Family Medicine OB Survival Guide

Schedule

• You will be sent a float schedule for your rotation. Please let Dr. Makarova (nmm2135@gmail.com) or Dr. Murray (akankshasaxena00@gmail.com) know if you have not received it.
• During your Days rotation, you will be at The Womens Institute on Wednesdays (9AM-5PM) and on L&D on Thursdays (7AM-4PM). You will also occasionally be assigned weekend call shifts (7AM-4PM).
• Please be aware that these are the times for signout, so your shifts on L&D will likely be longer. You will be expected to round before signout and wrap up necessary tasks after signout. Please reach out to your co-intern on L&D to help plan rounding. Frequently this means coming in before 6AM and leaving after 5PM.
• You will also have a "NAPS" rotation where you are on every other night from 4PM-7AM
• Please let us know if you have any questions regarding your schedule.

Labor & Delivery

Board Check-Out

1. Be on time. Morning sign out 7am daily. 4pm afternoon signout except Fridays at 3pm.
2. Be respectful of the person checking out their patient. Resident turnover is dangerous for patients, so don’t exacerbate this by distracting the fresh people from getting all necessary info. Allow the resident to fully sign out their patient before interrupting or asking questions.
3. Pages Non-emergent pages (not tagged with 911) can typically wait until after checkout. If you feel the matter is urgent to call back, talk quietly and ask if the issue can wait.
4. Cell Phones silenced
5. Teaching Pearls: Expect to have teaching/ discussion throughout and/or after every checkout. Maintain the above principles while the attending/ chief is teaching. When you get asked a question, take your best shot. Wrong answers sometimes bring about the best discussions! We’ve all been in your seat before, and have certainly answered things wrong. We’re all just here to learn.
6. Please sit around the table. Allow attendings to sit on the couch.
7. Don’t type notes during sign out. One Intern will be assigned the “Check Out List” to send.
8. Update the Board: Have this completed and updated prior to 0700 and 1600. Brand new admits are exceptions—try to find as much info on them as possible to check out.
9. Be Professional. Be respectful of your colleagues and patients (even when they can’t hear you). Important social history is crucial to pass along, but personal opinions aren’t.
10. Stay Awake: We can all be tired after a long night delivering babies, but do everything in your power to keep your eyes open during checkout.

As a residency, we have a casual environment in most situations, and we are very social and interconnected with most of our faculty/staff/administration. Checkout one of the more formal environments, but don’t fear, it’s not at all threatening!

What Goes on the Board … and How to Present It

Keep the board updated prior to check out

Format
Room Number — Name — Doctor — Gs / Ps — GA — SVE — CC — BMI — GBS

Don’t Forget:
* *patient’s presentation—subscript after SVE (c= cephalic, v= vertex, br= breach, trv= transverse, var= variable) consents—superscript after SVE & circle; x1, 2, 3, etc (csxn/ blood/ BTL/ TOLAC/ etc *follow-up results*—put an empty check box next to it: “□ UA dip” (PNR, labs, GBS status, U/S)

Presenting

Tell your patient’s story— don’t just regurgitate the board.
Example: Ms. Yu is a 24yo MOGA patient who is a G1P0 at 38weeks, 1day by LMP c/w a first trimester ultrasound. She presented to OB triage at 1am at 2/50/-2 and changed to 4/80/-1 after walking for an hour. We expectantly managed her as she transitioned into active labor. Fetal position is cephalic, and I think she’s LOA. She is GBS negative. Her PMH is significant for well- controlled asthma, so we’ll avoid hemabate should she have a postpartum hemorrhage.

Labor & Delivery Tips

Admissions

• Take a full history and do a complete exam (general/heart/lungs/abdomen/GU/ext) on EVERY patient.
• EVERY patient should get a bedside ultrasound (BSUS) for fetal presentation (cephalic vs breech, etc). Patients should also get measurements for dates/growth. An AFI should be performed on anyone in whom it might be relevant (ie- suspected PPROM, PreE, etc)
• For EVERY patient, you should know how they are dated (i.e “LMP consistent with first trimester ultrasound”).
• Prenatal Records are usually found in the blue folders somewhere at the nurse’s station, but your best bet is just to ask the nurse for them. If we don’t have them yet, put in an order for the unit secretary to call for them.
• In Cerner, you should complete a “History & Physical Exam” document and enter the “OB Labor/Postpartum” order set along with any other orders that are relevant.
  • DO NOT forget to do the admission Med Rec.

