Volume 31 Spring 2008

Obstetrical Injury

Alison McDonald, MD, Obstetrical Resident Dept. of Obstetrics & Gynecology, Faculty of Medicine & Dentistry, UWO Edited by Renato Natale, MD, FRCSC Chief, Dept. of Obstetrics, London Hospitals Obstetrical Co-Director, Perinatal Outreach Program of Southwestern Ontario

Introduction which generally resolves quickly via remyelination. In more serious injuries, there lthough neurologic injury sustained can be axonal damage, which resolves more during labour and delivery are slowly, and can cause permanent impairment relatively rare (0.008-0.92%)1, it is A of nerve function.2 Signs and symptoms of important to prevent these injuries, and to impending nerve damage may be masked in recognize them when they occur. Nerve labour by anaesthesia, or may be dismissed injuries sustained by the obstetric patient are by health care providers who consider them generally short-lived, but can be a cause of part of labour discomfort.2 Also, patients with significant short-term and, more rarely, long- epidural anaesthesia may be unaware of term morbidity. We most often consider discomfort and the need to change position lower extremity neuropathies in association regularly.1 with labour and delivery, but upper extremity injuries can be sustained as well. Neurologic injury can occur during labour, spontaneous vaginal delivery, operative vaginal delivery, or The lumbosacral trunk is formed by the L-4 cesarean section. This article will review the and L-5 nerve roots. It travels in close common lower and upper extremity contact with the ala of the adjacent to neuropathies associated with labour and the sacroiliac joint and is cushioned by the delivery, pertinent neuroanatomy, psoas muscle except at its terminal portion mechanisms of injury, and means of preventing injury during care of the obstetrical patient. The discussion will not include neurologic injury specifically related to obstetrical anaesthesia, although it must be What’s Inside . . . understood that Obstetrics and Anaesthesia work in concert in our patients’ care. Obstetrical Nerve Injury 1 Newborn Hearing Loss 4 Acute nerve injury may occur as a result of For Your Information: 7 transection, traction, compression, or vascular You Asked Us: 9 injury. Compression or traction on a nerve Upcoming Events: 10 can result in compromised perineural blood flow and resulting ischemia. This can cause focal demyelination and conduction block,

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near the pelvic brim where it is joined by the symptoms of the anteromedial . Motor S-1 nerve root to form the . It is compromise can cause significant functional here that the plexus becomes susceptible to impairment. Compression of the femoral compression by the fetal head as it descends nerve under the can occur into the pelvis.2 Radicular symptoms can also with prolonged pushing in extreme hip flexion be caused by bulging or ruptured 4. Since the femoral nerve does not traverse intervertebral discs, trauma, infection, the true pelvis, it is relatively unaffected by inflammation, or muscle spasm.1 factors such as cephalopelvic disproportion which is implicated in lumbosacral trunk and Lumbosacral plexus or trunk injury can cause sciatic lesions.3 foot drop, and other neurologic symptoms consistent with peripheral mononeuropathies (single or multiple) of the that branch The common peroneal nerve separates from from the plexus. Risk factors for lumbosacral the posterior tibial branch of the sciatic or trunk injuries include fetal above the popliteal fossa, perforates between macrosomia, malpresentations (occiput the insertions of the gastrocnemius and posterior or brow presentation), and certain plantaris muscles to pass over the lateral pelvic features like platypelloid pelvis, shallow head of fibula and descend down the lateral anterior sacral ala, and flattened sacral calf. Injury to the common peroneal nerve 3 promontory. can result in paresthesias on the dorsa of the feet and lateral calves, as well as foot drop. Lateral Femoral Cutaneous Nerve There have been several cases of peroneal The lateral femoral cutaneous nerve exits the nerve palsy related to prolonged squatting pelvis under the inguinal ligament and then during childbirth5, hyperflexion of the passes medial and inferior to the anterior during delivery6, and direct compression of superior iliac spine. It is a pure sensory nerve the nerve over the fibular head by the patient which supplies the anterolateral thigh. Injury holding her own legs with fingers placed over to the lateral femoral cutaneous nerve causes the anterior tibia and palms over the fibular burning, pain, or numbness of the head.7 Certain types of stirrups which may be anterolateral thigh, known as meralgia used for pushing during the second stage of paresthetica syndrome.4 The lateral femoral labour in patients with epidurals, may also cutaneous nerve is at risk of injury during cause compression of the common peroneal prolonged pushing with hip flexion as the nerve. This seems more likely to occur nerve is compressed under the inguinal though during gynecologic surgery when the ligament. A wide Pfannensteil incision at patient needs to be placed in stirrups for the cesarean section may lead to transection of lithotomy position. the lateral femoral cutaneous nerve 4. Compression injuries due to the use of self- Sciatic Nerve retaining retractors used in abdominal Reports in the gynecology literature suggest gynecologic procedures can also occur. the possibility of sciatic nerve stretch injury in Obstetricians may consider frequent position high lithotomy position with prolonged hip changes in labour, avoidance of prolonged hip hyperflexion and excessive external rotation. flexion, and shortening the pushing time by Certainly this mechanism of injury during allowing for passive descent of the fetus vaginal delivery is plausible as well. The before pushing begins as means of avoiding sciatic nerve may be compressed by the fetal 4 lateral femoral cutaneous nerve injury . head at the pelvic brim during descent into the pelvis.3 One case report suggests that Femoral Nerve positioning of the patient undergoing cesarean The femoral nerve emerges from the psoas section in the dorsal supine position with left muscle, travels between psoas and iliacus lateral tilt can apply enough pressure to the muscles, then passes under the inguinal left buttock to cause a sciatic neuropathy, ligament, lateral to the femoral vein and especially if the pressure is prolonged.8 artery.

