Clinical Guidelines for Obstetrical Services 1

Home , Cervical dilation, Vacuum extraction

Clinical Guidelines for

ATObstetrical CRICO-INSURED INSTITUTIONS Services

Created: 1988 Revised: 1990, 1992, 1995, 1998, 2003, 2006, 2009, 2010, 2014 Current: 2017 IN MEMORIAM

CRICO and the obstetrical care leaders across the Harvard medical community dedicate the 2017 edition of CRICO’s Clinical

Guidelines for Obstetrical Services at CRICO-insured institutions to the memory of Fredric D. Frigoletto, Jr., MD, who passed away in 2016. Across more than 25 years working with CRICO and his clinical and teaching peers, Dr. Frigoletto was a driving force behind the continuous effort to improve the safety of obstetrical care for mothers and newborns as codified in these Guidelines.

While his presence in the process of reviewing and refining the

2017 edition was missed, Dr. Frigoletto’s imprint on obstetrical patient safety will always be visible. Contents

page page Introduction ...... 1 20 Management of Breech Presentations ...... 21

THE GUIDELINES 21 Management of Twins ...... 23 22 Prolonged Pregnancy...... 24 1 Documentation for Patient Safety ...... 2 23 Macrosomia ...... 25 2 Informed Consent ...... 3 24 Management of Shoulder Dystocia ...... 26 3 Clinical Coverage and Transfer of Patient Care ...... 4 25 Patients with Previous Cesarean Delivery ...... 26 4 Consultation...... 5 26 Cesarean Delivery on Maternal Request ...... 27 5 Resolution of Clinical Discord ...... 6 27 Obstetrical Surgery Safety Communication...... 28 6 Preconception Care ...... 6 28 Anesthesia in Obstetrics ...... 29 7 Pregnancy Dating/Estimated Date of Delivery...... 7 29 Placental Pathology Evaluation ...... 31 8 Antenatal Care...... 8 30 Maternal Early Warning System (MEWS) ...... 32 9 Second Trimester Pregnancy Termination ...... 10 31 Postpartum Care...... 33 10 Antenatal Tests of Fetal Well-being ...... 11 32 Therapeutic Hypothermia for Neonates ...... 34 11 Use of Antenatal Corticosteroids for Fetal Maturation ...... 11 33 Newborn Male Circumcision ...... 35 12 Prevention of Neonatal Sepsis 34 Reporting of Adverse Outcomes ...... 36 Due to Group B Streptococci ...... 12 35 Institutional Responsibilities ...... 37 13 Availability of Clinician and Case Load APPENDICES in Labor and Delivery...... 13 14 Scheduled and Elective Delivery...... 13 A Sample Documentation Form for Shoulder Dystocia. . . . 39 15 Assessment and Monitoring in Labor and Delivery . . . . 14 B Sample Documentation Form for Operative Vaginal Delivery...... 40 16 Induction of Labor...... 17 C Maternal Early Warning System Algorithm...... 42 17 Augmentation of Labor ...... 18 D About Your Care During Labor and Birth ...... 43 18 Operative Vaginal Delivery...... 19 E Breech Version or External Cephalic Version ...... 48 19 Prevention of Retained Sponges and Needles Following Vaginal Delivery...... 20 F Delivery Following a Previous Cesarean Delivery...... 50 G The Delivery of Twins...... 53 H Primary Cesarean Delivery on Maternal Request. . . . . 55

Index ...... 57 The entire Clinical Guidelines CRICO Obstetrical Care Guidelines Committee for Obstetrical Services, Alisa Goldberg, MD Lisa Heard, RN along with related information Brigham and Women’s Hospital CRICO and links, is available at Allyson Preston, MD Lisa Leffert, MD www.rmf.harvard.edu/guidesob North Shore Medical Center Massachusetts General Hospital Bill Camann, MD Louise Wilkins-Haug, MD For more information contact the Brigham and Women’s Hospital Brigham and Women’s Hospital CRICO Patient Safety Department Blair Wylie, MD Margi Coggins, CNM at 617.450.5100. Massachusetts General Hospital Mount Auburn Hospital Carol Keohane, RN Maria Smyth, RN CRICO Mount Auburn Hospital Carrie Siefken, RN Marie Henderson, CNM North Shore Medical Center Massachusetts General Hospital Colleen Mannering, CNM Mary Collari, CNM Atrius Health North Shore Medical Center Daniel Katz, MD Mary Gosney, CNM Newton-Wellesley Hospital Atrius Health DeWayne Pursley, MD Michael Reich, MD Beth Israel Deaconess Medical Center North Shore Medical Center Edwin Huang, MD Michelle Helgeson, CNM Mount Auburn Hospital Newton-Wellesley Hospital Elizabeth Buechler, MD Nicole Smith, MD Atrius Health Brigham and Women’s Hospital Fredric Frigoletto, MD Philip Hess, MD Massachusetts General Hospital Beth Israel Deaconess Medical Center Jock Hoffman Ruth Tuomala, MD CRICO Brigham and Women’s Hospital Jonathan Hecht, MD Sarah Little, MD Beth Israel Deaconess Medical Center Brigham and Women’s Hospital Julian Robinson, MD Steve Pratt, MD Brigham and Women’s Hospital Beth Israel Deaconess Medical Center Kathleen Harney, MD Susan Caffrey, CNM Cambridge Health Alliance Massachusetts General Hospital Laura Riley, MD Tarcia Edmunds-Jehu, CNM Massachusetts General Hospital Brigham and Women’s Hospital Leslie MacDonald, MD Thomas Beatty, MD Mount Auburn Hospital Newton-Wellesley Hospital Lisa Cavallaro, RN Toni Golen, MD North Shore Medical Center Beth Israel Deaconess Medical Center Lisa Dunn Albanese, MD William Barth, MD Brigham and Women’s Hospital Massachusetts General Hospital CRICO CLINICAL GUIDELINES FOR OBSTETRICAL SERVICES 1

Introduction

TheClinical Guidelines for Obstetrical Services at CRICO-insured Institutions are intended to provide guidance for clinicians and to support optimal maternal and fetal outcomes for patients receiving care by CRICO-insured clinicians 1. The recommendations for practice included in this document were arrived at through careful consideration of the available evidence . TheseGuidelines offer a framework for provision of obstetrical care, rather than an inflexible set of mandates . Clinicians involved in obstetrical care must use their professional knowledge and judgment when applying any recommendations to the management of individual patients . These Guidelines are subject to revision at regular intervals as changes in clinical practice evolve .

