newborn babyMATERNITY GUIDE
UTHSCSA Family & Community Medicine Dept.


TRIAGE

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General information:

  • Fill out entire triage sheet including patient’s weight and height
  • Include on triage sheet:
    • Previous OB Hx:  GDM, GHTN, PIH, eclampsia, placenta previa, PML or premature delivery, wt of previous infants, method of delivery, postpartum hemorrhage
    • Physical Exam:  fundal height, vaginal exam, position, bishop score
    • Labs:  recent H/H, 1 hr GCT, 3 hr GTT, GBS, Accu-Chek, HBsAg,
      RPR, Rubella, GC/Ch, Pap
  • Consent patient completely
  • If patient is to be discharged home:  check BP and temp, size=dates, 1 hr GCT is at > 24 weeks, set up FU appt, update prenatal card, SAB vs PML vs Labor precautions, continue PNV and FeSO4
  • If no PNC:  treat triage as 1st OB visit:  Routine labs with HIV (including Rubella), sono to assess dates, Make pt a new OB book with updated info including sono.

Post dates protocol:

>/= 40 weeks:  AFI and NST, if okay FU at 41 weeks, if abnormal discuss with FM attending and OB
>/= 41 weeks:  AFI, NST, Bishop score, if favorable cervix or abnormal testing, present to FM attending for induction, if okay FU in ½ week
>/=42 weeks:  AFI, NST, Bishop score, present to FM attending for induction

Inductions/Bishop Score: Good Candidate >/=6

Factor
0
1
2
3
Cervical Dilation
Closed
1-2
3-4
5+
Effacement
0-30
40-50
60-70
80+
Station
-3
-2
-1 or 0
+1, +2
Consistency
Firm
Medium
Soft
---
Position
Posterior
Mid
Anterior
---

*May find on OB Wheel (www.FPpda.com) OR InfoRetriever (*NOTE: InfoRetriever can only be access through a UTHSCSA computer or through a virtual private network (VPN) with the university.

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Admission for Observation:

  • Present all patients to FM attending
  • Consent those who may be induced or who may go into labor
  • Sono within the last 2 weeks, if not then repeat sono
  • NST

R/O Premature labor:
Dx:  Estimated gestational age <36 completed weeks associated with uterine contractions
Cervical dilation > 2 cm  or 80 % effaced. PreTerm Labor is premature labor at 24- 32 weeks.

R/O: Chorio, ROM, drug abuse

USG: get EFW, position

  • NST to assess contractions and reactivity
  • Sterile spec exam  
    • note thickness, position, dilation
    • If ruptured:  note color, wet prep, time of ROM, pooling, ferning, Nitrazine
    • Swab for Chlamydia, gonorrhea  and GBS
  • If 24-34 weeks: you may do fetal fibronectin (FFN) test- (DO NOT USE GEL if collecting swab for FFN). Swab the posterior fornix for FFN, before doing the digital exam. This is only valuable if pt. has not have sex within last 24hrs.
  • If preterm:  NO DIGITAL EXAM IF ROM
  • If term:  digital exam to assess dilation
  • UA, C&S
  • Document presentation
  • Electronic monitors
  • Hydrate:  500 ml NS bolus then D5 ½ NS at 125 ml/hour
  • Consider tocolysis if 24-32 weeks, regular CTX and cervical change
  • Recheck cervix in 2-3 hours
  • Consent patient
  • Absolute contraindication to tocolysis: Severe PIH, Hemorrhage, Chorio.top of page

 

R/O Preeclampsia:

Mild Preeclampsia: It’s the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman, with BP >=140/90mmhg.and >=300mg protein in 24 hrs urine collection  or proteinuria 1+ dipstick

Severe preeclampsia: BP >160/110, Proteinuria > 5000mg/24hr or 3-4 + dipstick
Any mild preeclamptic with oliguria <400ml/24hr, pul edema, RUQ pain, headache, abn LFT’s ,thrombocytopenia, or IUGR is dx with sever preeclampsia.
Any preeclampic with seizure is diagnosed with  Eclampsia

Admit to Observation

  • Serial sitting BP x 3 at least 6hrs apart.
  • Notify OB if BP > 160/100 needs immediate Rx (hydralazine )
  • Labs: CBC, Chem 7, LFTs, uric acid, (typically associated with a rise in the plasma urate level to above 5.5 to 6 mg/dL),creatinine, begin 24 hr urine collection for protein estimation and creatine clearance.
    coagulopathy profile (PT, PTT, fibrinogen) should be sent if the ALT and AST are more than twice normal or if the platelet count is less than 100,000 cells/microL.
  • Draw and hold routine labs with HIV
  • Strict recording of fluid intake, daily weights and urine output I and O cath for UA and DOA
  • Assess for RUQ pain, visual changes, HA, facial/hand edema
  • Document 1st trimester BP’s
  • Bishop score
  • Consent
  • Management: 
    • Preeclampsia:   Pts are usually started on Mgsulfate for seizure prophylaxsis (4gm load and 2g/hr maintenance) during labor and delivery and it should be cont. until 12-24hr after delivery.
    • Severe Preeclampsia: Pts should be stabilized with MgSO4 for seizure prophylaxsis and hydralazine for BP control, once pt stabilized delivery should be done immediately.
    • Eclampsia: Seizure mgt, bllod pressure control and prophylaxsis against further convulsion.