Laboring Patients

• Active labor/on pitocin—rounded on with progress notes in place every 2 hrs.
• Cervical ripening with a cervidil or foley bulb— rounded on with progress notes every 6 hrs. (they need to be seen 6hrs after placement and at 12hrs when it is removed (or whenever the foley falls out— whichever comes first).
• Cervical ripening with misoprostol—rounded on with progress notes every 4hrs.
• For the first note after an H&P, a new “OB Labor Progress Note” must be entered. For subsequent rounding, annotations of this note with “brief rounds notes” are appropriate with EFM, vag exam info and brief A/P. When you take over a patient clearly state this in the addendum and then write a note that shows you have completely reviewed the patient’s chart.
• Keep your attendings updated! Ask them how often they would like to be updated, when to call for a delivery, how far away they are, etc. A good habit to start a “game-plan” for labor course & gain attending ideas for “if this → then that”. [ex. If she’s not changed in 2hrs., then is it ok to AROM/ IUPC or start pit?]
• Documentation is key – even a brief labor progress notes are effective when things get busy. Remember, if you don’t document, it didn’t happen!
• Each day starting at 12 midnight a new Labor Progress Note needs to be started. When you come on at 7am or 4pm, you can addend the prior Labor Progress Note with a statement saying “I have assumed care of this patient, in summary she is ____”

Vaginal Exams

• Check every patient on admission. This gives you a chance to get your baseline SVE and also assess her pelvis for adequacy (the nurse will enter the exam in Cerner for you).
• If your patient was JUST checked in OBT 20 minutes ago, it’s reasonable to complete the rest of your admission/PE/ultrasound and wait until it’s been 1-2 hours since the last exam. Just make sure to let your nurse know that it’s important to you to get to do the next SVE.
• Try to tell fetal position (LOA/ROT/LOP, etc) on every SVE (the earlier you can tell, the less caput that will get in your way!). Also practice feeling for the ischial spines. Do this every time and eventually you’ll be a pro!
• Remind your nurses (especially early in the year) that you’d like their help in learning/practicing SVEs. Have them call you every time they want to check the patient. For the first month or so, they’ll check the cervix behind you. This is part of the learning process, and we’ve all done it. You can say something to your patient like “It’s really important that we know for sure what your cervix is doing, so I’m going to ask RN Megan to check behind me.”
• If there’s conflict with the nurse on when to check or who’s to check, have a conversation with them and state the reasons for why you do, or do not, want to do a cervical exam so everyone is on the same page.

Antepartum patients on L&D

• You should do a bedside ultrasound for position, EFW, AFI, placenta location EVERY TIME you admit an ante patient! This is your chance to really practice (and then you can compare what you got to what the “official” ultrasound comes back as). PPA attendings on call are willing and available to assist you with this any time.
• Any patient NOT in labor that is NOT undergoing IOL and is NOT sick only needs to be rounded on 3x/day. The night resident should do the AM note in the morning before AM checkout (and this should include a FULL physical exam). The day resident rounds mid-day (usually 1330-1400ish) and the night resident typically rounds right before bedtime.
• When there are changes to a patient’s status, you should round and write a note (even if it’s quick & even if it’s not your scheduled rounding time). Use common sense… if a patient’s status is more critical, more frequent rounding might be necessary!

Handoffs / Check-Out

• Try to round on each of your active patients within an hour of checkout (this is nice for the person coming on and saves them from needing to rush to round to make it by the 2 hour mark).
• Your most recent rounds note should be complete and thorough (sometimes including H&P info). The person taking over for you should be able to read your most recent note and know almost everything they need to about the patient.
• Be on time to board checkout!!
• If you are in a delivery at the time of checkout, let the chief know where you are (you can have the nurse call x5067 to pass on the message if you’re scrubbed at someone’s perineum)
• Keep your patients updated on the board throughout your shift so that if you miss part of checkout for a delivery, the on-coming team will still figure out what’s going on.
• Please do not pass off admissions—even the last-minute ones. If an admission came in on your shift and you are unable to admit that patient before board checkout, please obtain the vital info and offer to go finish it after board check out.