Injury to the femoral nerve can result in quadriceps weakness and/or sensory

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Obturator Nerve plexopathy. Muscle Nerve 2002;26:340-7 The crosses the pelvic brim 3. Vargo MM, Robinson LR, Nicholas JJ, Rulin MC. and may be compressed by the descending 4 Postpartum Femoral Neuropathy: Relic of an fetal head or by forceps. The lithotomy Earlier Era? Arch Phys Med Rehabil position causes angulation of the obturator 1990;71:591-6 1 nerve as it leaves the obturator foramen. blocks have also been known 4. Borg-Stein J, Dugan SA, Gruber J. to cause hematomas and entrapment of the Musculoskeletal Aspects of Pregnancy. Am J obturator nerve.1 Phys Med Rehabil 2005;84:180-92

5. Babayev M, Bodack MP, Creatura C. Common Upper Extremity Nerves Peroneal Neuropathy Secondary to Squatting The upper extremities of obstetrical patients During Childbirth. Obstet Gynecol can also be affected by neurologic injury. For 1998;91(5):830-1 the patient undergoing cesarean section under general anaesthesia, the usual arm 6. Colachis SC, Pease WS, Johnson EW. A positioning risks apply. The preventable cause of foot drop during childbirth. can be injured by improper arm positioning Am J Obstet Gynecol 1994;171(1):270-1 including hyperabduction or positioning of the 7. Adornato BT, Carlini WG. “Pushing palsy”: A armboards below the level of the operating case of self-induced bilateral peroneal palsy table. Inadequate or improper padding over during natural childbirth. Neurology the bony prominences of the elbow may result 1992;42:936-7 in ulnar nerve injury. Radial nerve injury has been reported with use of the birthing bar 8. Roy S, Levine AB, Herbison GJ, Jacobs SR. when patients position their arms to rest on Intraoperative Positioning During Cesarean as a the bar directly across the spiral groove of the Cause of Sciatic Neuropathy. Obstet Gynecol humerus.9 2002;99:652-3

Nerve injury in the obstetrical patient must be 9. Roubal PJ, Chavinson AH, LaGrandeur RM. a consideration by obstetricians. It is Bilateral Radial Nerve Palsies from Use of the Standard Birthing Bar. Obstet Gynecol important to prevent these injuries by 1996;87(5):820-1 avoiding prolonged hyperflexion and abduction of the hips during birth. This may be accomplished by allowing for passive descent of the fetal head into the pelvis before pushing begins. However, this technique may not be successful in preventing nerve injuries related to compression of nerves in the pelvis by the fetal head.

