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
FM Maternity Care - Resources
 http://youtu.be/nizKRUv37ls
 Human Labor and Birth, Oxorn - Foote, Sixth Edition – Dr.
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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
“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
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
Intra-partum Competencies
1. Diagnose SROM
2. Perform accurate cervical assessment
3. Manage labour / fetal surveillance
4. Scalp electrode placement
5. Manage amniotomy & labour augmentation
6. Manage spontaneous vaginal delivery
7. Manage obstetrical emergencies
8. Participate in assisted vaginal delivery
9. Perform uncomplicated perineal repair
10. Communicate/collaborate effectively (patient,family,
team)
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6
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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 2014 - 2015:
 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)
FM Resident OB Supervisors
Maternity & Newborn Field Note - can be completed by:
 Family Physicians
 Staff Obstetrician
 Senior OB/Gyn Residents
 Obstetrical Nurses
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
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
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 0700
weekdays and 0800 on Sat/Sun/holidays – vitally
important skill
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
 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
 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
Obstetrical Areas
1.
OAU – Obstetrical Assessment Unit (Triage)
2.
Birthing Unit (BU/Case Room)
3.
Postpartum ward – A4 OCH, 8E OGH
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
 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
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
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
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
Technical Skills
1.
Clinical Assessment:
a)
b)
Abdominal Exam (Leopold’s Maneuvers)
Cervical Exam - confirmed by RN initially
i.
2.
3.
4.
5.
6.
7.
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
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
1. a) Leopold’s Maneuvers
First
Second
Fundal
Grip
Umbilical
Grip –
fetal back
Third
Fourth
Pawlick’s
Grip –
presenting
part
Pelvic
Grip –
fetal
brow
Martin, 2002
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
1.b) Vaginal exam
2) Presenting Part
 Vertex / breech / other?
 position
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
1.b) Vaginal exam
Occiput posterior position
1.b) Vaginal exam
Occiput transverse positions
ROT
LOT
1.b) Vaginal exam
3) Station
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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)
Assessing descent by vaginal examination
-2 station: - leading bony edge of presenting part is 2cm
above ischial spines
0 station: - head is engaged
1.b) Vaginal exam
4) Pelvic Architecture
 Assess ischial spines, pelvic sidewalls & sacrum for adequacy
5) Amniotic Fluid Assessment
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Ferning
Nitrazine
Clear or meconium?
1.b) Vaginal exam
pH of vaginal discharge using nitrazine paper
A) Normal
B) Bacterial vaginosis
C)Pregnant woman with premature rupture of membranes.
1.b) Vaginal exam
Ferning
2. Technical Skills - ARM
 practice
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)
5.Technical skills – Perineal Repair
 Academic Day July 17, 2015
 Foam model simulation
6. Technical Skills - AVD
 Assisted vaginal delivery
 In hands-on workshops: session 3 (OBS emergencies)
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FETAL HEALTH SURVEILLANCE
Fundamentals Workshop
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
41
© PPPESO
2009
Paper speed - 3 cm/min
42
© 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
43
© 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
110-160 
> 160 
< 110 
44
© PPPESO
normal
tachycardia
bradycardia
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
45
180
180
150
150
120
120
90
90
© PPPESO
Presence of
variability is a crude
indicator of fetal
oxygenation as it
reflects an intact CNS
2009
FHR Variability
ABSENT
Amplitude range undetectable
MINIMAL
Amplitude range detectable but
 5 bpm
MODERATE
Amplitude range 6-25 bpm
MARKED
Amplitude range > 25 bpm
46
© 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
FHR Variability
MODERATE VARIABILITY: 6-25 bpm
MARKED VARIABILITY: > 25 bpm
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© 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
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© 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
Reflex vagal
response associated
with
head compression
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© PPPESO
180
180
150
150
120
120
90
90
100
100
75
75
50
50
25
25
0
0
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
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Reflex response to
cord compression
during or between
contractions
© PPPESO
180
180
150
150
120
120
90
90
100
100
75
75
50
50
25
25
0
0
2009
Variable Deceleration
“Shoulders”
NORMAL (REASSURING)
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© PPPESO
“Overshoots”
ABNORMAL (NON-REASSURING)
2009
Complicated Variable Decelerations
 Deceleration <70 bpm >60 sec.
 Loss of variability of baseline and in the


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53
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
© 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
Chemoreceptor &
vagal response to
utero-placental
insufficiency ,
reflecting marginal
fetal oxygenation
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© PPPESO
180
180
150
150
120
120
90
90
100
100
75
75
50
50
25
25
0
0
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
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© 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
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© PPPESO
2009
Intermittent Auscultation (IA)
Appropriate
for low risk
labor
Classification of NON STRESS TEST (NST)
Classification of EFM tracings
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!
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© 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
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© 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 > 7.19
( 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)
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© PPPESO
2009
Intrauterine Resuscitation
GOALS:
 Improve uterine blood flow
 Improve umbilical circulation
 Improve oxygen saturation
 Reduce uterine activity
INTERVENTIONS:
•
•
•
•
•
•
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© PPPESO
Change position
Give O2 per mask ?
Decrease/discontinue oxytocin
Temporarily increase IV rate
Support woman / family
Communicate / Document
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
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© PPPESO
2009