PRINCIPLES Optimal care requires a collaborative process among obstetrical • Practice Guidelines for Obstetrical Anesthesia (American clinicians who respect the right of the patient to make informed Society of Anesthesiologists) . decisions for herself and her fetus . The 2017 revisions to theClinical Guidelines for Obstetrical RESOURCES Services were guided by a multi-disciplinary group of clinicians, including obstetricians, nurse leaders, nurse midwives, and TheGuidelines are a codification of: anesthesiologists from several CRICO-insured institutions . The • existing best practices, clinical leaders of the obstetrical departments of the CRICO- • recommendations of the American College of Obstetricians insured institutions have approved the current version of these and Gynecologists (ACOG) and the American College of guidelines . Questions regarding this document should be Nurse-Midwives, directed to the Patient Safety Department at CRICO, Boston, Massachusetts . • Guidelines for Perinatal Care (American Academy of Pediatrics and ACOG), and

1. As of July 2017, the following institutions insured through CRICO provide obstetrical service: Atrius Health, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Hospital Plymouth, Brigham and Women’s Hospital, Cambridge Health Alliance, Cooley Dickinson Health Care, Martha’s Vineyard Hospital, Massachusetts General Hospital, Mount Auburn Hospital, Nantucket Cottage Hospital, Newton-Wellesley Hospital, and North Shore Medical Center.

GUIDELINE 1

Documentation for Patient Safety

GENERAL PRINCIPLES OF DOCUMENTATION available in the hospital after 24 weeks of pregnancy 3. If any Themedical record is a sequential record of patient care, a significant changes occur after 24 weeks, the obstetrical provider storage place for diagnostic test results, a communication tool must send an update to Labor and Delivery . Periodic updates for clinicians, and a legal document . after 36 weeks are advised . 1 . Include date and time of each encounter (telephone, For vaginal delivery, completion of the institution’s standard electronic, and face-to-face) . delivery summary is required . A short written note shall be 2 . Include the diagnostic rationale in the assessment portion of entered in the medical record . In the case of all operative the note . deliveries (i e. ., non-spontaneous vaginal and cesarean), and those complicated by shoulder dystocia, a dictated operative 3 . Clearly state the plan of care . note or its electronic equivalent should be completed . This note 4 . Consent discussions are appropriate to include in the body of shall include the indications and rationale for any procedure or a note as well as in a signed form . maneuvers selected . 5 . Proofread and correct dictated notes prior to signing . A printed or electronic copy of any EFM strips and recorded 6 . Only medical information is appropriate in the medical ultrasound images is to be maintained as part of the patient’s record; references to legal action, clinical discord, or incident permanent medical record . If an electronic health record is used, reports are not intended for the medical record . then use only electronic notes (i .e ., not handwritten on the 7 . Do not obliterate errors, remove pages, or otherwise alter a paper strips) . medical record . PRESERVATION OF EFM RECORDS 8 . Patient requests for changes in the medical record should be managed by institutionally approved procedures . Department of Public Health-licensed facilities are required by Massachusetts law4 to keep a record of EFM tracings for at least ANTEPARTUM, INTRAPARTUM, AND POSTPARTUM five years CRICO( recommends 20 years) . The tracings should MEDICAL RECORDS include the patient’s name and hospital number; date and time Each encounter should be documented in the medical record at the beginning of the tracing; and—if delivery concludes the or be retrievable electronically . The note should include, as monitoring—date and time of delivery . EFM tracings need appropriate: history, physical, vital signs, test results, assessment, not be stored within the individual patient record, but must be plan, and instructions . Documentation of electronic fetal readily retrievable by the hospital or institution . If electronic monitoring (EFM) pattern terminology, pattern recognition, copies of EFM strips are kept, then preservation and storage of and interpretation should be consistent with current paper strips is not necessary . recommendations supported by the National Institute of Child Health and Human Development and American College of INSTITUTIONAL RESPONSIBILITY Obstetricians and Gynecologists 1-2. The institution has a responsibility (shared with the medical staff ) mandated by the Joint Commission to provide adequate An antenatal record shall be completed on every obstetrical resources for record processing, to support quality improvement patient, and should be retrievable electronically or via paper activities, and to adhere to record keeping standards including copy maintained in the medical record . Department of Public compliance with federal regulations (e .g ., HIPAA) and its Health-licensed facilities are required by the Commonwealth mandate for a designated institutional compliance officer . of Massachusetts to have a copy of this antenatal record made

GUIDELINE 2

Informed Consent

1. Macones GA, et al. The 2008 National Institute of Child Health and Informed consent is a process employing oral and written Human Development Workshop report on electronic fetal monitoring communication to convey to the patient the significant and update on definitions, interpretation, and research guidelines.Obstetrics and Gynecology. 2008;112:661–66. material risks, benefits, and alternatives of medical treatments, including the risk of not pursuing any treatment . The 2. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. consent form should be considered the documentation of the July 2009, Reaffirmed 2017. American College of Obstetricians and discussion(s), and both the discussion with the patient and the Gynecologists. completed consent forms are necessary to ensure and verify that 3. Commonwealth of Massachusetts: Hospital Licensure Regulations. the patient is informed about her and her baby’s care . Consent 105 CMR §130 Hospital Licensure, Mass.Gov Available at: http://www. forms should be presented to patients in a language they mass. gov/eohhs/docs/dph/regs/105cmr130.pdf - section 130.627. can understand . If this is not feasible, a competent translator 4. Commonwealth of Massachusetts: Hospital Licensure Regulations. should be available to translate the consent form orally into the 105 CMR §130 Hospital Licensure, Mass.Gov Available at: http://www. mass. gov/eohhs/docs/dph/regs/105cmr130.pdf - section 130.370. patient’s primary language . Prenatally, the clinician will initiate the informed consent process for labor and delivery care, guided by the general written obstetrical consent form . Consistent use of an institutionally approved informed consent form is expected . Discussions involving specific obstetrical interventions, such as external version or vaginal delivery for second twin (non-vertex), use of tocolytic or uterotonic drugs, or forceps delivery, should be initiated with the patient as early as is feasible . Informed consent during the course of antenatal care and labor management (when appropriate) should be documented in the medical record . The person who is actually performing a procedure is responsible for reviewing and confirming theinformed consent with the patient and for documenting that conversation in the medical record . Specific and separate written consent is required for: • trial of labor after cesarean delivery1 • cesarean delivery on maternal request1 • delivery of twins1 • breech vaginal delivery • external version1 • circumcision

