DR C BRAVADO
for the interpretation of FHR tracings
Mnemonic Reference Cards
Fetal Surveillance Vacuum Extraction Forceps Shoulder Dystocia Postpartum Hemorrhage
DR Define Risk low or high C Contractions comment on
frequency, etc.
Intermittent Auscultation is appropriate for healthy women with uncomplicated pregnancy. In the active stages of labor, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least every 15 minutes in the first stage and every 5 minutes in the second stage. Continuous electronic monitoring is recommended if there is evidence on auscultation of a baseline less than 110 bpm or greater than 160 bpm or if there is evidence on auscultatiaon of any decelerations or if any intrapartum risk factors develop. Electronic Fetal Monitoring
HELPERR
for Shoulder Dystocia
Shoulder Dystocia
HELPERR Techniques
Combine McRoberts Maneuver with suprapubic pressure. This will resolve most cases.
Management of Massive PPH Organizing the Team
HEAD Check airway Check breathing Administer oxygen Lie flat Note time of relevant events
BRa Baseline Rate bradycardia,
normal 110 160 bpm or tachycardia
V Variability at least 10 15 bpm
(persistent, reduced variability is a particularly ominous sign)
These cards supplement the Advanced Life Support in Obstetrics (ALSO) Provider Course. For more information about the ALSO Program, contact the American Academy of Family Physicians at: 913-906-6000, ext 6554 1-800-274-2237
Copyright 2005 American Academy of Family Physicians
A Accelerations present or
absent (at least greater than or equal to a 15 beat change from the baseline lasting greater than or equal to 15 seconds) variable, or late
Early Decelerations Causes: Head compression Intervention: None Variable Decelerations Late Decelerations
Rubin II Rubin II + Woods Screw Reverse Woods Screw
Cord compression
Uteroplacental Insufficiency Stop oxytocin Give oxygen
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D Decelerations early, O Overall assessment
(reassuringor nonreassuring) and plan of management
Amnioinfusion Reposition mother
H Call for Help E Evaluate for Episiotomy L Legs: McRoberts Maneuver P External Pressure E Enter: rotational maneuvers R Remove the posterior arm R Roll the patient to her hands
and knees
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Enter maneuvers:
Roll the patient: Gaskin Maneuver
Removing the posterior arm: Follow the posterior arm to the elbow Flex arm at the elbow
Sweep forearm across the chest without pulling directly on the hand
ARMS Check pulse and BP Establish LARGE BORE IV X2 Check blood counts, clotting and crossmatch 4-6 units Start FLUID RESUSCITATION if required with 2 liters crystalloid Drugs: Oxytocin/Syntocinon Methylergonovine/Ergometrine Prostaglandin F2 (consider surgery if >2 doses required)
Copyright 2005 American Academy of Family Physicians
Printing of these cards was supported by an educational grant from CooperSurgical
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Amnioinfusion for variable decelerations: Infuse 250 to 500 cc warm saline through intrauterine pressure catheter and follow with 50 to 60 cc per hour drip.
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UTERUS START HERE CALL FOR HELP Massage uterus to stimulate contraction COORDINATE: Helper 1 at HEAD Helpers 2 and 3 at ARMS If bladder full or palpable empty with catheter If atony persists apply bimanual compression Review other causes 4 Ts (Tone, Trauma, Tissue, Thrombin) Move to surgery early if bleeding persists
Postpartum Hemorrhage (PPH)
Manual Maneuvers
Emergency treatment of uterine atony
Bimanual massage and compression Intramyometrial prostaglandin injection
Postpartum Hemorrhage (PPH)
The Four TS
Tone: Uterine Atony
70% of cases Perform uterine massage Perform bimanual compression Medications: Oxytocin/Syntocinon (10 units IV or IM. 10-40 units in 1000cc saline at 250cc/hr.) Methylergonovine (0.2mg IM or Ergometrine 0.5mg IM) use with caution in hypertensives Prostaglandin F2 0.25mg IM or intramyometrial; may repeat every 15 minutes up to 8 doses but consider surgery after 2 doses 20% of PPH cases Examine and repair
FORCEPS APPLICATION
A B C D E F G H I J
Forceps Essentials and Safety
Definitions:
Outlet: Fetal skull on pelvic floor; scalp visible between contractions Low: Fetal skull at, or below, +2 station Mid: Head engaged, but above +2 station (Midforceps application not taught in ALSO course)
VACUUM APPLICATION
A B C D E F G H I J
Vacuum Use and Safety Tips
Both bell-shaped and mushroom-shaped cups can be folded to facilitate insertion
A B C D E F G H I J
Address the patient, Ask for help, Anesthesia adequate? Bladder empty? Cervix must be completely dilated Determine position of the head. Think of shoulder dystocia. Review the HELPERR Mnemonic Equipment ready Forceps ready
A B C D E F
Address the patient, Ask for help, Anesthesia adequate? Bladder empty? Cervix must be completely dilated
Gentle traction following the pelvic curve, rising as head crowns
Traction outward
Traction outward and upward
Position Forceps for Safety
Posterior fontanel midway between shanks, 1cm above plane of shanks Fenestrations admit no more than one fingertip Sutures: lambdoidal above, and equidistant from, upper surface of each blade; sagittal suture is midline
Manual extraction
Copyright 2005 American Academy of Family Physicians
Manual removal of placenta
Exploration for fragments
Determine position of the head. Think of shoulder Dystocia. Review the HELPERR Mnemonic Equipment ready Extractor ready
Trauma: Cervix or Vagina
Place cup in proper relation to Fontanelles on Flexion point
Crowning, delivery and direction of traction is mostly upward
Tissue: Retained Placenta
Prevent with active 3rd stage management 10% of PPH cases Manual removal Explore for fragments
Gentle traction Handle elevated to follow thej shaped pelvic curve Evaluate for Incision for a possible episiotomy when the perineum distends Remove forceps when the Jaw is reachable
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Pajots Maneuver
Axis traction follows pelvic curve Initial traction downward, then sweeping in large, J-shaped arc Opposite hand exerts downward traction, causing two vectors of force: horizontal outward and vertical downward
Correction of uterine inversion
Recognition Replacement Restitution
Thrombin: Coagulopathy
1% of PPH cases Confirm with bedside clot test Replace blood products
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Proper cup placement on the flexion point is essential for safety and efficiency. Traction centered on the flexion point helps keep the neck flexed.
Halt traction between contractions Halt procedure if cup disengages 3 times Halt if no progress in 3 pulls Halt procedure after 20 minutes of use Be prepared to abandon the procedure and move to cesarean. Avoid prolonged use beyond the Halt guidelines. Avoid pivoting and rocking motions.
Vacuum extraction must be performed to promote flexion of the fetal head. Flexing the head reduces the diameter of the head that must pass through the pelvic outlet. If the infants head is acynclitic, the sagittal suture will be located lateral to the midline. Placement of the cup on the flexion point will require that the cup be positioned lateral to the midline so that is is located over the sagittal suture.
I J
Incision: Evaluate for episiotomy when head is crowning. (May not be necessary) Remove the vacuum cup when the Jaw is reachable
