When to schedule posterm induction
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The document provides guidelines for postterm induction, including: 1) Using the Bishop score, cervical dilation, parity, and EGA to determine when to schedule inductions between 41w 0d-41w 6d. 2) Scheduling outpatient Cytotec inductions in the evenings staggered to allow for assessment and additional dosing if needed. 3) Scheduling inpatient Pitocin inductions staggered in the mornings. 4) Favorable criteria for induction include Bishop score of 6 or more and cervical dilation of 3-4cm for nulliparous and 2cm for multiparous patients.
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The document provides guidelines for postterm induction, including:
1) Using the Bishop score, cervical dilation, parity, and EGA to determine timing of induction between 41w 0d-41w 6d
2) Favorable cervix for induction is a Bishop score of 6 or more
3) Risk of cesarean section is increased for Bishop score <5 or multiparous with cervix <2cm dilated/nulliparous with cervix <3-4cm dilated
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- Early amniotomy and oxytocin ("pop and pit") results in faster labor onset, shorter delivery time, and lower C-section rates compared to delayed amniotomy or oxytocin alone.
- Outpatient cervical ripening with misoprostol (Cytotec) should allow assessment for admission or discharge by 8:30am following the induction attempt.
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2. Inpatient Pitocin-only inductions should arrive at 6:00 AM to start Pitocin before 7:00 AM.
3. Favorable criteria for induction include a modified Bishop score of 6 or more and cervical dilation of 3-4 cm for nulliparous patients.
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MANAGEMENT OF PRETERM PROM ON INDUCTION OF LABOUR
INCIDENCE OF PPROM
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It is the leading identifiable cause of premature birth ( 30%)
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Kpsc diabetes in pregnancy pathway 8.6.2012
The document outlines guidelines for managing diabetes in pregnancy across medical centers. It discusses:
1. Individual centers being graded on compliance with performing HbA1c tests on all prenatal patients and FBS tests for GDM patients at 6 weeks postpartum. Bonuses may be tied to these performance measures.
2. Risk stratification of patients into low, medium, and high risk groups based on diabetes history and control. This determines interventions like medication management and fetal monitoring.
3. Screening all prenatal patients for GDM risk and providing diabetes education. High risk patients receive early glucose testing while low risk patients are tested at 24-28 weeks.
4. Postpartum follow-up
Economy
The document discusses issues with the current scheduling system including too many changes and vague requests. It proposes implementing scheduled cesarean sections on call days to improve efficiency by ensuring the primary surgeon performs the surgery and eliminating wasted time. This could add 30 hours of clinic access per month. Some providers argue they are too busy, but deliveries have decreased so scheduling cesareans this way could help protect staffing levels. No more than 2 cesareans would be scheduled per provider per call day.
Twins clinical management 2012
This document provides guidelines for managing twin pregnancies, including determining chorionicity and amnioticity. It recommends that all twins undergo an NT ultrasound before 14 weeks to validate chorionicity/amnionicity and detect early complications. Management of monochorionic twins requires more intensive surveillance due to increased risks of complications affecting fetal growth and well-being. Dichorionic twins generally require less frequent monitoring while monochorionic twins should be monitored more closely, with delivery planned before 37 weeks.
New Progesterone Guideline for Preterm labor and incidental shortened cervix
This document summarizes recommendations for using progesterone to prevent preterm birth based on a woman's history and cervical length. It recommends 17-hydroxyprogesterone caproate injections weekly from 16-20 weeks until 36 weeks for women with a prior spontaneous preterm birth. For women without a prior preterm birth but an incidental short cervical length of 10-20mm before 24 weeks, it recommends daily vaginal progesterone until 36 weeks. Safety follow-up of children exposed to 17-hydroxyprogesterone caproate in clinical trials found no differences compared to placebo.
Medication 53333-phpapp02
The document discusses improving patient satisfaction scores related to communication about medications at Riverside Medical Center's maternity service. The goal is to increase the HCAHPS medication communication score from 66% to 75% by December 2012 and 85% by June 2013. This will be achieved through education of providers, patients, and staff. Providers will be educated on medications through meetings and flashcards. Patients will receive verbal and written information about new medications. Staff will track medication discussions on patient care boards. Progress will be measured through education documentation and eventual HCAHPS scores.
Hcahps score trends in the past 4 years
This document shows trends in patient experience scores over 4 years from 2008-2012 at KP Riverside Medical Center based on the HCAHPS survey. The line graphs depict scores for various measures related to nurse and doctor communication, responsiveness of staff, pain management, medication communication, discharge processes, cleanliness and quietness. Scores fluctuate over time but generally remain between 60-90% for most measures.
Coccidioidomycosis in pregnancy
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Von Willebrand disease is the most common inherited bleeding disorder caused by mutations that decrease or impair von Willebrand factor, which promotes platelet adhesion and clotting. It ranges from mild to severe. Type I is the most common form with a quantitative deficiency, while type II has qualitative defects affecting function. Treatment involves desmopressin, which releases stored VWF, or VWF replacement for refractory or severe cases. Careful management is needed around procedures and delivery to maintain adequate VWF and factor VIII levels through replacement to prevent bleeding.
Hini2012 update
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Pph share drive
This document discusses the management of postpartum hemorrhage (PPH). It defines PPH and risk factors. It outlines the roles and responsibilities of the nursing team in responding to a PPH. It also details the differential diagnosis, initial resuscitation steps, and therapeutic escalation based on the severity of bleeding and patient's response to treatment. The goal is to recognize and treat PPH early through decisive clinical response and prevent complications like shock.
