Rh-sensitized, or growth-retarded infant; medical complications associated with uteroplacental insufficiency (hypertension, diabetes, severe anemia, heart disease, renal disease), presence of abnormal FHR by Doppler scanning, VBAC, other intrapartum obstetrical complications (failure to progress, excessive vaginal bleeding).

Fetal heart rate tracing interpretation .

• Baseline fetal heart rate .
  • Normal 120 to 160 bpm.
  • Tachycardia >160 bpm. Cause : fetal hypoxia, maternal fever, maternal hyperthyroidism, parasympatholytic or sympathomimetic drugs.
  • Bradycardia <120 bpm. Cause : fetal asphyxia, anesthetics, fetal cardiac conduction defect. Usually benign if good variability is present.

Variability.

• Short-term variability. Beat-to-beat variation is normally 5 to 10 bpm (reliably assessed with only a scalp lead).
• Long-term variability. Waviness of the FHR tracing, which normally has a frequency of 3 to 10 cycles/min and an amplitude of 10 to 25 bpm.
• Decreased variability. Variability may be decreased by fetal sleep cycles, CNS depression secondary to hypoxia or drugs, parasympatholytic agents, extreme prematurity, or congenital anomalies. Loss of variability is associated with a high incidence of fetal acidosis and low Apgar scores.

Common periodic patterns .

• Accelerations . Reassuring if associated withfetal movement. May be compensatory before or after deceleration.
• Early decelerations . Occur coincidentally with uterine contractions and are associated with fetal head compression. These are vagally mediated and not ominous when they occur late in labor. These start early in the contraction phase, reach their lowest point at the peak of the contraction, and return to baseline levels as the contraction finishes. The FHR does not fall below 100 bpm.
• Late decelerations . Transient but repetitive deceleration of the FHR observed to occur late in the contraction phase. Reaches its lowest point after the acme of the contraction and returns to baseline rate once the contraction is over. Late decelerations result from fetal hypoxia, indicate uteroplacental insufficiency, and are always considered ominous.
• Variable decelerations . Characterized by variable duration, timing in relation to contraction and intensity. This is a reflex pattern, typically secondary to umbilical cord compression. May benefit from amnioinfusion. Poor prognostic signs are the following:
  • Association with poor FHR baseline variability.
  • Lack of pre-deceleration and post-deceleration accelerations.
  • Slow return to baseline or failure to return to baseline.
  • Biphasic shape (W = knot in cord).
  • Prolonged decelerations . Isolated decelerations >120 seconds can be seen with maternal hypotension, maternal hypoxia, tetanic contractions, prolapsed umbilical cord, fetal scalp procedures (vagal), and paracervical or epidural anesthesia. A prolonged deceleration after severe variable deceleration may signal impending fetal demise.

Management of abnormal FHR pattern or fetal distress .

• Turn patient onto left side to alleviate vena cava compression.
• Discontinue intravenous oxytocin .
• Apply 100% oxygen to mother by face-mask.
• Correct maternal hypotension or hypertension .
• Vaginal examination to rule out prolapsed cord.
• Consider fetal scalp blood sampling for pH determination.
• With decreased variability , consider fetal scalp stimulation. The return of variability is reassuring. If tracing maintains poor variability, consider points a to f above.
• With prolonged bradycardia unresponsive to other maneuvers or late decelerations with worsening fetal acidosis (pH <7.20), consider delivery by C-section.