Most of the nerve injuries sustained by our Did you know . . .

obstetrical patients will be short-lived and Neonatal Resuscitation Program (NRP) most often spontaneously resolve. Patients with motor impairments, or with longer-lived Instructor Courses may be requested through symptoms may be aided by referral to a the St. Joseph's Health Centre Respiratory physiatrist, neurologist, or physical therapist. Therapy Department, provided there is sufficient interest. References To arrange, please contact: 1. Wong CA, Scavone BM, Dugan S, Smith JC, Mike Keim, RRT Prather H, Ganchiff JN, McCarthy RJ. Incidence Coordinator, Respiratory Therapy of Postpartum Lumboscaral Spine and Lower (519) 646-6100 x 64535 Extremity Nerve Injuries. Obstet Gynecol 2003;101(2):279-88

2. Katirji B, Wilbourn AJ, Scarberry SL, Preston DC. Intrapartum maternal lumbosacral

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Newborn Hearing Loss

Jin Wang, MD, Neonatal Fellow, NICU St. Joseph's Health Care London Edited by Kevin Coughlin, BScH, MD, MHSc Bioethics, FRCPC, FAAP Neonatal-Perinatal Medicine, St. Joseph's Health Care Neonatal Co-Director, Perinatal Outreach Program of Southwestern Ontario

Introduction Pre-lingual: A hearing loss occurring before the development of speech and language.

he Infant Hearing Program is becoming Post-lingual or adventitious: A hearing loss familiar to both newborn health care occurring after the development of speech professional and parents in Ontario. It T and language. As opposed to prelingual, was started in 2002 to identify infants born before the development of speech. deaf, hard of hearing, or those at risk of early, progressive childhood hearing loss. Newborn Unilateral: A hearing loss involving only one hearing screening is important because it ear. achieves optimum success since the recommended age to begin the rehabilitation Bilateral: A hearing loss involving both ears. with a deaf or hard of hearing infant is no later than 6 months. The average age of Conductive: Loss of hearing sensitivity identification prior to universal newborn caused by problems involving either the outer screening was 2.5 years of age. The program or middle ear. Common causes of conductive improves the time to identification of losses are: perforated eardrum, infection in childhood hearing deficits by 4 months and the middle ear, build-up of ear wax, problems the average time to beginning rehabilitation with any of the three little bones in the middle by 6 months. All babies with a confirmed ear, atresia and stenosis. Atresia is the hearing loss and their families will begin complete closing off of the ear canal as in services that support communication before 6 congenitally absent or malformed outer ears. months of age. The earlier they are identified, Stenosis is the narrowing of canal. Many of the more time there is to take advantage of these problems can be treated by medication the services. With support, children who are or surgery and hearing can be restored. deaf or hard of hearing can grow up learning language and communicating similar to Sensori-neural: Loss of hearing sensitivity children who hear normally. caused by damage to the hair cells in the

inner ear or along nerve pathways to the About four in 1000 babies are born deaf, hard brain. The loss is permanent and cannot be of hearing or will develop early, progressive cured by medication or surgery. The causes childhood hearing loss. This number is are many: German measles or other viral increased to around three percent in babies infections in pregnancy, birth asphyxia, who require intensive care after. As a prolonged high fever, other illnesses such as healthcare professional who may work with measles, rubella, mumps and meningitis, toxic this special population, it is helpful to effects of some drugs and injury to the skull. understand more detail about hearing loss. There are also a number of inherited forms of

hearing loss. In about half of the cases, no Definitions of Hearing Loss cause for hearing loss can be identified. There are many types of hearing loss, classified according to different definitions. Mixed: A combination of sensori-neural and conductive hearing loss. Medical treatment Congenital: Occurring before or at birth. can improve the conductive difficulty, but the nerve damage cannot be repaired. Hearing is worse when a conductive hearing loss exists