Notes for the Floor

• At the beginning of the year, the chief runs the board during the day and the PGY3 at night. Text, call, or text page them with deliveries so they know how many pts everyone has & where new pt assignments need to go. Later in the year, 1 intern will run the board assignments for normal laborers only at night and weekends
• Keep the 3rd yr./chief aware of any sick patients, unstable patients, bad strips, or questionable management decisions. (This includes waking people up at night, and we want you to do it!). We are all in this together, and you are never alone.
• If you have a pt that goes to c-section that you have followed all day, you should continue to follow them postpartum. PLEASE let the board runner know if your patient needs a c-section as soon as the decision is made.
• If you have questions, try to ask up the chain of command - Day: 2nd yr 3rd chief (but don’t ever hesitate to move up the ladder if the 2 and the 3 are busy). Night: 3rd yr chief (2nd yr off the floor doing consults/ ER).
• Don’t break the bed down until a 3rd yr or attending is in the room for the delivery.
• Do not wear booties around the hospital! It’s unsanitary and unprofessional.

Postpartum Tips

• If your patient is a normal vaginal delivery with no/ 1st degree lacerations, do not order narcotics (Percocet/ Tylenol #3) unless requested by your attending. If they have postpartum pain, try a one-time dose of Tylenol #3 before you jump to scheduling Percocet.
• For narcotic prescriptions, try to not send the Rx until you know how many they need to reduce the number of narcotics on the streets.
• All postpartum pts need to be seen with notes written by 7am on a normal day. Having an attending beat you to a note after 7am doesn’t build a good rapport/ work ethic.
• Discharge summaries need to be done only on deliveries that necessitate hospitalization > 48 hours. It is helpful to start this document at time of delivery for those anticipated to stay for that duration, such as csxn patients (most of it can be filled out immediately postpartum and then changed as needed if something occurs).
• Round only 1 day: PP patients with normal SVD— unless they are PPA, no doc/TWC patients (seen every day).
• Round every day: PP patient with complications/ medical problems requiring intervention or monitoring—PPH, vacuum, forceps, chorio, endometritis, diabetes, Pre-E., etc. C-sections are seen daily. PPA, MOGA, no doc/ TWC patients seen daily.
• ALL PP need a FULL PE each time you round (general, heart, lungs, abd, ext). In general, you can defer a perineal/vaginal exam unless your patient has a specific complaint, in which case you should grab a RN to be your chaperone
• Grab an upper level or call someone if you have questions/ concerns during rounds. We are happy to help!! You will never go wrong calling the attending, but for PP rounds, sometimes asking someone in-house is easier and gives you an idea to call your attending with.
• Be sure to communicate any postpartum labs, consults or work-up needed to the 5363/GYN resident or oncoming day team. If you are unsure, please bring up any concerns to your chief. It is better to bring it up than to assume that someone will take care of it for you.

Emergent C-Sections

1. As an intern, you can and will call an emergent (“crash”) c-section. Your nursing staff is helpful with this, but indications to head to OR immediately:
   • Fetal bradycardia > 4 min
   • Deceleration <60 bmp that is NOT recovering
     • Upon arrival to OR, fetal heart tones should be reassessed (unless there is a terminal bradycardia, frank abruption, prolapsed cord or other maternal/fetal instability). If recovered, then await attending for further decisions. Otherwise, ensure chief/ 3rd yr. is available to proceed with c-section if attending not in-house.
2. Make sure the ATTENDING is paged/ informed of the situation. Personally confirm this in the OR.
3. Accompany the patient to the OR. You are critical to provide sign out
4. Personally confirm with the RN staff/unit secretary that the “Crash” page has been sent. This brings Anesthesia, R3, R4 and the team leader to the OR.
5. If the attending is NOT in-house, the R4 assists R3.
6. If the attending is present and the situation has stabilized but c-section will proceed, the R4 will leave, and the decision as to who will assist the attending will be determined by the clinical scenario and attending preference (R3 vs R1).

