Step Up To Residency

[obstetrics]
Objectives
• Enhance knowledge of Obstetrics through application of simulated
patient cases
• Practice skills helpful in the early stages of residency
• Discuss critical issues necessary for success in residency
Milestones in Obstetrics
• Demonstrates basic knowledge of normal obstetrical care and
common medical complications seen in pregnancy
• Demonstrates basic knowledge of routine/uncomplicated intrapartum
obstetrical care, including conduct of normal labor
• Demonstrates basic knowledge of normal postpartum care
• Demonstrates basic surgical principles, including use of universal
precautions and aseptic technique
• Performs basic procedures, including speculum examination and
cervical examination
Milestones in Obstetrics
• Performs initial warming and drying of a non depressed infant
• Demonstrates basic knowledge of normal pelvic floor anatomy
• Recognizes limitations and failures of a team approach in health care
as the leading cause of preventable patient harm
• Understands the importance of providing cost effective care
• Understands the role of physicians in advocating for appropriate
women’s health care
Milestones in Obstetrics
• Understands the importance of compassion, integrity, and respect for
others
• Demonstrates sensitivity and responsiveness to patients
• Understands physicians are accountable to patients, society and the
profession
• Acts with honesty and truthfulness
• Understands the importance of respect for patient privacy and
autonomy
• Understands the ethical principles of appropriate patient/physician
relationships
Milestones in Obstetrics
• Demonstrates adequate listening skills
• Communicates effectively in routine clinical situations
• Understands the importance of relationship development,
information gathering and sharing, and teamwork
Obstetric Case Simulation
• A 27 year old, gravida 3, para 2, at 38 weeks gestation presents to
labor and delivery complaining that she thinks she is in labor.
What are key elements in the history?
What are key elements in the history?
• Last menstrual period? • Pregnancy and obstetric history
• Estimated date of delivery? • Vaginal bleeding?
• Loss of fluid? • Contractions?
• Fetal movement? • Group B streptococcus status?
• History of infections? • Past surgical history
• Past medical history
• Social history
What are key elements in the physical?
What are key elements in the physical?
• Vital signs
• Abdominal examination
• Speculum examination
• Cervical examination
• Leopold
Obstetric Case Simulation
• History:
• Last menstrual period 39 weeks ago
• Uncomplicated pregnancy to date, two prior full term vaginal deliveries
• Possible leaking, no bleeding, painful contractions every 8-10 minutes
• No history sexually transmitted infections
• No significant past medical or surgical history, no allergies
Obstetric Case Simulation
• Physical:
• Vitals: blood pressure 90/60, heart rate 102 bpm, respiratory rate 12,
temperature 37.6 Centigrade
• Abdomen: term uterus, fundal height 39 cm, cephalic, otherwise soft, non-
tender
• Speculum examination: negative for pooling, ferning, and nitrazine
• Hemoglobin 12.1 g/dL
• Blood type O+, antibody screen negative
Prenatal Care
• Visit frequency
• Every 4 weeks through 28 weeks
• Every 2 weeks through 36 weeks
• Every week thereafter
• Accomplish the following:
• Assess well being
• Ongoing education
• Perform routine screening
Prenatal Care
• Routine measurements
• Blood pressure, weight, uterine size, fetal heart rate, urine dipstick
• Routine lab
• HIV, hepatitis B, syphilis, chlamydia, gonorrhea, urine culture
• Blood type, Rh status, antibody screen
• Complete blood count
• Glucose screening at 24-28 weeks
• Group B streptococcal screening at 35-37 weeks
Prenatal Care
• Immunizations
• Influenza, pertussis
• Other considerations
• Genetic screening options
• Alpha fetal protein
• Hemoglobin electrophoresis
• Cystic fibrosis screening
Medical Complications - Asthma
• Increased risks of prematurity and low birth weight (growth restriction)

• Intermittent – symptoms < 2 days per week, < 2 nights per month, peak flow > 80%, no
activity limitation, albuterol as needed
• Mild persistent – not daily but > 2 days per week, > 2 nights per month, peak flow > 80%,
minor activity limitation, low dose inhaled corticosteroid
• Moderate persistent – daily symptoms, nights more than 1 per week, peak flow 60-80%,
some activity limitation, low dose inhaled corticosteroid and salmeterol
• Severe persistent – throughout the day, nights more than 4 per week, peak flow < 60%,
extreme activity limitation, high dose inhaled corticosteroid and salmeterol, possible
oral corticosteroid

• Moderate and severe asthma – fetal surveillance with growth ultrasounds and
antenatal testing starting at 32 weeks
Medical Complications - Obesity
• Increased risks of spontaneous abortion, cardiac dysfunction, sleep
apnea, gestational diabetes, preeclampsia, congenital anomalies
• Weight gain
• Overweight (body mass index 25-29.9) – 15 to 25 pounds
• Obese (body mass index >30) – 11 to 20 pounds
• Recommend early glucose tolerance screening, consider additional
evaluation for sleep apnea
• Postpartum – consider additional pharmacologic management for
thromboembolic disease, increased risk for surgical site infection
Medical Complications - Hypertension
• Preeclampsia
• Blood pressure >140/90, 2 occasions > 4 hours apart after 20 weeks, or
>160/110 over short intervals (minutes)
• Protein/creatinine ratio > 0.3
• Gestational hypertension
• Blood pressure elevation after 20 weeks in absence of proteinuria or systemic
findings
• Chronic hypertension
• Blood pressure elevations predate pregnancy or prior to 20 weeks
• >140/90
Medical Complications - Hypertension
• Preeclampsia without severe features and gestational hypertension
• Manage blood pressures <160/110
• Delivery by 37 weeks 0 days