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on top of a sensori-neural loss e.g. having an Newborn babies that suffered perinatal ear infection on top of a permanent hearing asphyxia with inadequate blood inner-ear loss. barrier function may have hearing loss and equilibration disorders secondary to damage High risk babies in NICU to the inner ear. The incidence of the hearing loss in this group of patients is about 10%. Evidence suggests that the prevalence of Damage to the inner ear includes the significant, permanent bilateral hearing degeneration and disappearance of outer hair impairment is in the range 1 to 3% for NICU cells and edematous changes in the stria graduates. All infants who meet the following vascularis. Degeneration of spiral ganglion risk criteria are considered at high risk for and vestibular ganglion have been observed in permanent hearing loss. These infants should some cases. be screened prior to discharge from the birth hospital admission, and then monitored Patients with CDH have been thought to be at through the community clinics for progressive high risk of sensory-neural hearing loss. It or late onset hearing impairment. may be due to the prolonged ECMO, high

frequency ventilation, periods of hypoxia, the NICU Risk Criteria use of aminoglycoside antibiotics or a. Birth weight less than 1200 grams pharmacologic paralysis with pancuronium. A b. Five-minute Apgar score less than or equal recent study reported that hearing loss to 3 requiring amplification was diagnosed in 44% c. Congenital Diaphragmatic Hernia(CDH) of CDH patients. And the same as other d. Persistent Pulmonary Hypertension of neonatal respiratory failure patients, Newborn (PPHN) progressive sensory-neural hearing loss is e. Hypoxia-Ischemic Encephalopathy (HIE), 53% in the respiratory failure patients. Sarnat II or III Cumulative doses and duration of use of f. Intra-ventricular Haemorrhage (IVH), diuretics; neuromuscular blockers; use of Grade III or IV Vancomycin; and overlap use of diuretics with g. Peri-ventricular Leukomalacia (PVL) neuromuscular blocker, aminoglycoside, and h. Extra-Corporeal Membrane Oxygenation Vancomycin individually linked to sensory- (ECMO) or inhaled Nitrous Oxide (iNO) or neural hearing loss. The underline diagnosis of High-Frequency Oscillatory (HFO) or Jet these respiratory failure patients could be (HFJ) ventilation Congenital Diaphragmatic Hernia (CDH), i. Hyperbilirubinemia≥400 uM/L OR those Persistent Pulmonary Hypertension of requiring exchange transfusion Newborn (PPHN), pneumonia/sepsis, j. Serologically proven and symptomatic Meconium aspiration syndrome (MAS), Cytomegalovirus (CMV) infection Respiratory distress syndrome (NRDS), k. Other proven perinatal TORCHES infection Pulmonary hypoplasia. Group studies of (toxoplasmosis, rubella, herpes, syphilis) children with PPHN report 0 to 50% of l. Serologically proven meningitis, survivors have hearing loss. A study in 1996 irrespective of the pathogen showed 8 of 10 children with hearing loss m. Other high risk indicator specified by associated with PPHN or ECMO had late onset baby’s treating physician hearing loss.

For very low birth weight infants (VLBW), the Neonatal hyperbilirubinemia is another incidence of hearing loss varies from 3 to 25% important cause of childhood deafness. Its depending on different testing methods. The incidence has been reduced with the use of higher incidence of hearing loss in this phototherapy and blood transfusions. A population likely results from an increase in retrospective review reported 6.5% of the above mentioned conditions, many of pediatric patients with hearing loss had a which are associated with prematurity, e.g. history of severe hyperbilirubinemia in the CLD/ BPD and low Apgar score. A recent study neonatal period. After severe neonatal showed that the incidence of conductive jaundice, the auditory neural pathways, hearing loss in VLBW infants is higher than cochlea, or both may be affected. Some sensory-neural hearing loss, 2.7% and 0.3% studies suggest dual screening of hearing by respectively. ABR and OAEs should be done in newborns