Important numbers

• Crash pager: 201-0750 -alerts R4, R3, Anesthesia team, scrub tech, and team leader to proceed directly to the OR.
• Universal pager: 201-0792 -alerts Anesthesia, scrub tech, and team leader of c-section
-typically used for an add-on c-section (*NOT A CRASH) -STILL inform the chief/ board runner to let them know this case is going back.

Sample L&D Notes

BEWARE OF COPY-AND-PASTING NOTES! /Many attendings have a heightened awareness for mistakes found due to copy/ pasted notes. If you do it, update ALL info to be correct. RE-READ your note and ensure it’s accurate & up-to-date. Inaccurate notation is a medico-legal issue and is unprofessional to your colleagues./

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Admit Assessment and Plan 26yo G3P1101 at 38w2d by LMP c/w 10w sono presents with painful regular ctx and SROM. Her pregnancy is complicated by A2GDM and asthma. Term IUP, spontaneous labor
— SVE 5/90/-1, soft, anterior
— cephalic by bsus
— SROM at 1330
— toco 4 q 10min, regular

#FWB
— CEFM: baseline 140s, moderate variability, +accels, no decels (category 1)
— EFW 3200g by Leopold’s (or 3455g by last u/s 5/13/17)

#A2DM
— Antepartum regimen: 2.5mg glyburide BID
— Admit random BG= 97

#Mild Intermittent Asthma
— No hx of intubations/hospitalizations
— Albuterol MDI at bedside

#PNL
— A+, Abscr neg, RNI, RPR NR, HIV NR, HBsAg neg
— GBS negative

#Obstetric History
— #1 PTD at 34w in the setting of PPROM at 28w
— was on 17OHP this pregnancy (discontinued at 37w)

#Pain:
— IV analgesia or epidural prn

#PP Plan
— Breast
— Mirena

#PPH Risk
— Low

#Analgesia
— s/p Epidural

#PLAN
— Continue routine care
— q2H BG checks in latent, q1H BG checks in active
— Goal BG < 110
— Expectant management for anticipated active labor
— Repeat SVE in 2 hours or as clinically indicated
— Anticipate SVD

Plan d/w Dr. Attending

Labor Rounds Notes

(these can and should be more brief) R1 Rounds Note:

S: Pt comfortable with epidural, but notes intermittent pelvic pressure.

O: VS T 37.1, BP 109/83, HR 98, O2sat 99% RA SVE: 8/100/+1, soft, anterior, ROA @ 1030 CEFM: 140s, mod. variability, + accels, no decels (cat 1) Toco: 5 ctx q 10min

BG: 90, 78, 83

A/P: 26yo G3P1101 at 38w2d admitted in active labor, progressing appropriately. Anticipate cervical change with next SVE. Sugars have been within goal.
— Continue expectant management.
— Repeat SVE in 2 hours. If no change, will discuss AROM
— BG goal < 110, q1H BG checks
— Anticipate SVD

Dr. Attending updated.

R1 Rounds Note:

S: Pt complains of ctx pain. Denies urge to push.

O: VS T 37.1, BP 109/83, HR 105, O2sat 99% RA SVE: 8/100/+1, ROA @ 1400—(unchanged from last exam) CEFM: baseline 140s, mod. variability, +accels/ no decels (cat 1) Toco: 3-4 ctx q10min

BG: 78, 68, 72

A/P: 26yo G3P1011 at 38w2d admitted in active labor, without cervical change in 2 hours. BG still within goal.
— Begin Pitocin per protocol
— IUPC Placed
— BG Goal < 110, q1H BG checks
— Call anesthesia for epidural top off
— Anticipate SVD
Patient and plan d/w Dr. Attending.

Hand-off Note (your last note of your shift)

R1 Rounds Note:

S: Pt without complaints. Denies f/c, abd tenderness. Comfortable with epidural. Denies urge to push.

O: VS T 38.1, BP 112/81, HR 121, O2sat 98% RA Gen: NAD Abd: No fundal tenderness SVE: 9/100/+1, ROA @ 1540 CEFM: baseline 170s, mod. variability, no decels (cat 2) Toco: 4 q 10min

Oxytocin at 8mu/min IUPC: 220 mvu’s

A/P: 26yo G3P1101 at 38w2d by LMP c/w 10w sono admitted in active labor, now with protracted active phase and chorioamnionitis.

