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Agenda

Increase familiarity with some of the basic procedural skills for obstetrical care
Increase comfort with identifying FHR tracings
Understand common triage scenarios
Identify resources to support learning on OB

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Introduction

OB is unfamiliar territory for most interns
The learning curve is steep (but we don't have the volume that OB residents have)
OB nurses have worked very hard for their skill set and are advocates for their patients
You will work with many different providers with many different styles

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Stations

DFMCH OB Bootcamp

Cervical Checks and Delivery Review

FHT and

Category 2

Algorithm

Balloon Catheters, IUPCs, FSEs, dilapan, and amniohooks

Triage Scenarios

Resources and expectation

management

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Cervical Checks and �Delivery Review

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ThePhoto by PhotoAuthor is licensed under CCYYSA.

Cervical Check "Rules"

Always have a guide during your first OB rotation

Must have RN, senior, or faculty "back check" for you during your first rotation
May also have them check first and you second until you start to feel more comfortable
There is some variability between provider exams - if possible check the patient early in your shift so you can assess for change

Do NOT guess – make sure that your exam fits with the clinical picture (this can happen with a closed cervix that is very posterior)

Its okay to not be confident, your job is to negotiate this lack of confidence with professionalism
If you're not sure don't need to announce in the room, can say "I'd like to have [your nurse/my senior/my attending] to do their exam first” or “I will have [x] confirm my exam before we talk about the plan

Give yourself all advantages

Early labor cervixes are very posterior – may need to reach around baby's head
Positioning:

Have patient flatter on their back
Use a towel or bed pan under bottom to tilt pelvis
Ask people for their tips and tricks, especially the nurses

Watch the rest of your hand position -- keep your thumb off the clitoris!!!

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Assessing Labor Progress and Safe Prevention of the Primary Cesarean Section – aka rethinking the Friedman curves�

https://www.ajog.org/article/s0002-9378(14)00055-6/fulltext

ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

Latent labor: �0-4 cm dilation�Lasts up to 20 hr for nulliparous, 14 hr for multiparous, but “prolonged” latent labor is not necessarily an indication for intervention��4-6 cm? Not active but not really latent�In this range nullip and multip dilate at essentially the same rate

Active phase arrest should not be dx at <6 cm��Active labor:�6-10 cm�Active-phase dilation was substantially slower than the standard rate derived from Friedman's work, varying from 0.5–0.7 cm/h for nulliparous women and from 0.5–1.3 cm/h for multiparous women

Definition of arrest: Spontaneous labor: ≥6 cm dilation with membrane rupture and no cervical change after:

≥4 h of adequate contractions (eg, >200 Montevideo units)

≥6 h of inadequate contractions

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When might you defer a cervical exam?

PROM (rupture of membranes but no spontaneous labor, don’t confuse with PPROM)

ACOG says can allow for expectant management for up to 24 hr; in practice here, most people give max of 6-12 hours. Of note in the most recent PB induction at presentation was preferred to expectant management
Number of exams after ROM is correlated with risk of chrioaminonitis in a “dose-dependent relationship”

Prelabor Rupture of Membranes: ACOG Practice Bulletin Summary, Number 217 Obstetrics & Gynecology 2020; 135(3): 739-743.

Would not change management – ex cooks in place, not yet contracting while titrating pit, etc

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Delivery�Review

Delivery review page on Hub

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Delivery Review Resources

ACOG Management of First and Second Stage of Labor - Jan 2024

Creogs Over Coffee Summaries

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Station Break

DFMCH OB Bootcamp

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Triage Scenarios

Triage Scenarios link

on the Hub

Video of birth suites tour at Meriter

Video of birth suites tour at St Mary's

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Station Break

DFMCH OB Bootcamp

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FHT and Category 2 Algorithm

Intrapartum Surveillence on the Hub

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Non-Stress Test

Monitor fetal heart rate and contractions externally over 20-40 minutes
Classified as reactive or non-reactive

Reactive: two heart rate accelerations within 20 minutes

If not reactive within 20 minutes, extend monitoring to 40 minutes
Can also give pt glucose (ie something to eat) and fluids
May use acoustic stimulation or head stimulation

Non-reactive: lack of two heart rate accelerations within 40 minutes
Decelerations may or may not be significant – single sporadic decel is not associated with adverse fetal outcomes

Weinberger, H.; Nekave, S.; Hallak, M.; Naeh, A.; Gabbay-Benziv, R. Single Sporadic Deceleration during Reactive Nonstress Test—Clinical Significance and Risk for Cesarean Delivery. J. Clin. Med. 2023, 12, 3387.