GUIDELINE 3

Clinician Coverage and Guideline 2 continued Transfer of Patient Care1

If an obstetrical patient refuses to sign the consent form, then For clinicians working as a group, coverage should be formally more dialogue between the clinician and the patient about the agreed to with adequate communication within the group to patient’s preferences vis-a-vis medical judgment during labor ensure good follow up . Each patient should be informed early in and delivery is indicated . Issues of trust should be addressed . her pregnancy about group coverage arrangements . The obstetrical team and hospital administrators should For non-group practice, coverage arrangements for a clinician develop a coordinated plan to address those issues and manage who is unavailable must be carefully made with a qualified the patient’s labor and delivery . This discussion should be clinician who has adequate time and has agreed to provide documented in the patient’s medical record . Documentation coverage . A formal transfer of care should occur at the time the should include the dialogue about the pregnancy and plans for coverage is initiated . labor and delivery that have occurred and note the proposed obstetrical procedures, activities, risks, and benefits, including When a patient is in the hospital and the clinician arranges for unexpected risks and complications . The patient’s oral consent coverage, the transfer of care should ensure the following: for continuing obstetrical care and refusal to sign a consent • the patient is notified and knows who will be covering; form should also be documented . The institution’s printed • other members of the health care team are notified of the obstetrical consent form can serve as a reference for the detailed coverage arrangements; note . • the clinician assuming the coverage is qualified and has the If written consent cannot be obtained in an emergency necessary clinical privileges; situation, then an attempt should be made to obtain oral • the covering clinician is notified in a timely manner and consent . This will be sufficient, and can be documented in the agrees to cover; and record after the emergency has resolved . • both clinicians’ office staffs are informed of coverage arrangements, and know how and where to reach the clinician who has agreed to assume coverage . 1. Sample consent forms can be found in the Appendix to these Guidelines. TRANSFER OF PATIENT CARE The process for the transfer of patient information and knowledge from one clinician to another clinician should include: • interactive communications, including the opportunity to ask questions and to clarify and confirm the information being transmitted; • limited interruptions; • a process for verification; and • an opportunity to review relevant historical data .

1. Communication strategies for patient handoffs. ACOG Committee Opinion No. 517. February 2012, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

GUIDELINE 4

Consultation

Consultation occurs between two professionals who are both When a consultation occurs, clear documentation should be licensed and credentialed to provide patient care . One (the made in the patient’s medical record defining the nature of the “requesting clinician”) requests an opinion from the other consultation and indicating whether it is a) a one-time consult, (the “consultant”) . The requesting clinician considers the b) care that will now continue jointly, or c) a transfer of care . recommendations of the consultant and decides whether or not An informal consultation (curbside consult) occurs when the to follow them based on his or her clinical judgment . discussion between clinicians lacks details specific to one All clinicians are encouraged to seek additional medical advice patient . An informal consultant is not named in the record . whenever they have concern about a diagnosis or course of When these consultations occur, both parties should be clear treatment . Consultation is essential when the experience, that the discussion is not intended to constitute individual expertise, or comfort level of the attending clinician is exceeded . patient care, and does not create a clinician/patient relationship . Once the limits of a clinician’s privileges are exceeded, care must Absent a formal consultation, avoid entering limited statements be transferred . such as “physician aware .” Such wording may imply that the Consultations may be formal or informal . indicated physician has knowledge of the case when he or she does not . A formal consultation occurs when an opinion about a specific circumstance is requested . The requesting clinician is responsible for documenting the request . • If the consultation is in person, the consultant shall personally evaluate the patient including a physical examination, where appropriate, and a written note will be placed in the hospital record . • If a telephone consultation is obtained, both parties should be clear that this is a formal consultation and that a summary of the discussion and the consultant’s name will be entered into the medical record . • If the final management plan differs from the consultant’s recommendation, then the requesting clinician should document his or her rationale for choosing a different course of action .

GUIDELINE 5 GUIDELINE 6

Resolution of Clinical Discord Preconception Care

Each institution shall have a formal process to resolve differ- When feasible, the clinician should discuss pregnancy and ences of opinion or judgment between professional staff about preconception issues with a woman who is anticipating medical management, conduct of labor, or interpretation of tests pregnancy . The patient should be encouraged to consider a of fetal status . The process should consider these points: preconception visit . Such a visit may include: 1 . Priority should be given to optimizing quality patient care . • lifestyle issues including tobacco, alcohol, drugs of abuse, 2 . In cases of discord, the involved parties shall first discuss diet, exercise, caffeine, weight, oral care; the discord and attempt to resolve it . The “two challenge • assessment for domestic violence and psychosocial issues; rule,”1 and other methods of conflict resolution may be • safety of prescribed and non-prescribed medications, considered to facilitate structured communication and including herbal remedies and alternative choices; avert medical errors . • dietary supplements, including recommendation for folic 3 . If the involved parties cannot resolve the discord, they should acid supplementation; seek assistance, initiating the chain of command2 through • review of major medical problems or risk factors, such as medical, resident/fellow supervisory physician, midwifery, hypertension, diabetes, advanced maternal age, obesity, and/or nursing hierarchy, as indicated 3-4. A list of medical eating disorders; staff, supervisory physician, midwifery, and nursing hierarchy should be available in the clinical areas . • review of risks of infectious exposure related to travel; 4 . All discussions pertaining to differences in clinical opinion • review of previous pregnancy problems such as date of last should occur among professional staff only, and out of birth, gestational age, prior cesarean delivery, gestational earshot of the patient and family . diabetes, hypertension in pregnancy;

5 . Differences in clinical observations and opinions should be • review of family history with specific attention to conditions documented in an objective, non-editorial fashion in the that may place the woman at risk (e g. ., parental medical record . thromboembolic disease, diabetes); 6 . Unexpected medical incidents should be reported to the • ethnicity; and institutional risk manager . • risk of genetic diseases with offer for genetic testing if 7 . The occurrence of the discord should be reported to the appropriate (e .g ., Tay Sachs, Canavan’s, cystic fibrosis, Chief of Obstetrics, the Director of Nurse Midwifery, and/or hemoglobin electrophoresis, PKU, history of birth defects or the Obstetrical Nursing Director, as indicated . intellectual disability) .