#Term IUP, protracted active phase
— SVE 9/100/+1
— SROM at 1100
— Cephalic by bsus, ROA on exam
— Toco 4/10 min
— Pt on Pitocin with adequate MVUs

#Chorioamnionitis (or III)
— Documented fever 38.1 x2, maternal and fetal tachycardia

#FWB
— Category II (tachy) likely 2/2 infection
— EFW 3200g by Leopold’s

#PNL
— A+, Abscr neg, RNI, RPR NR, HIV NR, HBsAg neg
— GBS Neg

#A2DM
— Antepartum regimen: Glyburide 2.5mg BID
— Well controlled this pregnancy
— Sugars in labor have been within goal of < 110

#Mild Intermittent Asthma:
— No hx of intubations/hospitalizations
— Albuterol MDI at bedside, pt asx

#Obstetric History
— #1 PTD at 34w in the setting of PPROM at 28w— was on 17OHP this pregnancy (discontinued at 37w)

#Pain
— Epidural in place

#PPH Risk
— High 2/2 chorio, protracted labor

PLAN
— Start Amp/Gent
— 1g Tylenol for fever
— Continue pit
— BG Goal < 110, q1H BG checks
— Uterotonics at bedside, avoid Hemabate
— Anticipate SVD
Plan d/w Dr. Attending.

Postpartum Assessment and Plan

26yo G3P2103 s/p FAVD for Category II FHT and maternal exhaustion. Labor and delivery c/b chorioamnionitis. Pregnancy c/b A2DM, mild intermittent asthma, and hx PTD.

#PPD1
— meeting milestones
— pain controlled with ibuprofen/tylenol

#Chorioamnionitis
— S/p one additional dose of amp/gent postpartum
— Afebrile, nontender

#A2DM
— Fasting BG today 62
— Previously on Glyburide, d/c’d postpartum

#IWB:
— Baby girl (“Amy”) in NICU given chorio; doing well per pt
— Pt pumping

#PNL
— O+, RNI, GBS Neg

#Contraception
— Desires Mirena

#PLAN
— Continue routine postop care
— Anticipate d/c tomorrow as baby in NICU, final d/c per attending
— Discharge instructions, PP depression education reviewed
— F/u in 6 wks with OB Provider
— MMR Prior to d/c
— Pt will need 2 hr GTT at postpartum visit

Postpartum Rounds Coverage Tips

1. You are responsible to round on any patient that you deliver for the duration of their hospital stay.
   a. Notes finished by 7am. You can begin rounds at 4am.
   b. “Pre-Round” to save time: check vitals, labs, meds, print Rx prior to 4am to save time.
   c. NAPS A sees NAPS B patients + their own (& vice versa).
2. If an upper level resident does a c-section on your patient, that patient is still your responsibility to round on every morning (the upper level may also round).
3. Weekend day shift should cover weekday day shift’s postpartums.
4. Completely NORMAL, term, SVD’s only need to be seen PPD#1 (unless they are TWC, no doc, MOGA or PPA).
   a. If they stay longer, these patients should still be chart-checked every day to make sure no events happened overnight (bleeding, infection, etc), which would necessitate resuming rounding on them.
   b. Patients with complications/ medical conditions requiring ongoing care/ ANYTHING not routine during delivery need to be seen daily: PPH, any lac >3rd degree, forceps, vacuum, pp BTL, chorioamnionitis.
   c. When in doubt, see the patient! It makes ALL of us look bad if we miss rounding on someone!!
5. Discharge summaries and med reconciliations should be done before your shift ends– it’s inconsiderate to leave this for your classmates covering to do prior to discharge.
6. Always check to make sure post-op patients have their outpatient prescriptions in their chart. If changing or canceling an ePrescription, you will need to call the pharmacy directly. Changing the order in Cerner DOES NOT change to order that was sent to the patient pharmacy and may even duplicate the order if you do not call the pharmacy.
7. Most residents will commonly prescribe the following prescriptions after a cesarean delivery: oxycodone 5mg every 6 hours as needed (15-20 tabs), ibuprofen 600mg every 6 hours, acetaminophen 650mg every 4 hours, and a stool softener. Some will order the prescriptions at time of delivery, but if you do, make sure your patient's actual opioid requirements are equivalent to what you order. If not, call the pharmacy to cancel the order and send a new one.
8. Keep track of your postpartum patients through a “patient list” in Cerner. You will share these lists with your classmates, and you all can have easy access to any patients that need to be rounded on.
   a. Therefore, it is important to keep the provider handoff tool in Cerner updated (especially on NAPS).
   i. Example:
   38 y/o G4P4004 s/p NSVD without lacs. Labor c/b PreE w/o SF. Pregnancy uncomplicated. O+, RI, GBS Neg Breast/Mirena PPD1 5/15 ii. Make note of language-barriers, if present, to help with rounding planning in the morning
9. When transitioning between rotations, NAPS should still cover NAPS and new L&D day shift should cover old L&D day shift’s patients if he/she is transitioning to NAPS.
10. If you are in the hospital in the morning, you should round on your patients no matter what rotation you are on. The best way to prevent patients being missed is to see them yourself.
11. Everyone will have a turn at having a long postpartum list. Being aware and asking/ offering to help others when yours is small is good karma!