Late preterm delivery
Late preterm infants born between 34 0/7 and 36 6/7 weeks have higher rates of morbidity than full term infants. During the initial birth hospitalization, late preterm infants are more likely to experience conditions like temperature instability, hypoglycemia, respiratory distress, and jaundice. The risks are even higher for late preterm infants whose mothers have complications like hypertension, diabetes, bleeding, or infections. Readmission rates within the first year are also higher, around 15%, for late preterm infants compared to full term infants. Late preterm infants also have higher mortality rates within the first year of life and are at greater risk for long-term neurodevelopmental issues.
Insulin resistance and pcos
The document summarizes key findings from a review of literature on polycystic ovary syndrome (PCOS). It finds that the most consistent predictors of PCOS are hyperandrogenemia (high levels of "male" hormones) in 60-80% of cases, hirsutism (excess hair growth) in 60% of cases, and polycystic ovaries in 75% of cases. It also discusses debates around definitions of PCOS and relationships with insulin resistance.
Hyperemesis6 12
Hyperemesis Gravidarum is a condition characterized by persistent and severe nausea and vomiting during pregnancy. It can lead to weight loss of 5% or more of the woman's pre-pregnancy weight and the presence of ketones in the urine. Potential causes include multiple gestation, trophoblastic disease, or genetic conditions like trisomy 21. Treatment focuses on managing symptoms, avoiding triggers, dietary changes, medications like antihistamines, phenothiazines, and serotonin antagonists. Intravenous fluids and supplementation of vitamins and minerals may be needed to address nutritional deficiencies and prevent complications like Wernicke's encephalopathy. Enteral nutrition through nasojejunal feeding tubes is preferable to parent
Gbs 2010
The document summarizes changes to CDC guidelines for prevention of early-onset group B streptococcal (GBS) disease. Key changes include: expanded laboratory detection options for GBS; revised thresholds for reporting GBS in urine cultures; clarified definitions of adequate antibiotic prophylaxis and high risk for anaphylaxis; and adjustments to neonatal management algorithms to reduce unnecessary evaluations. Guidelines emphasize using cefazolin over clindamycin or vancomycin when possible for penicillin-allergic women.
Foley bulb
The document discusses the use of Foley bulbs for cervical ripening and labor induction. It finds that:
1) A Foley bulb induction is as effective as common prostaglandin methods like misoprostol for cervical ripening and inducing labor, with fewer risks of complications.
2) Inflating the Foley bulb to 60-80ml is more effective for cervical dilation and shorter delivery times than only inflating to 30ml.
3) Using a Foley bulb alone without additional prostaglandins or oxytocin is equally effective while avoiding increased need for pain management.
Fht interpretation & management
This document provides guidelines for the management and interpretation of intrapartum fetal heart rate tracings. It discusses important factors to consider when interpreting tracings such as gestational age, maternal conditions, and fetal conditions. It describes the physiology underlying different fetal heart rate patterns. It also presents the NICHD nomenclature for standardized description of tracings, including definitions for baseline rate, variability, accelerations, and decelerations. Tracings are categorized as Category I, II, or III based on patterns that reflect fetal acid-base status. Category I tracings are normal while Category III tracings indicate abnormal fetal status and need for prompt evaluation and treatment.
Asymptomatic short cervix and vaginanal, progesterone
1. Vaginal progesterone reduces preterm birth in women with an asymptomatic sonographic short cervix in the midtrimester. The meta-analysis found vaginal progesterone once daily from identification of a short cervix <25mm until 37 weeks decreases preterm birth <33 weeks by 45% and decreases neonatal morbidity and mortality.
2. Treatment with vaginal progesterone was associated with significant reductions in preterm birth before 28 weeks, 33 weeks, and 35 weeks as well as composite neonatal morbidity and mortality.
3. There were no significant differences in adverse maternal events or congenital anomalies between the vaginal progesterone and placebo groups.
Prevention of pertussis
The document discusses pertussis (whooping cough) prevention, treatment, and epidemiology. It provides guidelines for vaccinating pregnant women and new mothers with Tdap to prevent transmission to infants. It describes the symptoms and phases of pertussis, recommends antibiotic treatment and prophylaxis, and defines close contacts for evaluation and post-exposure prophylaxis. Pertussis cases are increasing significantly in California and infants are most at risk for severe disease.
Magnesium sulfate
The document discusses evidence that magnesium sulfate administered to mothers at risk of preterm birth reduces the risk of cerebral palsy in infants. Several large randomized controlled trials and meta-analyses involving over 15,000 women found magnesium sulfate decreased the risk of cerebral palsy without increasing mortality. The number needed to treat to prevent one case of cerebral palsy is estimated at 63 women. The document also describes a modified magnesium sulfate neuroprotection protocol used at Riverside Hospital for imminent preterm deliveries between 23 and 33 weeks.
Labor down
1) Studies on delayed pushing, also called "laboring down", have shown mixed results, with the main consistent benefit being a reduced need for operative vaginal deliveries in nulliparous women with epidurals.
2) Delaying pushing can prolong the second stage of labor by about an hour and may increase risks like chorioamnionitis with delays over 1 hour.
3) Delayed pushing may be considered for nulliparous women with epidurals who do not have an urge to push and the fetal head is not yet at station +2, as long as the fetal heart rate is reassuring and no other risk factors exist. The delay should not exceed 90 minutes.
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- 1. Postterm Induction Guidelines USE 1) THE BISHOP SCORE 2) CERVICAL DILATION 3) PARITY 4) EGA TO MAKE DECISONS WHEN TO SCHEDULE THER IS A RANGE FROM 41W 0d – 41 6d TO CONSIDER
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