1. Assertively voicing your concern(s) at least twice to ensure your concerns Review environmental exposures such as: have been heard by your colleague. • lead, pesticides, workplace hazards; 2. A series of steps ascending the administrative and clinical lines of authority established to ensure effective conflict resolution in patient care • infectious exposures, including toxoplasmosis, Zika, latent situations. TB, malaria, HIV, STIs (with offer ofHIV , STI testing); and 3. Patient safety in obstetrics and gynecology. ACOG Committee Opinion • evaluation of vaccine status and offer vaccines if indicated No. 447. December 2009, Reaffirmed 2015. American College of (e g. ., rubella, Tdap, hepatitis B, varicella, HPV, influenza) . Obstetricians and Gynecologists.

4. American College of Nurse-Midwives. Code of Ethics. 2005. Reaffirmed 2008. Availableat: http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000048/Code-of- Ethics.pdf

GUIDELINE 7

Pregnancy Dating / Estimated Date of Delivery (EDD)

Accurate assessment of gestational age is of paramount Gestational age based on third trimester ultrasound should importance for management of pregnancy, interpretation of test be interpreted with caution, due to the decreased accuracy of results, and timing of interventions . Pregnancy dating should ultrasound for dating late in pregnancy . be determined by a combination of the historical, clinical, and When necessary for clinical decision making, fetal pulmonary laboratory criteria listed below: maturity may be presumed if early reliable dating confirms that • known normal last menstrual period (LMP), corrected for the patient is no more than seven days before her estimated date cycle length; of delivery (EDD) .

• date(s) of HCG testing (urine or blood); As soon as data from the LMP or first accurate ultrasound (or • uterine size on initial physical exam; both) are obtained, the EDD should be determined, documented • date of detection of FHT with Doppler; in the record, and discussed with the patient by the primary obstetrical provider . • first trimesterultrasound measurement of crown-rump length; and • second trimester ultrasound measurement of multiple fetal biometrics . 1. Ultrasound in pregnancy. ACOG Practice Bulletin No. 175. December 2016. American College of Obstetricians and Gynecologists. If the pregnancy resulted from assisted reproductive technologic 2. Methods for estimating the due date. ACOG Committee Opinion No. (ART) intervention, then the ART-derived gestational age 700. May 2017. American College of Obstetricians and Gynecologists. should be used to assign the EDD . Ultrasound dating should take precedence over clinical dating if:

• the LMP is uncertain or abnormal, • there is a more than 5 day discrepancy between historical / clinical parameters and ultrasound measurements at ≤ 8⁶⁄₇ weeks, or • there is a more than 7 day discrepancy between historical / clinical parameters and ultrasound measurements at 9⁰⁄₇ – 15⁶⁄₇ weeks, or • there is a more than 10 day discrepancy between historical / clinical parameters and ultrasound measurements at 16⁰⁄₇ – 21⁶⁄₇ weeks, or • there is a more than 14 day discrepancy between historical / clinical parameters and ultrasound measurements at 22⁰⁄₇ – 27⁶⁄₇ weeks . 1-2

GUIDELINE 8

Antenatal Care1

INITIAL VISIT • HIV and recommendations for testing; The initial visit to the obstetrical provider should be scheduled • suggested readings; in the first trimester (whenever possible) . The visit should • recommended vaccinations: influenza, Tdap, include a detailed evaluation of the patient and her history to hepatitis A & B, and Pneumovax 23, if at risk; and assess and plan for the pregnancy . At a minimum, the initial assessment should encompass: • substance abuse or abuse screening, including tobacco, alcohol, and drugs, with interventions offered, as 1 . A detailed history, including: appropriate . • past and current illnesses; 4 . Genetic counseling should include: • surgeries; • offering testing for cystic fibrosis with specific information • allergies; about carrier frequency and sensitivity of the test; • family history (including genetic history and ethnicity); • offering testing as appropriate for ethnicity including: • prior pregnancies; • Tay Sachs testing, such as for patients of Ashkenazi • a menstrual history, with specific attention for accurate Jewish, French-Canadian, or Cajun descent; dating of the pregnancy; • Canavan’s disease and familial dysautonomia screening, • medications and supplements currently being taken; such as for patients of Ashkenazi Jewish descent; • psychosocial history (mental health, depression; alcohol, • hemoglobin electrophoresis for those at risk for tobacco, and drug use; type of work; relationship status; hemoglobin disorders, such as for patients of Asian, domestic violence); and African, Caribbean, or Mediterranean descent; • environmental and occupational exposure history . • others as appropriate to history, family history, or ethnicity; and 2 . Screening for current psychosocial concerns: • offering counseling on methods available to screen or test • depression, for fetal aneuploidy . • living situation, and 5 . A detailed physical examination that includes blood pressure, • safety/domestic violence . height, weight, and breast, heart, lung, abdominal, and pelvic 3 . Counseling about: examinations . • normal course of pregnancy; 6 . Establish the estimated date of delivery (see Guideline 7). • frequency of visits, office hours; 7 . Recommended laboratory testing, including: • when and how to contact the clinician; • complete blood count (CBC) with indices, • balanced nutrition, recommended weight gain based on • blood group and Rh type determination, BMI, vitamin supplementation, and foods and beverages to avoid; • antibody screen, • exercise; • rubella immunity status (unless previously documented or adequate vaccination documented), • sexual activity; • hepatitis B surface antigen, • environmental hazards; • hepatitis C antibody (if indicated), • health maintenance (e .g ., dental health, appropriate use of seat belts);