• Chronic hypertension
• Manage blood pressures between 120-160/80-105
• Initial treatment:
• Labetalol, nifedipine or methyldopa
• Angiotensin enzyme inhibitors and angiotensin receptor blockers not
recommended
OB Case Simulation
• Hands on Exercise:

Perform a cervical examination on the series of models provided

Record your estimate for each model for discussion and feedback
Stages of labor
• First stage: onset of labor until complete dilation and effacement
• Latent: gradual cervical change
• Active: rapid cervical change (contemporary data = 6 cm)

• Second stage: complete cervical dilation to delivery

• May have passive and active components

• Third stage: from delivery of infant to delivery of the placenta

Abnormal Labor
• Prolonged latent phase
• Greater then 20 hours nulliparous, 14 hours multiparous
• No longer an indication for cesarean delivery

• Active phase arrest in the first stage

• 6 cm or greater dilation, with ruptured membranes, failing to progress with 4
hours of adequate uterine contractions (>200 Montevideo units)
• Or 6 hours of oxytocin administration with inadequate uterine activity and no
cervical change
Abnormal Labor
• Arrest of labor in the second stage
• No specific maximum time identified
• At least 2 hours of pushing in multiparous
• At least 3 hours of pushing in nulliparous
• Longer durations may be appropriate if progress documented and
maternal/fetal status permits
Fetal Heart Rate Monitoring
• Baseline: Rounded to nearest 5, minimum of 2 minute duration in a
10 minute segment, 110 to 160 normal
• Variability: fluctuations in the baseline
• Absent: undetectable
• Minimal: <5 bpm
• Moderate (normal): 6-25 bpm
• Marked: >25 bpm
• Acceleration: abrupt increase (less than 30 sec) in FHR
• Before 32 weeks: 10 beats above baseline for 10 seconds
• After 32 weeks: 15 beats above baseline for 15 seconds
Fetal Heart Rate Monitoring
• Early deceleration: gradual decrease and return to baseline associated with
contraction
• Nadir of deceleration same time as peak of contraction
• Late deceleration: gradual decrease and return to baseline associated with
contraction
• Deceleration delayed, with nadir occurring after peak of contraction
• Variable deceleration: abrupt decrease in the fetal heart rate (less than 30
seconds)
• Prolonged deceleration: decrease in baseline > 15 bpm, lasting > 2 minutes
and < 10 minutes
• Sinusoidal pattern: sine wave like undulating pattern, 3-5 cycles per minute
for at least 20 minutes
Fetal Heart Rate Monitoring
• Intermittent decelerations: occur with less than 50% of contractions

• Recurrent decelerations: occur with greater than 50% of contractions

• Bradycardia: fetal heart rate baseline is less than 110 beats per
minute
Fetal Heart Rate Monitoring
• Category I
• Baseline 110-160 bpm, variability moderate, no late or variable decelerations,
early decelerations may be present, accelerations may be present
• Category III
• Absent variability with any of the following: recurrent late decelerations,
recurrent variable decelerations, bradycardia
• Sinusoidal pattern
• Category II
• Everything else
OB Case Simulation
• Group Exercise

As a group, please review the fetal heart rate tracings provided

Please utilize the previous slides for vocabulary, commenting on:

baseline, variability, presence of accelerations and decelerations, and
overall category
Cardinal Movements of Labor
Perineal Anatomy
Perineal Anatomy
Perineal Anatomy
Perineal Anatomy
Perineal Anatomy
Perineal Anatomy
OB Case Simulation
• Hands On Exercise

Each student will perform an uncomplicated vaginal delivery using the

simulation model
APGAR Score
0 1 2

Heart Rate Absent <100 >100

Respiration Absent Hypoventilation/weak cry Regular, crying

Tone and Movement Limp Moderate Active

Color Totally blue Blue extremities Pink

Reflex irritability No response Whimpering/Grimace Crying

Newborn Assessment
• Three characteristics:
• Is the baby full term?
• Is the baby breathing with regular rhythm or crying?
• Does the baby have good muscle tone?
• If you answered yes:
• Baby does not require resuscitation and may remain with the mother skin to
skin
• Baby should be dried and covered with dry linen to maintain temperature
while skin to skin
What are key elements to postpartum care?
What are key elements to postpartum care?
• Blood pressure every 15 minutes • Pericare performed vulva to anus
for the first 2 hours (not other way)
• Temperature every 4 hours for the • Void as soon as possible (and
first 8 hours monitor for the first 24 hours)
• Early ambulation (with assistance • Length of stay (24 - 48 hours for
the first time) vaginal, 36 - 72 hours for cesarean)
• Regular diet • Postpartum visit within 4-6 weeks
• Shower as desired • Postpartum contraception
• Ice pack to perineum discussed
• Assess for postpartum mood • Immunizations: TdaP (if not done),
disorder anti-D immune globulin, Rubella,
influenza (if not done and in
season)
Thank you for your participation!
Please remember to fill out your
post-course evaluation prior to leaving.