If non-reactive, proceed with biophysical profile vs induction

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EFM

Remember:

Surrogate marker for fetal oxygen and acidemia to prevent stillbirth
Little evidence that it improves outcomes
A lot of fetal monitoring falls into “gray area”

We don’t know how the result correlates to fetal outcomes

Don't forget about intermittent auscultation too!

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Fetal Heart Tracing:

X-axis: Time

Each small box is 10 seconds

�Y-axis: BPM

Each small box is 10 beats

Tocometer:

X-axis: Time

Each small box is 10 seconds�

Y-axis: Strength in Montevideo Units ***

*** Actual strength can only be measured by IUPC; check y-axis for scale

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DFMCH OB Bootcamp

Fetal Heart Tracing (FHT): Early Decelerations�ob-efm.com

Nadir of FHT matches peak of contraction

FHR usually does not drop <100 bpm

Etiology:

Fetal head compression

**Early and late decels can look surprisingly similar so may need to get out a straight edge***

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DFMCH OB Bootcamp

Fetal Heart Tracing (FHT): Variable Deceleration�ob-efm.com

Deep V shape not necessarily correlated to contraction
FHR usually drops <100 bpm

15 bpm x 15 seconds

Etiology:

Umbilical cord compression

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DFMCH OB Bootcamp

Fetal Heart Tracing (FHT): Late Deceleration�ob-efm.com

More shallow than variable
FHR may drop <100 bpm

Nadir after peak of contraction

Etiology:

Placental insufficiency

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Brief treatment of recurrent variable/late review

Improve oxygenation

Reposition patient
Give supplemental oxygen (falling out of favor)
Give IV bolus
Slow down contractions

Reduce contractions

Stop pitocin
Remove Cervadil or Cook’s catheter

Give terbutaline

Decompress umbilical cord

Start amnioinfusion (gen only improve variables)
Consider umbilical cord prolapse

4. Consider expedited delivery

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DFMCH OB Bootcamp

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Category 2 Algorithim

DFMCH OB Bootcamp

If you have a patient with a Category 2 FHT:

Use the Clark algorithm to guide management steps
AND (at Meriter) document this in your progress note using the phrase ".CAT2FHTALGORITHM" which can be found by accessing Allison Couture or Kathleen Antony's SmartPhrases.

Web-app version:

http://cat2.perigen.com/cat2/

*Added to the shared phone homescreen so you can access!

Presentation with Summary of Clark Algorithm from Ally Couture

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Practice, practice, practice . . .

EFM "game" - over 200 tracings with "answers"
EFM quizzes and general review site

Five-tier algorithm - well validated tool for describing EFM and actions to take next, however this is not the classification we use at either hospital – does map onto I/II/III description. Can help in thinking about next steps.

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Station Break

DFMCH OB Bootcamp

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Resources and Expectations

Logistical Page on Hub

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Key Learning Resources

https://sites.google.com/wisc.edu/dfmchobnewborn

Iphone: Go to this site on your phone browser. On the website, tap the box with the little up arrow, scroll down the list of options, then tap Add to Home Screen
Android: Go to this site on your phone browser. Hold the address bar and an option will come up to add to home screen, you can name this what you would like

Additional resources to review

CMQCC toolkits
APGO (search tools and topic) ex. Intrapartum
Creogs Over Coffee - podcasts and summaries (think curbsiders)
ObG Project – good summaries of the big topics

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L&D Rotations

Meriter - FMONs

Team of 3: attending, 2nd year resident, intern
Family medicine obstetric and newborn service

Deliver with 4 different fm groups: DFMCH Residency, DFMCH community, Wildwood, GHC
Care is for the dyad, not just the pregnant person

