OB Deliveries

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Routine Vaginal

See YKHC Clinical Guidelines This should be the norm as it presents in the form of Primigravida or Multiparous. Anything that might be High Risk (and not planned to be managed in Bethel) during prenatal care should have already been screened out and sent to Anchorage.

Pre-term Delivery

See YKHC Clinical Guidelines See preterm triage situations above. Transfer to ANMC in consultation with ANMC OB on-call should be considered. Peds as well needs to be aware of this potential situation early on.

Failure to Progress

This requires evaluation for CPD, LGA, poor contractions and other etiologies in consultation with HROB and may result in a trial of pitocin augmentation with internal monitors. Depending on the assessment, a C-section is a possibility.

Meconium

If meconium is noted ‘peds on call’ should be at the delivery for possible meconium aspiration. Hospitalist physicians should be familiar with the meconium aspiration procedure and set up. They should also be familiar with the newborn bag, mask, and suction equipment available in case the pediatrician cannot make it in in time for the initial resuscitation. If meconium is not noted until delivery, have peds paged STAT, and be prepared to aspirate meconium if the baby does not cry at delivery.

Induction

See new Induction Policy in the NWing Doc’s Office in the “Induction Book.” The current YKHC Clinical Guidelines (2011) are not current on this matter.

Episiotomy

This is discouraged and is usually unnecessary unless an urgent delivery is required as in Shoulder Dystocia or for a forceps delivery usually involving fetal distress.

Vacuum Extraction

This is usually done by the HROB (or FM if privileged or in an emergency situation) in place of forceps for difficult deliveries.

C-Section

This is a HROB decision when the baby needs an urgent/emergent delivery. Other indications might be prevention of a birth canal disease exposure or birth canal trauma for a very early imminent preterm delivery or a higher risk prior C-section in Bethel in labor. There are situations when a scheduled C-sections can be done. When a planned Bethel VBAC is done, a C-section is always possible.

VBAC

See YKHC Clinical Guidelines. These deliveries are screened for the most LOW RISK situations. As mentioned above for VBAC OB Triage patients, anything less than a Category 1 fetal heart strip will require HROB presence in-house.

Postpartum Care

There are standing postpartum orders plus nursing protocols that cover the basic needs of postpartum care. A discussion about birth control can also be beneficial during this time. If a village term newborn cannot be discharged at the usual 48 hours (usually due to late preterm status or an elevated “high-intermediate” bilirubin level by Bili-Tool), the mother can still be discharged at 36-48 hours (but room-in with the newborn). Mom will follow up in Bethel for postpartum visit at 6weeks. Before discharge, update both mom and baby’s problem list – newborn, EGA, weight, etc.