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following severe hyperbilirubinemia. Cytomegalovirus (CMV) infection is the most Although many causes of neonatal hearing common congenital infection resulting in loss have been confirmed by studies, some hearing loss. Sensory-neural hearing loss still remain controversial. The ongoing (SNHL) was detected in 25% of infants with identification of specific risk factors and asymptomatic CMV and 50% of infants with etiologies will be helpful to design appropriate symptomatic CMV infection during the first 6 treatment and management plans for these months of life. Some infants who passed the high risk patients. For now, our goal is to newborn hearing screening had a delayed- identify the high risk infant with hearing loss onset SNHL in follow-up examinations up to 4 before 6 months of age and provide timely years of age. Congenital HSV infection may and effective therapy. present as disseminated infection, encephalitis or localized infection. Neurologic impairment References including hearing loss is found in most 1. Regional Infant Hearing Program. Infant children with disseminated infection, 40% of hearing program screening training manual. the children with encephalitis, and 25% of the Rev. June 2005. children with the infection localized to the 2. The Canadian Hearing Society. Starting Point: skin, mouth, or eyes. Congenital rubella, A Resource for Parents of Deaf or Hard of nd syphilis, toxoplasmosis, and varicella Hearing Children. 2 Edition. 2004 syndrome also can cause infant hearing loss, 3. Roizen NJ. Nongenetic Causes of Hearing Loss. Mental Retardation and Development but the incidence of these diseases is not very Disabilities Research Reviews. 2003, 9: 120- high. Although congenital rubella is rare, 127. hearing loss may be present in 68 to 93% of 4. Yoshikawa S, et al. The effects of hypoxia, these children. The prevalence of congenital premature birth, infection, ototoxic drugs, syphilis has increased since the 90’s. In 3% circulatory system and congenital disease on of children with congenital syphilis, sensori- neonatal hearing loss. Auris Nasus Larynx. neural hearing loss develops in association 2004, 31: 361-368. with vertigo. The hearing loss begins in the 5. Cortes RA, et al. Survival of severe congenital high frequencies and progresses in severity diaphragmatic hernia has morbid consequences. Journal of Pediatric Surgery. and scope. Significant hearing loss has been 2005, 40: 36-46. reported in 10% to 15% of infants with 6. Robertson C.M.T, et al. Ototoxic drugs and congenital toxoplasmosis. Six cases of sensorineural hearing loss following severe children with hearing loss whose mother neonatal respiratory failure. Acta Paediatrica, suffered severe varicella and severe herpes 2006, 95: 214-223. zoster have been reported. 7. Roth DA, et al. Low prevalence of hearing impairment among very low birth weight The incidence of meningitis has decreased infants as detected by universal neonatal since the introduction of HIB and Prevnar hearing screening. Arch Dis Child Fetal vaccinations, but it is still a reason for early Neonatal Ed. 2006, 91: 257-262. 8. Iwasaki S, et al. Audiological outcome of infant hearing loss. A study of brainstem auditory with congenital cytomegalovirus infection in a evoked potentials (BAEP) in meningitis prospective study. Audiology & Neuro-otology. patients found hearing loss associated with 2007, 12(1): 31-36. Epub 2006 Oct 10. bacterial meningitis in 30.8% and aseptic meningitis in 13.9%. Children with post- meningitis hearing loss may be identified as potential candidates for cochlear implants. Studies report ototoxic medications including aminoglycosides and furosemide as contributing to the increasing incidence of hearing loss in preterm and ill infants. Hearing loss has also been described with prenatal exposure to alcohol, trimethadione, methyl mercury and in iodine deficiency. Cranial trauma, recurrent otitis media and hypothyroidism may be causes of hearing loss in newborns and children.

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For Your Information . . .

