OB Special Circumstances
- 1 GBS Positive (or unknown)
- 2 Retained Placenta
- 3 Postpartum Hemorrhage (PPH) (high incidence)
- 4 Pre-eclampsia (PEC)
- 5 Intrahepatic Cholestasis of Pregnancy (IHCP)
- 6 Newborn Baby transferred out
- 7 Fetal Demise
- 8 Still Birth
- 9 Labor in the Village
- 10 Term Labor in the village
- 11 Preterm Contractions/Labor in the Village
- 12 Term HIGH RISK patient laboring in village
GBS Positive (or unknown)
These guidelines are reflected in the standing OB admission orders and involve treating this infection usually during the active labor period and hopefully prior to vaginal delivery to reduce neonatal morbidity/mortality. Four hours is the minimal treatment time regardless of the antibiotic used (but presumes second dose of PCN onboard). If that standard is not met, no septic evaluation for the newborn is required but a 48 hour admission is recommended.
For women with limited prenatal care or presenting in preterm labor, we can now do Group B Strep (GBS) PCR or Xpert GBS for a presumptive screening of GBS status; if positive, will be confirmed with a routine GBS screen.
Allow at least 30 minutes prior to making this determination. The “active management of the third stage of labor” (see ALSO) can reduce this occurrence. Manual extraction of the placenta with appropriate analgesia may be required.
Postpartum Hemorrhage (PPH) (high incidence)
For those patients at high risk for this (includes AMA and prior history of PPH), a few extra hemostatic agents (such as Pitocin/methergine [if BP not elevated]/Cytotec/Hemabate) should be in the delivery room (see ALSO Guidelines).
Induce as able at EGA 38 weeks or arrange transfer to ANMC prior to 39 weeks. Also see PEC section above under “OB Triage Patients.” A new PEC and Induction Policy exists for this situation and is kept in the “Induction Book” in the NWing Doc’s Office (YKHC Clinical Guidelines for PEC and Induction are out-of-date <2011>). The best treatment for PEC is delivery of the baby. Vigilance is key to prevent the sometimes fatal progression of PEC to eclampsia up to 48 hours or more postpartum.
Intrahepatic Cholestasis of Pregnancy (IHCP)
See YKHC Clinical Guideline for IHCP This is very common here. In addition to the guideline there is an Induction Policy kept in the “Induction Book” in the NWing Doc’s Office. IHCP can result in a bad newborn outcome and may need to be treated with induction at 37 weeks at ANMC We can do an induction in Bethel at 38 weeks as indicated.
Newborn Baby transferred out
If a newborn is unstable for any reason and is transferred to a referral center by Peds, the recent postpartum mother will stay admitted to OB for at least 24 hours until she is stable to travel to reunite with her newborn child. In some instances the mother can travel with the baby at eight 8 hours post partum if she is very stable.
Consult with HROB.
- Generally treat this situation as “an induction,” confirm IUFD status with US, including vertex position. No need to assess Bishop score. Only use Cytotec.
- Delay Cytotec induction by at least 24 hrs (up to 3-4 ds) to allow grief process to proceed-there is no rush to induce if membranes are intact.
- Use Cytotec 25mcg PV Q4 hrs until delivery. Use expectant management along with Morphine + Ativan analgesia during labor.
- Discuss with mother option of autopsy (which will involve shipping details and Admin approval for shipping and procedure costs) to assess reason for IUFD
- ANMC guidelines for IUFD include the following work-up for etiology:
- Placental fetal tissue for genetic testing; maternal blood for CMP, PTT, cardio-lipid ab, Kleihauer-Betke, lupus anticoag, beta 2 glucoprotein, bile acids, and fibrinogen; and urine for UDS.
- Finally, a “Certificate of Fetal Death” needs to be completed for >20 week fetuses and sent to HIS
- see YKHC Clinical Protocol: Unexpected Death Protocol (page #2)
Notify HROB. The mother should be allowed time as she desires with her baby for the grieving process.
Labor in the Village
Term Labor in the village
Low risk pregnant who have not come to Bethel by their Be in Bethel Date (BIB) will deliver in the village.
Preterm Contractions/Labor in the Village
For immediate CHA responses, consider SQ terbutaline 0.25mg up to 3x in the initial hour, PO Motrin 800mg now, and IVF NS or LR 1L now in an attempt to shut down contractions and buy time for transport of this patient to Bethel. It is helpful to LOOK at the patient on the VTC to see if they seem to be having painful contractions. For a term or near term patient, it may not be wise to use ibuprofen due to issue of premature closure of the ductus, however, a single dose is not likely to be harmful and may buy you some time to get the patient to Bethel. It is also worth noting that if the terbutaline does not change the “contractions” then the sensation that the patient is feeling is not likely contractions. Even in advanced dilated with imminent delivery, terbutaline will stop contractions for a few minutes.
(For early Preterm Contractions/Labor that can be arrested and for PPROM, both in a village setting, the best solution may be for the patient to hop on a very soon departing commercial flight (if there is one). If this is not an option, LifeMED crew alone may be able to transport such a prenatal patient to OB Triage.)
Otherwise, FM and PEDS (with compact incubator) must both go to the village with LifeMED to assess labor and determine whether it is safer to transport or deliver a newborn in (a likely cold and remote) village clinic. If it is at night, call BOTH peds and FM hospitalist. If you are called in at night, come to OB first and get the OB pack in case of village delivery.
Term HIGH RISK patient laboring in village
The above also applies to a HIGH RISK term patient who is not in Bethel (as per signed agreement) but is having contractions or is SROM. A LOW RISK patient is this situation would deliver in the village (usually by the CHA or mid-level) also per a signed agreement. If there is no signed agreement, then legally the patient may need to be medevaced.