Obstetric Tips

For Working on Labour & Delivery

OB Admission/Assessment History
ID, age, GTPAL, EDD/LMP/GA, CC, HPI
Contractions: onset, frequency, duration, intensity
Bleeding: colour, amount, clots, pain, trauma
ROM: time, volume (gush/trickle), color, fever/chills, abdo tenderness
Fetal movement present/absent
Hx of current pregnancy: complications, infection, GHTN, GDM, ultrasounds (when?, presentation, placenta, amnio)
Bloodwork: type, Rh, Rubella, Hep B/C, HIV, VDRL, MSS, GBS. Women in labour need a stat HIV and blood type if not done.
OB Hx: date, term?, labour duration, route (SVD/AVD/LSCS), complications, weight, pregnancy complications.
GyneHx: last pap? Ab/N?, Hx of PID/STI, abdo/pelvic surgery
SurgHx: thyroid, cardiac, asthma, renal
MedHx, Allergies, Medications
SocialHx: smoker/EtOH/drugs, support, abuse.
Admission Orders
1. DAT, clear fluids in active labour
2. AAT
3. VSR
4. (IA/EFM) for fetal surveillance
Indications for Intrapartum EFM
Fetal: abnormal FHR on auscultation, IUGR, premature, oligohydramnios, isoimmunization, multiple pregnancy, breech, meconium stained amniotic fluid
Maternal:  hypertensive disorders of pregnancy, insulin-dependent DM, antepartum hemorrhage, significant maternal medical disease, maternal MVA/trauma, TOLAC, BMI > 35, PTL, post-term (>42 weeks), vaginal bleeding in labour, chorioamnionitis, IOL/augmentation with oxytoxin, PROM (> 24 hours at term)
Analgesics in Pregnancy/Labour
Morphine 10-15 mg IM Q4H + Gravol 50mg IM once
Tramacet  37.5/325mg PO QID PRN (safe in breastfeeding)

Antiemetics in Pregnancy/Labour
Gravol 25-50mg PO/IV/IM Q4H
Maxeran 10mg IV/IM Q4H
Phenergan 12.5-25mg PO/IV/PR QID
Ondansetron 8-16mg SL or 4mg IV
GBS Positive in Labour
Pen G 5 million units IV, then 2.5 million units IV Q4H
OR, Ampicillin 2g IV then 1g QID
OR, Clindamycin 900mg IV TID until delivery
Treat for GBS if:
1. Previous GBS-infected baby
2. GBS bacturia
3. GBS unknown AND:
• < 37 weeks GA
• intrapartum fever
• ROM > 18hrs
4. GBS positive
Goal is one dose on board at least 4hrs before delivery.
MERCER Protocol PPROM <36 weeks (FFN first if <34wks)
• Ampicillin 2g IV QID for 48hrs, then Amoxil 250mg PO TID x 5/7 AND
• Erythromycin 250mg IV TID for 48hrs, then 250mg PO TID x 5/7
Gestational Hypertension
Treat at BP 170-160/105-110
Goal BP 140-155/90-105
- MgSO4: 4g IV bolus, then 1g IV Q1H
- Labetolol (works in 5-10min, last 3-6hrs): 10mg IV push over 2min, then every 10min: 20mg IV push, 40mg IV push, 80mg, 80mg. Max 300mg. CI: asthma, bradycardia, cocaine, AVB.
Once BP controlled: labetolol 200mg PO BID or nifedipine 10mg PO TID.
- Nifedipine (Adalat) (works in <30min, lasts 5hrs): 5mg PO (chew & swallow), then 5-10mg Q30min. Side effects: flushing, headache, palpitations, tocolysis
- Hydralazine (works in 10-20min, lasts 3-6hrs, risk of hypotension): 5mg IV test dose then 5-10mg IV Q20min, max 30mg OR IV infusion at 0.5-10mg/hr.