• HIV testing (unless declined by patient), • Group B Streptococcus screening should be done, if • syphilis screen, appropriate, at 35–38 weeks (see Guideline 12); and • varicella immunity status (if not known), • HIV testing should be re-offered if declined at first visit or patient at high risk . • urine culture, • baseline urine screen, Counseling in the second and third trimester may include: • genetic screening (as selected by patient), • offering a fetal survey ultrasound; • cervical cytology (if appropriate), and • reviewing instructions on when/how to call the clinician; • if indicated: • reviewing and discussing informed consent for labor and delivery; • gonorrhea and chlamydia screening • reviewing and discussing the health care proxy; • diabetes screening • reviewing warning signs of preterm labor; • urine toxicology screening . • reviewing expected fetal movements; 8 . Identified medical problems and risk factors should be • preparation for childbirth including availability of addressed and a problem list created . childbirth classes, analgesic options, and expectations 9 . Folic acid or prenatal vitamin containing adequate folic acid during labor and birth; should be advised . • discussing and encouraging breastfeeding including SUBSEQUENT VISITS availability of community supports; At every routine prenatal visit, an interval history should be • selecting a pediatrician; obtained . Assessment should be made of the patient’s weight, • newborn issues, including circumcision, infant care classes, blood pressure, and uterine size . Urine testing for protein infant CPR classes, car seats; and and glucose should be obtained if indicated . Fetal assessment • postpartum recovery including postpartum appointments, should include heart sounds and movement as appropriate for maternity leave, depression, and contraception . gestational age . Fetal presentation should be assessed in the late third trimester . Additional interventions: Testing in the second and third trimesters: • during flu season, influenza vaccine should be recommended to pregnant patients; • fetal survey ultrasound may be performed at 17–20 weeks; • Tdap vaccine should be recommended in the third trimester; • TB testing should be performed in the early second trimester • other vaccinations may be considered in pregnancy as if indicated; indicated (e .g ., hepatitis B vaccination for women at • CBC and glucose screening, if appropriate, at 24–28 weeks; risk); and • antibody testing should be performed in Rh negative patients • Rh immunoglobulin should be provided for Rh negative at 28–30 weeks and as indicated; woman at approximately 28–30 weeks gestation, or as • STD testing should be repeated at 32–36 weeks for patients indicated (bleeding, trauma, or amniocentesis, external at risk; version); and postpartum as indicated .

GUIDELINE 9

Second Trimester Pregnancy Termination

INSTITUTIONAL GUIDELINES Patients for whom a second trimester termination is planned should have a plan of care and a discussion of the methods . Each facility shall develop guidelines for second trimester Medical-surgical consents and Massachusetts Department of pregnancy termination to include, at a minimum, details Public Health consents appropriate for the procedure should regarding: be obtained and documented . If appropriate, consent for • procedures, disposition of fetal remains should be obtained . • medications, Eligibility for second trimester termination should be deter- • monitoring the patient, mined by the best estimate of gestational age . The calculation of • description of training and competency of personnel, gestational age should be consistently applied and transparently • availability of a physician who can manage complications, obtained by all available dating criteria . Ultrasound verification • use of cervical ripening agents, of gestational age and determination of biparietal diameter is • potential role of intra-operative ultrasound, preferred, ideally within one week of the procedure . Gestational • potential role of feticidal agents, and age limits should be in accordance with state law . • strategy/plan in the event of a live birth .

PRIOR TO SECOND TRIMESTER METHODS OF SECOND TRIMESTER PREGNANCY TERMINATION PREGNANCY TERMINATION For eligible patients: Methods of second trimester termination include dilation • obtain medical and obstetrical history; and evacuation, and induction of labor . Hysterectomy • confirm the gestational age; and hysterotomy are not considered primary methods for terminating a second trimester pregnancy . • conduct a physical exam; and • counsel the patient regarding potential risks, agents and DOCUMENTATION methods for the chosen procedure, and the possible risks of Documentation should include, but not be limited to: the chosen procedure . • discussion of procedures or methods, and their risks and The plan of care should take into consideration: benefits; • the patient wishes for an intact fetus; • consents for medical-surgical procedures, and the • the patient wishes not to have a labor and delivery; Massachusetts Department of Public Health consents and disposition of fetal remains form, if applicable; • availability of care providers experienced in second trimester pregnancy termination procedures; • administration of medications: time, date, dose; • administration of medications or the use of hygroscopic • medical or obstetrical co-morbidities . dilators (e .g ., laminaria, dilapan), including date, time, and Plan of care may include, but not be limited to: number placed, as needed for cervical preparation; • discussion of the appropriate location for the • patient’s clinical response; proposed procedure; • delivery or removal of fetal tissue and completeness; and • anesthesia consultation as indicated; and • complications and need for additional procedures .1-2 • consultation with Social Work, Chaplaincy, or both as desired . 1. Second-trimester abortion. ACOG Practice Bulletin No. 135. June 2013. Reaffirmed 2015. American College of Obstetricians and Gynecologists.

2. Abortion Policy. College Statement of Policy. As issued by the College Executive Board. American College of Obstetricians and Gynecologists. November 2014. © 2017 CRICO CRICO CLINICAL GUIDELINES FOR OBSTETRICAL SERVICES 11