Challenges: Multiple attendings, more work than you can accomplish alone, no other FM services in the hospital
Benefits: Develop strong communication and triage skills, strong newborn experience, higher risk ob exposure

St Mary's - Low Risk OB

Team of 1: there is an OB attending and high-risk resident there but you are not officially a "team"

High risk resident is there to help you but they may or not embrace that role

Mostly obstetrical care from an obstetrician perspective:

Primary attending will be Dean OB or MFM
May also deliver with DFMCH Residency, Wildwood, and Dean FM (only Danielle Gindlesberger currently)

Challenges: Currently working with nursing on our relationship, volume can be challenging in both directions
Benefits: Navigating attendings much more straightforward, less triage volume

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Information management

DFMCH OB Bootcamp

You may not feel like you know a lot about the medicine (you do!!) but . . .

You can and should be the one who knows all about the patient!

You can also use a printed list but make sure you have this data

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Remember and review ALSO

Significant portion of labor management is preparing for the worst-case scenarios

At admission calculate pt's hemorrhage risk and think about risks for shoulder dystocia -- write this down and reassess throughout the labor process
Huddle with the patient's nurse and use their experience to help you plan for possible problems

If you see and abnormal tracing it is your job to be one of the first ones in the room

You will not know what to do at first (but use your mneumonics and think out loud when you can)
Can always turn off the pitocin and reposition the patient!

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Things to know on L&D

At a minimum, labor patients should have progress notes written

Every 4 hours in First Stage Latent Labor: cervical dilation of 0-6 cm
Every 2 hours in First Stage Active Labor: cervical dilation of 6-10 cm
Every 1 hour in Second Stage Labor: complete dilation to birth
AND For any pertinent clinical update to communicate evaluation and plan of care (if you didn't document it --> you didn't do it!)

This does not mean you need to do a cervical check this frequently (although often those go together), it is appropriate just to check in on patient and write a brief note

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Postparum Rounding

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When should I call an attending?

Whenever a treatment decision is being made

For example regarding workup for a patient in triage, whether a patient should be admitted/sent home, when a consult is needed, when a new medication is required, when a change in labor management is being made, etc
If the treatment decision has been previously discussed with an attending and a plan has been made, the resident should follow this plan for contacting the attending (for example, if you already decided another miso should be placed if no cervical change AND that the attending only needed to be notified if there was cervical change, you could place the miso without notifying the attending provided that the patient situation is otherwise appropriate. Communication about when someone would like to be contacted for ongoing management is key)

When there is a change in patient status

For example vital sign changes, rupture of membranes, significant cervical change (attendings should be alerted to facilitate being in house by 6 cm for multips and 8 cm for primips), etc

If there are any questions from the resident or if nursing has concerns that cannot be addressed by the resident independently
Or as otherwise discussed between the resident and the attending at the time of admission/arrival to triage

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What should I take away this year?

Master cervical checks -- you will need help and support to do this well
Understand how to do a labor evaluation
Know how to assess for hemorrhage risk and plan for management

Develop habits of strong team communication

Try to talk face to face, when at all possible, with your team members – do not overrely on secure chat!
Verbalize your thought process so that your team knows what you are thinking
Take the time for building relationships, this will pay off multi-fold

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Station Break

DFMCH OB Bootcamp

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Tools of the Trade

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FSE and IUPC

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Induction Methods

Induction page on the Hub

AFP Feb 2022 -- Cervical Ripening and Induction of Labor

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Dilapan

Review page on Hub

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Cooks Catheter Best Practices

All first-year residents should have an experienced guide when placing a cooks catheter (senior resident or faculty)
For patients with very little dilation consider using a speculum and ring forceps to aid in insertion
May want to consider using dilaudid or other pain control method with insertion to ease patient experience
Consider checking the cooks catheter at 2 hr by deflating the vaginal balloon and assuring that the uterine balloon is appropriately positioned.

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Section Break

DFMCH OB Bootcamp

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Questions?��Jennifer Svarverud (509)-954-0675�Jensi Carlson (715)-379-6148��The Hub - https://sites.google.com/wisc.edu/dfmchobnewborn

"I have no special talent. I am only passionately curious."

-Albert Einstein

DFMCH OB Bootcamp