External Fetal Monitoring--DR C BRAVADO

D Determine
R Risk

C Contractions

BR Baseline Rate (110-160)
A 
V Variability (10-15 bpm around baseline)
A Accelerations (>15 bpm, >15 sec)
D Decelerations
     --Early decel: Gradual decrease which mirrors the contraction caused by head compression (benign)
     --Variable decel: Abrupt decrease in heart rate which has no temporal association with contractions caused by cord compression
     --Late decels: Gradual decrease fetal heart rate after the contraction which is caused by in uteroplacental insufficiency (not so benign)
O Overall Assessment (reassuring/nonreassuring)








































Ferenczy Score


Color
        1--Faint to snow white squamous epithelium after 5% acetic acid
        2--Snow white to dull-gray white epithelium, usually shiny surface
        3--Dull white to oyster white


Margins
        1--Irregular, jagged, flocculent
        2--Regular, straight, and sharply demarcated
        3--Fragile epithelium, straight margins, often raised with internal demarcation


Vessels
        1--Regular and present as fine surface vessels. Can have fine mosaic/punctate
        2--No vessels seen
        3--Coarse, irregular, punctate, or mosaic vessels


Iodine
        1--Epithelium retains partial iodine (brown > yellow)
        2--Some uptake of iodine but less (yellow > brown)
        3--Devoid of all intracellular glycogen and stains mustard yellow.









































Vacuum Application
A Ask for help/ Adequate anesthesia/ Address patient
B Bladder empty?
C Cervix completely dilated?
D Dystocia? Determine position of fetal head
E Equipment ready
F Fontanelle--apply vacuum 3 cm in front of posterior fontanelle/ Flexion fetal head
G Gentle traction with ctx, at right angle to plane of cup
H Halt if pop off 3 times, applied over 20 mins, or 3 ctx without progress
I Incision needed?
J Jaw--remove vacuum when jaw reached









































Shoulder Dystocia--HELPERR
H Help (Call for additional nurse, additional ob, and pediatrician)
E Evaluate for episiotomy
L Legs -McRoberts
P Pressure (suprapubic)
E Enter--rotational maneuvers (Rubin, Woods Screw, Reverse Woods Screw)
R Remove Posterior Arm
R Roll pt on all fours









































OB/Gyn Rotation Hints


 • Tips for a successful OB rotation:
      Go to mom baby and check on postpartum and post cesarean section mothers in the afternoon
      Present in a concise manner during morning rounds and for triage patients. Use the template EVERY TIME
      Know your patients history, lab values, and hospital progress
      Have an overall plan for each prenatal or antepartum problem you have found
      Read about your patient’s problems
      Keep up with the patient’s labor progress throughout the day

  • You should evaluate and complete an admission H&P for all patients admitted for labor or induction of labor. Determine fetal presentation with bedside ultrasound, submit orders, and generate a proposed plan of care. The on-call attending should then be contacted to discuss the plan of care. In the event that the patient presents with a complex issue, the attending on call should be contacted immediately for discussion.

  • While patients are in latent labor they should be assessed every 4 hours or as indicated to ensure adequate care. Once patients are in active labor (contracting regularly and 6cm) they should be assessed and findings documented at least every 2 hours or as indicated.

  • Be prepared to deliver the infant and make any necessary repairs. You should be proficient in tying knots, and repair of 1st and 2nd degree perineal tears prior to starting the rotation.

  • The resident that delivered the infant is responsible for following the mother during her entire hospital stay. For hospital admissions that span the weekend, the cross-cover resident is responsible for seeing the patient and documenting findings. All patients should be seen and charts completed by 7:30am

  • Triage: Prior to examining a patient, the chart should be reviewed for the gestational age, any prenatal concerns, and prenatal course. You should evaluate the patient and perform the necessary exam. The attending should then be called to discuss the patient and disposition. In the event that the patient presents with a complex issue, the attending on call should be contacted immediately for discussion.

  • Cesarean sections: You should plan to follow all cesarean sections done by Carolina OB/Gyn. Hospital stays that go through the weekend should be signed over to the corresponding cross-cover resident for weekend rounds. All patients should be seen and charts completed by 7:30am.

  • Be nice and listen to the L&D nurses. Have the nurse check behind you when doing cervical exams. They are used to doing this and it will help you fine tune your checks. They have much more experience and it takes a while to get the hang of it.

  • Gyn clinic is held Monday afternoon and Thursday afternoon at the Family Practice Center. Each OB resident is expected to be at this clinic unless they are involved with on-call responsibilities or other office hours. Dr Clark has an OB/Gyn Clinic on Monday and Thursday afternoons. You should be at these clinics unless you are in office hours or on call.

  • The Tickler system - this system helps us keep up with scheduling yearly exams such as pap smears. When you order one of these tests, the results will appear on your desktop. You must sign the document with an appended note detailing your plans and recommendations. This document must then be forwarded to Melanie Lollis.

  • Especially for male residents: remember to keep it professional while on L&D. Late hours and a single-gender nursing staff often can lead to rather racy conversations-keep in mind you are at work, and are still bound by the hospital policies on sexual harassment. Sometimes the best option is to excuse yourself from the situation and catch up on notes/charting/watching TV/etc.

  • When an unassigned patient is admitted, you will call the service attending who is usually one of the private OB's in the area (Carolina OB/Gyn or Anderson OB/Gyn).

  • Check out all patients (even outpatients) to the attending. They expect this. If you are quiet too long, they may randomly page you and ask what's up?! They also have remote access to watch the rhythm strips for the patients in labor, so be sure to have an accurate description of the strips for them - They may be staring at the strip from their home or office as you describe it!

  • When a FP center patient comes to L&D, evaluate the patient. If the patient is in labor, check Epic and determine who their primary physician is. Call their physician and alert them regarding the patient's admission.

  • Circumcisions are usually done after rounds the morning after delivery or the morning of discharge. You will do these with supervision from your attending that morning. As a first year, you will do all Gomco techniques.

  • Check out all your patients to the OB resident on call after 5 pm. Once again, the post-call resident is expected to check out at 2 pm.