GUIDELINE 10 GUIDELINE 11

Antenatal Tests of Use of Antenatal Fetal Well-being Corticosteroids for

Tests of fetal well-being may be indicated for patients who Fetal Maturation All women between 24 and 34 weeks gestation who are at risk are at increased risk of adverse fetal outcome . for delivery within seven days, should receive corticosteroids . Tests available include fetal kick counts, non-stress tests, This includes women withrupture of membranes, unless oxytocin challenge tests, biophysical profiles, and Doppler individual circumstances affect this decision . studies . Treatment options include: Timing of initiation of testing should be based on: • two doses of betamethasone 12 mg IM 24 hours apart, or • underlying medical issues and their severity, • four doses of dexamethasone 6 mg IM 12 hours apart . • maternal age, The 2000NIH Consensus panel did not find significant • gestational age, evidence to support using one drug preferentially over the other . • obstetrical history, and A second course of antenatal corticosteroids may be considered • plurality . if clinically appropriate 1. Further repeat courses should be reserved for women enrolled in clinical trials . Administration of Antenatal testing should only be initiated at a gestational age steroids between 34⁰⁄₇ weeks and 365⁄₇ weeks necessitates careful and fetal weight at which, when necessary, delivery for an consideration of the risks, benefits, and unknowns . Tocolysis abnormal test result would be reasonable . The frequency and beyond 34 weeks gestation to complete steroid administration is duration of testing should be determined by the obstetrical not recommended .2 provider; testing should usually be continued until the pregnancy is delivered, unless the clinical scenario improves . When regular antenatal testing is considered at very early 1. Management of preterm labor. ACOG Practice Bulletin No.171. MFM NICU gestational ages (< 28 weeks), an and consultation October 2016. American College of Obstetricians and Gynecologists. may be considered . 2. Gyamfi-Bannerman, et al. Antenatal betamethasone for women at If regular antenatal fetal surveillance is indicated, then non- risk for late preterm delivery. New England Journal of Medicine. stress tests and/or biophysical profiles are recommended . 2016;374(14):1311–20.

GUIDELINE 12

Prevention of Neonatal Sepsis Due to Group B Streptococci

TheCDC has recommended that all obstetrical clinicians 5 . If a woman at term with a positive GBS culture ruptures her adhere to a screening culture-based obstetrical protocol for membranes without signs of labor, no more than 12 hours prevention of neonatal sepsis due to Group B Strep 1. This should pass prior to consideration of steps to effect delivery protocol requires that GBS-specific cultures be universally and antibiotic administration . performed during the antepartum period and that intrapartum 6 . Women with negative cultures within five weeks of delivery antibiotics be administered to women based on culture data . If do not require intrapartum antibiotic prophylaxis for culture results are not available, intrapartum antibiotics should GBS even if obstetrical risk factors develop . Intrapartum be administered according to defined risk factors . temperature ≥ 100 .4 °F orally (100 °F axillary) should prompt Adherence to this culture-based protocol requires the following: consideration for use of intrapartum antibiotics regardless of concerns regarding GBS prophylaxis . 1 . Antepartum GBS-specific cultures according to the 7 . At more than five weeks after Group B Strep testing, methodology specified by theCDC are performed between rescreen or treat as GBS status unknown . 35 and 37 weeks gestation . Women with positive screening cultures during a previous pregnancy should be recultured 8 . Women undergoing a planned cesarean delivery prior to during subsequent pregnancies and managed on the basis the onset of labor and membrane rupture do not require of the current culture . Women who have had GBS cultures intrapartum antibiotic prophylaxis for GBS . performed prior to 35 weeks (whether positive or negative) 9 . Penicillin is the first line antibiotic recommended for this should have a repeat screening culture performed between 35 purpose; ampicillin is also acceptable . For penicillin-allergic and 37 weeks gestation if it is anticipated that delivery may individuals, acceptable antibiotics include: occur more than five weeks after the prior culture . • cefazolin: (preferred alternative except for patients at high 2 . Intrapartum antibiotics are administered according to results risk for anaphylaxis);2 of these cultures . • clindamycin and erythromycin: (for patients at high risk 3 . If results of cultures are not available, intrapartum antibiotics for anaphylaxis, and whose susceptibility is known);3 and should be administered to all women with any of the • vancomycin: (for patients at high risk for anaphylaxis, and following risk factors: whose susceptibility is unknown) . • preterm labor (< 37 weeks gestation) • rupture of membranes ≥ 18 hours, or • intrapartum temperature ≥ 100 .4 °F orally (100 °F axillary) . 1. Verani JR, L McGee, and SJ Schrag. Division of Bacterial Diseases. National Center for Immunization and Respiratory Diseases, Centers 4 . Intrapartum antibiotics should be administered to women for Disease Control and Prevention. Prevention of perinatal Group B streptococcal disease: revised guidelines from CDC (2010): 1–36. with either of the following (regardless of culture results): 2. Women who are at high risk for anaphylaxis include those with a history GBS • previous infected neonate, or of immediate hypersensitivity reaction to penicillin and those with • GBS bacteriuria (of any magnitude of colony count) at concomitant conditions that may make anaphylaxis more difficult to treat, including active asthma and current treatment with beta-adrenergic any time during the current pregnancy . blocking agents. Penicillin-allergic women who do not have a history of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of a penicillin or a cephalosporin should receive cefazolin.

3. Susceptibility testing to clindamycin and erythromycin should be performed on all positive GBS cultures obtained from women at high risk for anaphylaxis.

GUIDELINE 13 GUIDELINE 14

Availability of Clinician Scheduled and and Case Load in Labor Elective Delivery and Delivery Elective Delivery refers to delivery of a normal pregnancy IN LABOR without a recognized maternal or fetal indication .1 Once active labor has begun, the responsible clinician should be Scheduled Delivery refers to a purposely timed delivery for immediately available to return to Labor and Delivery if needed . either induction of labor or for cesarean birth . Immediately available assistance by a qualified clinician from Delivery occurring more than seven days prior to the EDD is the obstetrical service is mandatory when a clinician’s case load associated with an increased risk of adverse neonatal outcomes exceeds three low-risk patients in active labor; or when the and may be associated with an increased risk of cesarean intensity of the care for the case load exceeds the clinician’s delivery in nulliparous women . Therefore: capacity to provide safe patient care . Elective delivery of singleton gestations should not be planned to The patients and the nurses caring for them should be notified occur before seven days prior to the EDD, i.e., prior to 39 weeks about any change in status of the responsible clinician . If gestation. a clinician becomes unavailable for reasons that would not permit timely return to labor and delivery (such as surgery or When scheduled for maternal or fetal indications, referred to involvement in a complex medical case), then that clinician must as a “scheduled indicated delivery,” the timing of delivery is provide the nursing staff with the name of an alternate clinician determined by the medical situation.2 who has agreed to assume responsibility and be immediately Confirmation of term gestation is dependent on satisfying at least available for that clinician’s laboring patients . one of the following gestational age criteria:3 At all times when there is an actively laboring patient on the • known date of assisted reproductive technologic intervention, labor floor, a physician credentialed to perform emergency • an ultrasound measurement of the fetus obtained at operative delivery must be readily available . < 20 weeks gestation supports gestational age of 39 weeks ALTERNATIVE COVERAGE or greater, When a clinician cannot be contacted or, if after being • fetal heart tones have been documented as present for appropriately notified, a clinician does not see a patient in a 30 weeks by Doppler, and timely fashion, and/or if a clinician has made no arrangements • it has been 36 weeks since a serum or urine human chorionic for alternative coverage, the nursing staff shall report this gonadotropin pregnancy test has been positive . occurrence through appropriate institutional procedures . Each A test indicating fetal lung maturity does not itself meet the institution shall devise a system by which alternative clinician criteria for elective delivery . coverage is provided in such situations; and the system of clinician coverage should be clearly communicated and available to all members of the labor and delivery staff . 1. Non-medically indicated early term deliveries. ACOG Committee Opinion No. 561. April 2013, Reaffirmed 2015. American College of Obstetricians and Gynecologists.