Diagnosis-Specific Tips

This section isn’t meant to be exhaustive of all of the info you need to know about these particular situations… simply a cheat-sheet primer to get you started as you admit the patient.

Inductions:

1. basic labor admit orders and documentation (EFW, pelvic adequacy, A/P)
2. Know the indication (whether a “true” indication or excuse for elective IOL) & document this in Cerner.
3. Know bishop score on EVERYONE who presents for IOL.

A1DM

A1 DM:

1. Basic labor admit orders and documentation (EFW, pelvic adequacy, A&P)
2. Check random BG on admission.
   —If <120, no more fingerstick checks necessary.
   —If >120, check with your upper-level/ attending to discuss what further BG assessment is required.
3. Postpartum: check fasting BG on PPD#1. If it’s normal (<100), no more checks & remind her of DM screening at 6wPP (2hr. OGTT). If abnormal, follow fasting and 1 or 2hr. postprandial BG for a day or two to make sure values are overall acceptable.

A2 DM or Pregestational DM:*

1. Basic labor admit orders and documentation (EFW—leopold’s & most recent US for weight, HC/AC, FL/AC measurements, pelvic adequacy, OB hx for prior deliveries/ birthwts./ complications)

2. Medications/ BG checks during labor: Cervical ripening:
   -continue home medication regimen as normal *(DM diet continued)
   -Fasting/ postprandial BG checks (need to be ordered in Cerner)

Latent labor +/- augmentation:
-q2-4hr. BG checks
-Confirm with attending plan for meds
*(typically clear liquid diet, no meds, corrective sliding-scale insulin (SSI) if >100)
Active labor:
-q1h BG checks until delivery
-Confirm with attending plan for meds
*(typically SSI vs. insulin drip to ensure tight control)

GOAL (BG’s): 80-110
*some attendings will be more tolerant of values outside range, so always check for threshold of when they’d like to start meds/ insulin drip. *EVERY diabetic patient that is on a hypoglycemic agent (oral or insulin) at home should have a REGULAR insulin gtt ordered to bedside AT ADMISSION for PRN use.
**Pharmacy takes forever to get these to us, so early order is necessary even if not anticipated.

**Use “regular” insulin ONLY for drip because it’s cheapest and, when administered IV, onset is the same as any fast-acting agent.

3. Intrapartum Insulin Infusion guidelines: (from Creasey 5th ed)
4. Hold AM insulin (or subsequent scheduled SQ doses)
5. Begin glucose infusion D5NS @ 75-100ml/hr—continue throughout labor (**very important for Type I DM)
6. Begin infusion Regular insulin @ 1 U/hr
7. Monitor glucose levels hourly
8. Adjust insulin infusion:
   • <80 insulin off (consider D5 bolus)
   • 80-100 0.5 U/hr
   • 101-140 1 U/hr
   • 141-180 1.5U/hr
   • 181-220 2U/hr (consider bolus)
   • >220 2U/hr (*consider bolus)
9. Postpartum: A2 DM—stop pregnancy meds and check fasting BG PPD#1 (similar to A1DM).