NEONATAL RESUSCITATION: SURVEY OF ROUTINE MATERNITY CARE

RESPIRATORY EQUIPMENT PRACTICES IN CANADIAN HOSPITALS

In follow-up to an article posted in the In May 2007 the Perinatal System of the Public previous edition of the Partner newsletter, entitled Health Agency of Canada in collaboration with the “Neonatal Resuscitation Guidelines 2006: Canadian Institute of Child Health initiated a Respiratory Equipment – What’s New to Know?”, survey of routine maternity care practices in we have recently been informed of some changes Canadian hospitals. This survey has been regarding equipment distribution. The Fisher & conducted three times in the past 30 years, most Paykel Healthcare company that provides the T- recently in 1993. The objectives of this survey are piece Resuscitator known as the “Neopuff Infant to: Resuscitator” and the “Cozy Cot Infant Warmer”, now offers direct sales and distribution for these • document current policies and practices in two products in Canada. For further information hospital services in Canada please contact: • monitor trends in maternity policies and practices when compared with data from Elisa Bisanti the previous surveys; and Clinical Product Specialist, Neonatal • provide comprehensive and current Fisher & Paykel Healthcare, Inc. information on maternity care in Canada, [email protected] complementing data collected from the www.fphcare.com Canadian Maternity Experiences Survey – a Office: (514) 624-1516 survey of women giving birth in Canada. Voicemail: 1-800-792-3912 Ext. 2355 (For more information regarding this survey Fax: (514) 626-8892 go to http://www.phac-aspc.gc.ca/rhs- ssg/survey_e.html) FAREWELL  Responses to the survey were received until Sept. The Perinatal Outreach Program extends a fond 2007. A phenomenal response rate of 91% has been achieved Canada wide. The data is now farewell to Dr. Jill Boulton, who has accepted a being analyzed and will be reported by province, position as the Regional Division Head of hospital size and hospitals teaching affiliation. The Neonatology at Calgary Health Region, Foothills CICH is to present its final report to the Public Health Agency of Canada at the end of March Medical Centre, as of September 2007. Dr. Boulton 2008. Hospitals will be sent the report in the is the former Senior Medical Director, Women & summer. We hope to also have a presentation on this report provided for our annual Children’s Clinical Business Unit for the London Perinatal Outreach Conference in Sept. We Hospitals, and Neonatal Co-Director of the look forward to using this report to learn what we do well in maternity care and where we need to Perinatal Outreach Program of Southwestern focus our efforts toward improvement. Ontario. Dr. Kevin Coughlin has been named to replace Dr. Boulton as Neonatal Co-Director of the Perinatal Outreach Program of Southwestern Ontario.

Page 8 For your information: have a role in mentoring novice care providers. Fetal Health Surveillance in Labour – • At the June CPPC meeting, the group Instructor Update agreed that they would like a re-design of the present program and develop it into a With the release of the SOGC fetal surveillance modular format. The advantage of the guidelines in Fall 2007, the educational curriculum modular format is that it will allow more for teaching fetal surveillance in Canada needs flexibility in course delivery and timing. revisions. In June of 2007 at the Canadian Instructors can opt to offer one or two Perinatal Partnership Coalition (CPPC) meeting, modules at a time or all the modules in a directors of perinatal programs across the country day-long format. agreed to support the work required to update the • There are seven proposed modules. Each educational programs. This involves updating the will be designed in a case-based format self-learning manual and revising the educational with standardized content and formatting. program. There have been a couple of conference • There has only been preliminary work calls of the CPPC group since that time to plan the done on the modules. The CPPC group is work and discuss funding and developing of a work investigating partnership with various plan. other perinatal organizations to enhance the applicability of the modules to all care We wanted to update you on the progress of each providers and to reduce the workload for of these components: any one group. Currently, there is no The Fetal Health Surveillance in Labour funding for this project, so it is being Self-Learning Manual: carried by the various perinatal programs • You will recall that this manual is used to across the country. We are looking for prepare participants with the fundamental potential funding sources. Consequently, knowledge about intermittent auscultation we don’t have a firm time-line for this (IA) and electronic fetal monitoring (EFM). aspect of the project, but the CPPC group • Work has begun on updating the chapters would like to have this complete in 2008. to reflect the new SOGC terminology and • We are also investigating the feasibility of guidelines. Nine authors from the developing a web-based application for disciplines of nursing, medicine and this modular FHSL program. midwifery have completed revisions of the chapters. We are now in the process of Formalization of a Fetal Health Surveillance editing these revisions, and getting them Committee ready to go out for external review. After • Members of the CPPC group are actively this is complete, the book will be readied working towards developing a more formal for the printer and production. The British fetal surveillance committee in Canada. Columbia Perinatal Health Program We envision having a “go-to” place for (BCPHP) is coordinating this project. regular content and resource updates, as • The anticipated production date for this is well as a secretariat for tracking now Fall of 2008. participants and instructors. • The BCPHP would appreciate knowing how many of the current edition of the books What to Do Until the New Resources are you may be ordering from them to get Ready you through to the Fall. They do not want • The CPPC is recommending that you to have a large stockpile and only want to continue to use the resources you have, print what is needed. You can email your but incorporate the new terminology into anticipated numbers to Lily Lee, perinatal the teaching. For example, when consultant at BCPHP ([email protected]) or discussing IA cases, NSTs or EFM tracings, to whomever coordinates FHSL discuss how it would currently be programming in your area if you purchase classified and how it will be classified with books from that group directly. the new terminology. You can print copies • The CPPC group is investigating the of the classification tables from the new feasibility of funding to further develop a SOGC guideline for participants and web-based application for this book. include it with the book, or bring to class.