2. Medically indicated late-preterm and early-term deliveries. ACOG Committee Opinion No. 560. April 2013, Reaffirmed 2015. American College of Obstetricians and Gynecologists.

3. Induction of labor. ACOG Practice Bulletin No. 107. August 2009, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

GUIDELINE 15

Assessment and Monitoring in Labor and Delivery

PATIENT EDUCATION • evaluation of status of labor, including a description of During prenatal care, the clinician and patient will discuss uterine activity, cervical dilation and effacement, and fetal common events and procedures in labor, including methods of station and presentation, unless vaginal exam deferred; assessing fetal well-being . • evaluation of fetal status, including interpretation of ADMISSION TO LABOR AND DELIVERY auscultation or electronic fetal monitoring strips, if generated; and The responsible clinician or designee shall evaluate the patient, • the plan for delivery . enter a note, and provide orders within two hours of his or her patient arriving at the Labor and Delivery unit . Fetal status must be assessed on every patient who is evaluated or admitted in a triage unit . This should be performed without The clinician or designee shall examine the patient before delay for any fetus of 24 or more weeks . A recording of fetal prescribing initial therapy with tocolytic agents in the second heart rate (FHR) and uterine contractions is advised until or third trimester . Documentation should include presumptive categorization of the FHR tracing is determined . If a Category I diagnosis, possible causes, and that informed consent has been pattern cannot be obtained in a reasonable time frame, obtained . continued evaluation should proceed . If the patient is not in active labor, and is low risk, i .e .: FIRST STAGE OF LABOR AFTER INITIAL EVALUATION • 37–41⁶⁄₇ weeks gestation, For a patient without complications, continuous FHR • estimated fetal weight appropriate for gestational age, monitoring is not required if the initial FHR tracing exhibits a • has a Category I electronic fetal monitoring strip on Category I tracing . admission or a reassuring auscultation, “Categorization of the FHR tracing evaluates the fetus at that • absence of meconium, point in time; tracing patterns can and will change . An FHR • vertex presentation, and tracing may move back and forth between categories depending • absence of any medical or obstetrical complications, on the clinical situation and management strategies employed .” 1 Then, initial assessment can be delayed until: Fetal heart rate (and variability—if electronically monitored) should be evaluated and recorded at least every 15–30 minutes, • a risk factor is identified, depending on the risk status of the patient, during the active • the patient enters active labor, or phase of labor) 2,3. The FHR should be evaluated as soon as is • the patient requests pain medication . feasible after spontaneous rupture, or immediately after artificial rupture of the membranes . INITIAL EVALUATION BY CLINICIAN IN LABOR AND DELIVERY Continuous fetal heart rate monitoring should be done for The clinician’s initial evaluation anddocumentation in Labor patients with any of these indicators: and Delivery shall include, at a minimum: • history of an abnormal antepartum FHR or rhythm, • reviewing the patient’s prior pregnancy(s); • breech presentation, • reviewing and summarizing the antenatal course; • history of prior cesarean delivery, • physical exam (including an estimated fetal weight); • multiple gestation,

EVALUATION DURING SECOND STAGE LABOR • nonreassuring fetal assessment, • significant maternal illness, The monitoring clinician should document in themedical record at the time of identification of second stage, after • use of oxytocin, two hours of second stage, and hourly thereafter . This • abnormality of active or second stage labor, documentation, which should be dated and timed, should • thick meconium, or include, at a minimum: • heavy vaginal bleeding . • assessment of maternal status; Electronic fetal monitoring is also preferred when auscultation • assessment of fetal status; is not feasible . Once continuous electronic fetal monitoring is • description of uterine activity; chosen and initiated, a technically satisfactory and continuous • fetal station and, if known, position; and tracing should be achieved . If this cannot be accomplished, the reasons must be documented and an alternative plan for fetal • assessment of progression and a plan for delivery . assessment must be developed . Fetal heart rate should be evaluated and recorded at least every In the event of a Category III FHR tracing, the attending 5–15 minutes, depending on the risk status of the patient 2-3. clinician or his or her designee shall promptly evaluate the fetal In the event of a Category III FHR tracing, the attending status and initiate efforts to resolve the abnormalFHR pattern . clinician or his or her designee shall promptly evaluate the fetal If corrective measures are not successful, preparations for status and promptly initiate efforts to resolve the abnormal FHR delivery will be initiated 2. pattern . He or she may consider obtaining another opinion An amnioinfusion may be considered when persistent variable about the fetal status . decelerations are seen on the FHR tracing 2. No later than the end of the second hour of the second stage of labor, and every hour thereafter, the attending physician or EVALUATION DURING FIRST STAGE LABOR midwife should personally evaluate the patient and document in The patient shall be evaluated by the responsible clinician or the medical record the minimum as noted above . Additionally, designee during labor at appropriate intervals . Each evaluation the providers involved (which may include the attending should include: physician, resident, nurse midwife, RN, and/or charge nurse) • assessment of maternal status; shall discuss the patient’s progress and plan of care at each • description of uterine activity; hourly interval . • assessment of fetal status; By the end of the third hour of the second stage of labor, the • description of findings on vaginal exam, if performed, attending obstetrician should personally evaluate and examine including cervical dilation and effacement, fetal station, the patient, immediately document details of this evaluation, change in status of membranes, and progress since last exam; and be involved in continued planning . • summary of maternal and fetal status; and DELIVERY • plan, including plans for or performance of clinical If a patient is moved to another room for delivery, fetal interventions and pain management . Each evaluation should be recorded in the medical record .