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Clinical response of MgSO4
Serum concentration
Clinical response
4.8-8.4 
seizure prophylaxsis
8
depression of CNS
10
loss of deep tendon reflex
15
resp depression
17
coma
20-25
CVS arrest
In case of overdose 10% calcium chloride or calcium gluconate should be given immediately IV.

External Version:  (Consider at 37 weeks if breech)

  • Routine version orders (including NST before and after version, hold routine labs, HEPARIN LOCK IV, T&S, Full consent, Terbutaline 0.25mg)
  • Document position and AFI
  • Consent for external version and any other medically indicated procedures
  • Risks:  pain, bleeding, infxn, ROM, initiation of labor, fetal distress, need for emergent c/s
  • NST before and after version

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Amniocentesis:

  • Consent: Risks of pain, infection, bleeding, rupture of membranes, needlestick to fetus, fetal distress, need for emergent C/S, fetal death, maternal death.
  • Assess AFI and find a good pocket

R/O PROM: (ROM  before 37 weeks is called  PROM)

  • Sterile speculum to document ROM – Nitrazine, pooling, ferning, color, wet prep, genital cx, gen probe for GC and Chlamydia
  • Collect pooling fluid with angiocath & syringe to send for PG testing if 34-36 wks
  • Document time and clarity of ROM (clear/thin/mod/thick meconium)
  • UA, C&S
  • Document presentation
  • If preterm:  NO DIGITAL EXAM, estimate dilation with sterile speculum exam
  • If term:  one digital exam, Bishop score, GBS culture
  • Prophylactic antibiotics if ruptured membrane
    • Erythromycin + Ampicillin OR Ampicillin/Sulbactam (Unasyn)

R/O Abruption/Previa (Vaginal Bleeding):

  • Document location of placenta prior to vaginal exam with abdominal ultrasound
  • Ultrasound should show that the placenta ends above or at level that head starts when position is cephalic
  • DO NOT DO VAGINAL EXAM UNTIL PREVIA IS RULED OUT
    • If previa:  call upper level OB or OB attending stat and type and cross patient
  • NST
  • Sterile speculum exam if no previa
  • Do Apt test if possible
  • Serial Hct Q 4h x 3
  • Pad counts
    • If serious bleeding (DIC panel, INR, PTT, D-dimer, Fibrinogen)top of page

     

Fever Work Up:  (for Temp > 100.4)

  • Tylenol
  • Transfer pt to GYN ER for complete exam including: OP, LAD, Lung, Breast, Heart, Abdomen, Skin, IV, DVT, Pelvic Spec & Bimanual Exam, Wound
  • Labs:  CBC, manual diff, blood cx x 2, genital cultures, wound cx, UA C&S
  • Antibiotics if:     Chorio, Endometritis, Pyelonephritis, or Mastitis/Cellulitis

Abdominal trauma or MVA:

  • Sono for retroplacental hemorrhage
  • NST
  • Sterile speculum exam
  • Hct q4 hours x 3

Decreased Fetal Movement:

  • Fetal movement device (clicker)
  • Digital Exam to evaluate for favorable cervix for possible induction
BPP = Biophysical Profile
  1. Reactive NST (2 accels in 20 min , No bradycardia*)
  1. Fetal Breathing Movements – one episode of 30 sec in 30 minutes.
  1. Gross Body Movement:  THREE discrete body/limb movements
    in 30 min (episode of continuous active movement is considered one movement)
  1. Fetal Tone:  At least one episode active extension with return to flexion of
    limbs or trunk  (Example:  open and closing of hand).
  1. One pocket of 2cm x 2cm in perpendicular plane.

Significance of Biophysical Profile (BPP) – determines risk of asphyxia and fetal death

8/10, 10/10 No intervention
8/8 (means NST not done) No intervention
6/10 (nml AFI)
  • >/=37 weeks-Deliver
  • <37 weeks- Twice weekly BPP
6/10 (oligo)
  • >/=37 weeks-Deliver
  • <37 wks- Repeat next day, if 6/10 Deliver
2/10, 4/10
  • >/= 26 weeks - Deliver

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Dehydration or Hyperemesis:

  • Admit to observation if large ketones
  • Dip all urine for ketones until clear
  • 500 ml NS then IVF
  • Phenergan
  • Advance diet as tolerated

Admission to antepartum for pre-eclampsia:

  • Strict I&O's
  • Daily weights on same scale
  • 24° urine for protein and CrCl
  • NST 2x/wk
  • FHT q shift
  • Dip urine for protein every am
  • Pre-eclamptic labs q 3d
  • PNV, FeSO4

Admission to antepartum for pyelonephritis:

  • Ancef 2 gm q 6°
  • Blood cx x 2
  • UA C&S (make sure sent prior to abx)
  • Gen probe, Genital Culture
  • Tylenol 650 mg po q 6° prn T > 100.4°
  • PNV po qd
  • FHT q shift
  • NST 2x/wk

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