The Fetal Health Surveillance in Labour – Fundamentals Course • This course (or a modification of it) is available in many locations in the country. It can easily be adapted for novices or those with more experience who may

Page 9 For your information: Fetal Heart Rate Auscultation Nancy Feinstein, RNC, MSN, PhD, Ann Sprague,

RNC, BN, MEd, PhD, and Marie-Josee Trepanier, NEW RESOURCES RN, BSCN, Med

This practice monograph describes how to perform The Best Start Resource Centre has recently fetal heart rate auscultation and discusses the released several new resources all of which can be benefits and limitations of intermittent auscultation downloaded from the Best Start Website: (IA). Fetal heart rate auscultation has been a (http://www.beststart.org/resources/rep_health/in method of fetal assessment for centuries but the dex.html). practice declined with the introduction of electronic

fetal monitoring. This monograph discusses the Prenatal Education in Ontario – Better knowledge to date about IA as a primary method Practices of fetal surveillance during labor.

Recommendations of various obstetric This manual is intended to provide childbirth organizations regarding the use of fetal heart rate educators with a review of current research and an auscultation for low-risk pregnancies are covered. outline of various types of group prenatal education. It provides a literature review, an One set of 2.4 contact hours included in purchase outline of topics and key messages, effective price. Available in the AWHONN Store: practices and resources. It is available in both www.awhonn.org print and PDF format.

Update Report on Teen Pregnancy Prevention You asked us: . . .

This manual was developed in collaboration with the Sex Information and Education Council of Canada (SIECCAN). It presents the latest research Q: In the event that a neonatal or pediatric on effective programming strategies and is meant transfer is required in southwestern Ontario who to encourage a broad view of the issues that relate should be called? to teen pregnancy. It includes a summary of international, national and Ontario statistics, A: To initiate all pediatric/neonatal transfers in context and effective strategies for the prevention the region the following phone algorithm is of teen pregnancy and examples of effective or recommended. For transfer of a neonate (< 28 promising initiatives. It is available in both print days of age), selecting Menu Option 2 will contact and PDF format. the Neonatologist on call at St. Joseph's Health Care London, who in turn can recommend neonatal Work and Pregnancy Do Mix … management and initiate dispatch of the transport team. If London is closed to the region, the This booklet is intended for working women who transport team will still be dispatched and the are or may become pregnant. It provides neonatologist will assist with locating an information on workplace risks, ways to reduce appropriate bed elsewhere in the province. risks, and courses of additional information.. It is Dr. Henry Roukema, Director of Nurseries, London Hospitals available in both print and PDF format.

Reflecting on the Trend: Pregnancy After Age 35

This manual provides a guide to Advanced Maternal Age for Ontario health care providers, including a summary of statistical trends, influencing factors, health opportunities health risks and recommendations for care. It is available in both print and PDF format.