Intrauterine Resuscitative Measures
Maternal repositioning (repeated)
Decrease/discontinue oxytocin infusion
Increase main live IV rate
Correct hypotension, if present
Vaginal exam: scalp stimulation (intrapartum only), elevation of presenting part if prolapsing cord
O2 at 8-10L/min/mask
Nitroglycerine for uterine hyperstim with bradycardia
Progress Note
Contractions: frequency, duration, oxytocin? (rate?)
Analgesia
FHR: Baseline, variability, accels, decels (interpretion: normal, atypical, or abnormal)
V/E: Dilation, effacement, station, position, consistency, moulding
A/P: Progress/no progress. R/A in 2hrs. ARM, Synto, expect SVD
Delivery Note
Age, GPTAL woman delivered a viable GA male/female infant via SVD/AVD at 0800.
Spontaneous labour/induced with Cervidil/Synto (reason?). PROM? Intrapartum fever? Mec? AVD with forceps/vacuum (# pulls?), reason?. Nuchal cord? (cut and clamped, pulled over), position LOA.
Infant APGARs 9 and 9. NICU called/present for delivery. Infant stable / taken to nursery/NICU.
Cord gases taken. Placenta delivered spontaneously, intact, 3VC.
Laceration (where? 1st, 2nd, 3rd, 4th) Repaired with? (2-0, 3-0 chromic, vicryl). EBL < 500ml.
Drs in attendance.
Postpartum Note
Bleeding		Blues (postpartum depression)
Bowel		Belly (LSCS)
Bladder		Baby (contraception)
Breathing (DVT)	Breastfeeding (latching? tongue-tied?)
Pain? Fever? Mobility? Abdomen SNT? (if LSCS)
PPH
empty bladder, massage fundus
Oxytocin 40 units/L IV wide open (150ml/hr)
Oxytocin 10 units IM
Cytotec / Misoprostol 800mcg PR OR 400mg SL OR 200mg PO
Hemabate 250mcg IM or intramural Q15min, max 8 doses

Infections
UTI in Pregnancy
Amoxiclav 500mg BID x 7/7
Macrobid 100mg BID x 3-7/7 (avoid after 36 weeks)
Cefixime 200mg BID x 7/7
Bactrim DS 1 tab BID x 3/7 (2nd trimester only)
Asymptomatic Bacturia
Amoxicillin 500mg PO TID x 3-7/7
UTI (Not pregnant)
Amoxiclav 500mg BID x 7/7
Cipro 250mg BID x 3/7 or 500mg daily x 3/7
Bactrim DS 1 tab BID x 3/7
Macrobid 100mg BID x 5/7
Intrapartum Fever
Cefoxitin 2g IV stat x 1 — no subs, then 1g TID OR
Ancef 2g IV QID + Flagyl 500mg IV TID
(continue 24hrs postpartum and afebrile)
Endometritis (Not pregnant)
Cipro 500mg PO BID + Flagyl 500mg PO BID, OR
Clindamycin 900mg IV TID + Gentamicin 90mg IV daily
PID (inpatient tx)
Cefoxitin 2g IV QID + Doxycline 100mg PO BID, OR
Clindamycin 900mg IV TID + Gentamicin 2mg/kg IV/IM loading dose then 1.5mg/kg IV TID
Chlamydia
Doxycycline 100mg PO BID x 7/7 OR Azithromycin 1g PO x single dose if poor compliance expected
Gonorrhea
Cefixime 400mg PO single dose + treat Chlamydia as well empirically

Herpes
First episode:
Acyclovir 200mg PO 5 times daily x 5/7 OR
Famiciclovir 250mg PO TID x 5/7 OR
Valacyclovir 1000mg PO BID x 10/7
If severe: Acyclovir 5mg/kg IV infused over 60min every 8 hours
Recurrent:
Acyclovir 200mg PO 5 times daily x 5/7 OR
Famiciclovir 125mg PO BID x 5/7 OR
Valacyclovir 500mg PO BID x 3/7
Suppressive therapy (not pregnant):
Acyclovir 400mg PO BID, OR
Famiciclovir 250mg PO BID, OR
Valacyclovir 500mg PO daily (1000mg if >9 episodes/year)
Suppressive therapy:
Acyclovir 400mg PO QID, OR
Famiciclovir 250mg PO TID, OR
Valacyclovir 500mg PO BID
Bacterial Vaginosis
Flagyl 500mg PO BID x 10-14/7 OR
Metronidazole Gel 0.75%, one application PV daily x 10/7
Trich
Flagyl 500mg PO BID x 7/7 OR 2g PO single dose
Candida
Fluconazole 150mg PO single dose
If recurrent, repeat Q3D for 3 doses
Wound infections
Keflex 500mg PO QID OR
Clindamycin 300mg PO TID

Other Meds
GERD / Reflux (safe in pregnancy)
Ranitidine 150mg PO BID
Pre-op Prophylaxis
Ancef 2g IV on call to OR
Ranitidine 150mg PO/IV
Maxeran 10mg PO/IV
Sodium citrate 30mg PO
Others:
Indomethacin supp. 100mg PR BID
Ferrous gluconate 300mg BID (if Hgb < 100)
Folic acid 5mg PO daily (Hgb < 80)