Pre-gestational DM2—resume pre-pregnancy regimen OR begin pregnancy regimen at 50% dosing. (**check with attending to ensure plan immediately after delivery) -s/p vaginal delivery: resume insulin immediately (will be eating) -s/p c-section: use SSI until POD1, and start new pp regimen POD1 AM. (will begin regular diet POD1) *CAUTION: Type 1-DM may have a “honeymoon phase” after delivery because their insulin requirements fall dramatically without placental hormones. They may require more intensive BG monitoring; consider continuing their gtt if labile.

5. Insulin Cheat Sheet: BG Goals in Pregnancy: 1h PP: <140mg/dL 2h PP: <120mg/dL
   Fasting/ Preprandial: 65-95mg/dL Insulin Pharmacokinetics in a Typical Pregnant Diabetic

Hypertensive Disorders:

1. Basic labor admit orders & documentation (see induction section, also, if applicable)
2. Know HOW/ WHY they qualify for their diagnosis (review PNR and look at their BPs/ labs!)
3. Order BP parameters: (ex: with GHTN, call MD >160 SBP/ >110 DPB)
4. Continue home Anti-HTN meds if applicable

COMMON BP meds (cheat sheet):

• Labetalol 100-800mg PO BID-TID (max 2400mg/day)
• Nifedipine 30-90mg ER PO daily (max 120mg/day)

ACUTE treatment (cheat sheet):

• Labetalol 20mg IV push followed by BP checks at 10min intervals by doubling doses (no greater than 80mg)

  • Ex: 20 → 40 → 80 → 80mg…MAX TOTAL DOSE: 300mg
  • **ideal if wide pulse pressure

• Hydralazine 5mg (test dose) IV push, check BP in 20 min.

  • If responds, use 5mg again next time.
  • If no response, use 10mg.
  • If no response, move to labetalol
  • MAX BOLUS DOSE: 20mg **ideal if elevated diastolic

• Nifedipine 10mg PO, check BP in 20 minute increments.

  • If inadequate response, 20mg PO. Repeat up to one additional 20mg dose before moving to IV antihypertensive .

5. Postpartum: • Continue home meds.
   • If no home meds, wait to see what BPs do, and initiate if persistently high (>150s/90s).
   • Titrate as necessary to achieve control (usually daily).
   • Labetalol takes longer to see an effect, needs more titrating, and cumbersome dosing, so another option is to start Nifedipine XL 30mg PO daily.

Preeclampsia/SiPreE/HELLP:

1. Labor admit/ induction orders & documentation
2. BP parameters, Home BP meds—see above
3. Know how Dx was made: (lab values, proteinuria, office BP’s, symptoms… look at her PNR!)
4. Document PreE sx (HA/vision changes/RUQ pain/etc)/ lab values currently.
5. Consider checking HELLP labs: CBC, CMP, uric acid, +/- P:C ratio Discuss frequency of repeating these labs with upper-level/ attending based on severity of disease.
6. Know indication for induction (If PreE w/ severe features, know which symptoms make her severe)
7. Begin magnesium if inducing for PreE indication
   Mg dosing:
   -4g bolus (based on body size)
   -2g/hr. maintenance (may vary based on renal function)
8. Mg toxicity:
   -1st sign = absent DTRs (ALWAYS check reflexes q2hrs. with rounding!! If gone, check a Mg level & turn off Mg gtt)
   -Blurry vision (Ask if TV looks more blurry)

-Serious sequalae = pulmonary edema/ respiratory failure (EVERY PreE pt. needs pulmonary exam q2hrs. with rounding!!)

Eclampsia:

• Re-bolus Mg (use another 2g)
• If not on Mg, bolus 6g IV over 15-20 min (*4g IM in each buttock if no IV)
• Persistent Seizures: Benzos

Postpartum: PreE/ Eclampsia Mgmt.
-continue Mg 24hrs. pp, make sure patient diuresing
(criteria varies by attending, so always check before discontinuing!)

Trial of Labor after Cesarean (TOLAC)

1. Basic labor admit orders & documentation (EFW, pelvic adequacy, A/P)
2. Know details about previous labor(s) and deliveries— especially her indication for previous cesarean.
3. Consent her for TOLAC, c-section, blood products (and document!)