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Acute Care of at-Risk Newborns Upcoming events: “ACoRN” Workshop

April 16-18, 2008 Location: Lamplighter Inn, London MARK YOUR CALENDARS . . . Contact: Perinatal Outreach Office MATERNAL NEWBORN NURSING COURSE (519) 646-6100, ext. 65859 London: Call for a brochure or download one from our Spring 2008 webpage: Mondays: Mar. 31 – May 12, 2008 www.sjhc.london.on.ca/sjh/profess/periout/periout.htm

Fall 2009 19TH ANNUAL AWHONN CANADA CONFERENCE Mondays: Sept. 15 – Nov. 3, 2008 “POWER, PASSION, POLITICS” October 23-25, 2008 St. Joseph's Health Care, London Location: Westin Hotel Offered in collaboration with Fanshawe College. Ottawa, ON Continuing Education: NRSG-6027 Contact: AWHONN website for more details Videoconferencing available http://www.awhonn.org/awhonn/section.by.state.do?state=Canada

Contact: REGIONAL PERINATAL NURSE MANAGER’S MEETING Gwen Peterek Friday, May 2, 2008 Perinatal Outreach Program Location: Roney B auditorium (D1-226) Phone: (519) 646-6100 ext 65901 St. Joseph’s Health Care London Fax: (519) 646-6172 Contact: Perinatal Outreach Office [email protected] (519) 646-6100, ext. 65901 check out our webpage to download a form: www.sjhc.london.on.ca/sjh/profess/periout/periout.htm FETAL HEALTH SURVEILLANCE WORKSHOP May 22, 2008 ND 22 ANNUAL PERINATAL OUTREACH CONFERENCE Location: Bluewater Health, Sarnia “INTENSIVE CARING: AN APPROACH TO HIGH RISK Contact: Kelly Ross PREGNANCIES AND BABIES” (519) 464-4400 x 8259 [email protected] Date: September 2008 Location: Best Western Lamplighter Inn, London Jun 3, 2008 Contact: Perinatal Outreach Office Location: Strathroy Middlesex General (519) 646-6100, ext. 65859 Contact: Mary Robertson watch our webpage for details: (519) 245-1550 www.sjhc.london.on.ca/sjh/profess/periout/periout.htm [email protected]

LUNCH & LEARN VIDEOCONFERENCE SERIES 85th Canadian Pediatric Society Annual “BABY TALK – LESSONS FROM THE NICU” Conference Jun 24-28, 2008 FEB. 19, 2008 Cultural Diversity in Perinatal Care Fairmont Empress Hotel, Victoria, BC APR. 15, 2008 Neonatal Stabilization http://www.cps.ca/english/AnnualConference MAY 20, 2008 Ethical Issues in Perinatology /2008/Highlights.asp JUN. 17, 2008 Neonatal Nutrition in the Special Society of Obstetrician & Gynecologist of Canada Care Nursery 64 Annual Clinical Meeting - June 25-29, 2008 Telus Convention Centre, Calgary, AB Watch our webpage for further details: http://www.sogc.org/cme/events-acm_e.asp www.sjhc.london.on.ca/sjh/profess/periout/periout.htm Or visit the Ontario Telehealth Network webpage: HTTP://TEST1.VIDEOCARE.CA/OTN/EVENTS_CALENDAR.PHP?MODE=VI EW

ALARM COURSES - 2008 This newsletter is a publication of the Perinatal Outreach Program. April 20-21, 2008 & December 7-8, 2008 Letters, queries and comments may be addressed to: Toronto ON Contact: SOGC Gwen Peterek, RN, BscN, PNC(C) Tel: 1-800-561-2416 Regional Perinatal Outreach Program of Southwestern Ontario www.sogc.org St. Josephs Health Care, 268 Grosvenor St, London, ON, N6A 4V2 Tel: (519) 646-6100, ext. 65901

To have your name included on our mailing list, please contact the above, or E-mail: [email protected] www.sjhc.london.on.ca/sjh/profess/periout/periout.htm