PPROM

1. Typical Admit documentation & Med Rec
2. SSE ONLY (no SVE!) to look for pooling/ferning (valsalva w/ exam to see any fluid coming from cervical os)
3. Swab for GBS (prior to latency abx!)
4. “Antepartum” order set for basics; NO labor orders unless >34w/ undergoing IOL
5. If <34w, start ACS (betamethasone 12mg IM q24h x2)
   • If 34-37w, discuss ACS use with attending
6. Latency Antibiotics (order set):
   • Ampicillin 2g q6h x 2d then Amoxicillin 500mg PO q8h x 5d
   • Azithromycin 500mg PO x 1 then Azithromycin 250mg PO daily x4 additional days
7. Order a neonatology consult
8. Order “official” OB u/s—growth, fluid, placenta, presentation
9. Consider Mg tocolysis through her ACS course (48hrs.)—“SW” or for neuroprotection <32w if threatening labor
10. CEFM
11. Bedside ultrasound for AFI, EFW, presentation, placentation (then compare results to “official” u/s)
12. Consider labs to evaluate etiology of PPROM:
    -CBC, UA, UDS, wet mount, abruption panel
13. Routine labs for delivery planning:
    -T&S, RPR, any routine prenatal labs not done in preg
14. SCDs (activity = bedrest w/ bathroom privileges)

PTL

• Typical Admit documentation & Med Rec
• Admit MUST include SVE
• Swab for GBS (prior to abx!)
• Start PCN prophylaxis for anticipated GBS+ while swab pending.
• “Antepartum” orderset for basics; NO labor orders unless she is >34weeks or is threatening delivery soon.
• If <34w, start ACS (betamethasone 12mg IM q24h x2)
  • If 34-37w GA, discuss ACS with attending
• Order a neonatology consult
• Order “official” OB u/s—growth, fluid, placenta, presentation
• Consider Mg tocolysis through ACS course (48hrs.)—“SW” or for neuroprotection <32w.
• CEFM
• Bedside ultrasound for AFI, EFW, presentation, placentation (then compare results to “official u/s)
• Consider labs to evaluate etiology of PTL:
  -CBC, UA, UDS, wet mount, ?abruption panel if concerned
• Consider routine labs:
  -T&S, RPR, any prenatal labs not yet done during preg
• SCDs (activity = bedrest w/ bathroom privileges)

What do all these abbrevs mean?

• ACD = Advanced Cervical Dilation
• ACS = Antenatal Corticosteroids
• AROM = Artificial Rupture of Membranes
• BSUS = Bedside U/S
• (resident documents fetal presentation on every admission)
• Cdil = Cervidil
• CHTN = Chronic Hypertension
• CI = Cervical Incompetence
• CL = Cervical Length
• GHTN = Gestational Hypertension
• IAI = Intra-amniotic Infection
• IOL = Induction of Labor
• FLM = Fetal Lung Maturity
• MOGA = Maricopa OB/GYN Associates—1 of our teaching groups
• MP = Mountain Park—1 of our teaching groups
• PPA = Phoenix Perinatal Associates—MFM teaching group
• PPROM = Preterm Premature Rupture of Membranes
• PROM = Premature Rupture of Membranes
• PreE = Preeclampsia
• PTC = Preterm Contractions
• PTL = Preterm Labor
• SiPreE = Superimposed Preeclampsia (on CHTN)
• SROM = Spontaneous Rupture of Membranes
• SSE = Sterile Speculum Exam (used for PPROM or HSV+ to evaluate lesions)
• Superscript © = consented
• Subscript c= fetus is presenting cephalic (based on bsus)
• **doesn’t confirm which part (brow/ face/ vtx/ etc.)
• Subscript br= the fetus is presenting breech
• Subscript trv ↓/↑ = transverse back down/transverse back up
• Subscript ROA, etc = you know the position of the vertex
• SVE = Sterile Vaginal Exam
• SW = steroid window—time is 48hrs. after initial dose ACS
• TOLAC = Trial of Labor After Cesarean
• VB = Vaginal Bleeding
• VBAC = Vaginal Birth After Cesarean
• VIP = Voluntary Interruption of Pregnancy