Guideline 15 continued

monitoring should be established in that room unless delivery relevant clinical issues shall be discussed and appropriate clinical is reasonably expected to occur imminently . For patients about and administrative plans agreed upon by the team caring for to undergo cesarean delivery, monitoring should continue as is the patients . feasible until abdominal preparation for surgery is begun . CLINICIAN EDUCATION When the delivering clinician is concerned about the fetal status Ongoing continuing education should be provided by each at delivery, a double-clamped segment of the umbilical cord institution for all obstetrical personnel . Subjects to be reviewed should be set aside for possible arterial blood gas assessment . If may include FHR monitoring, emergency measures for the the neonatal 5-minute Apgar score is 5 or less,4 or if requested treatment of shoulder dystocia and eclampsia, forceps or vacuum by the delivering or newborn provider, umbilical artery blood application, and management of therapeutic hypothermia . Each should be sent for analysis whenever possible . Blood can be institution shall develop a program to evaluate and document drawn from the clamped segment of cord at any time within an staff competence . hour of delivery .

AFTER DELIVERY

Following delivery, the clinician must record in the medical 1. Macones GA, et al. The 2008 National Institute of Child Health and record all the events relating to the delivery in a reasonable Human Development Workshop Report on Electronic Fetal Monitoring Update on Definitions, Interpretation, and Research Guidelines. period of time after the patient’s needs have been fully attended Obstetrics and Gynecology. 2008;112:661–66. to, using forms, notation, and/or dictation as appropriate to 2. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, the case . The clinician should be readily available to return to and general management principles. ACOG Practice Bulletin No. 106. the unit until the immediate (30 minute) postpartum period is July 2009. Reaffirmed 2017. American College of Obstetricians and Gynecologists. complete and the patient is stable . 3. Intermittent auscultation for intrapartum fetal heart rate surveillance. INSTITUTIONAL RESPONSIBILITY American College of Nurse-Midwives. Clinical Bulletin No. 11. Journal of Midwifery and Women’s Health. 2010;55:397–403. Each institution shall provide and maintain appropriate fetal monitoring apparatus to meet the needs of its patients . 4. The Apgar Score. ACOG Committee Opinion No. 644. October 2015. American College of Obstetricians and Gynecologists. Accommodations for preserving all electronic fetal monitoring tracings (see Guideline 1) is also the responsibility of the institution, with special consideration and allocation of resources to assure permanent and secure preservation of fetal monitor tracings (antenatal and intrapartum) for all babies born with five minuteApgar scores of 5 or less . If copies of electronic fetal monitor strips are kept, then preservation and storage of paper fetal monitor strips is not necessary . Each hospital shall have at least daily multidisciplinary meetings held on the Labor and Delivery unit, at which time all patients’

GUIDELINE 16

Induction of Labor1,2

METHODS OF INDUCTION Indications for the induction of labor should take into account maternal and fetal conditions, gestational age, cervical status, 1 . Amniotomy and other factors . Criteria for confirmation of fetal lung 2 . Oxytocin (e .g ., Pitocin): Each obstetrical unit shall develop maturity should be met in these circumstances (see Guideline 14). guidelines for the administration of oxytocin which, at a Labor may be induced for non-medical reasons after 39 weeks minimum, should include: gestation . • preparation and administration via a controlled The risks and benefits of induction should be discussed and infusion device, documented in the patient’s medical record . In general, the • monitoring of the mother and fetus, contraindications to induction are the same as those for • management of uterine tachysystole, spontaneous labor and vaginal delivery . For women with a • description of training and competency of personnel previous cesarean delivery, see Guideline 25 . administering oxytocin, and PRIOR TO THE INDUCTION OF LABOR • readily available physician who has privileges to 1 . Assess the pelvis; and fetal size, position, and presentation . perform cesarean deliveries . The clinical rationale for the induction should always be Adequate documentation of clinical reasoning is required documented in the patient’s medical record . when oxytocin infusion rates rise above 20 mu/min . 2 . Confirm gestational age . (See Guideline 7.) 3 . Synthetic prostaglandin E1 or E2 (e .g ., misoprostol/ 3 . Counsel the patient regarding potential risks to the Cytotec; or dinoprostone/Cervidil, Prepidil or Prostin mother or fetus, agents and methods of cervical ripening, E2): Each obstetrical unit shall develop guidelines for the and labor stimulation . administration of prostaglandin, which, at a minimum, 4 . Evaluate fetal status with a non-stress test . should include: 5 . Select the method of induction based on the indications • indications and contraindications; and assessment . • procedure, including dosage, frequency of administration, 6 . Documentation in the patient’s medical record should maximum number of doses, and the duration of fetal include the following: monitoring; and • the risks and benefits of induction, and the risks of • options for treatment of uterine tachysystole . continuing the pregnancy without induction, that have 4 . Mechanical methods of cervical ripening: if the status of been discussed with the patient and the patient’s stated the cervix is unfavorable, mechanical cervical dilators may understanding; be used . Each obstetrical unit shall develop guidelines for • the reason for indicated or elective induction, and the the use of mechanical or osmotic dilators, such as: clinical rational; hygroscopic dilators, osmotic dilators (e .g ., laminaria), • the patient’s gestational age and fetal status; and Foley catheter bulb . • the method of induction planned; and • the method of cervical ripening when the cervix is unfavorable .

GUIDELINE 17

Guideline 16 continued Augmentation of Labor

INSTITUTIONAL RESPONSIBILITY Labor may be augmented with the use of oxytocin, amniotomy, or both . Each obstetrical institution is responsible for establishing standard policies and procedures for scheduling elective PRIOR TO THE AUGMENTATION OF LABOR induction of labor, gestational age, and the indication and The following criteria should apply: method for induction of labor, including the preparation and use • patient was evaluated and the pelvic exam documented; of oxytocin and use of cervical ripening agents . • an indication for augmentation of labor, e .g ., arrest or protraction of labor, prolonged latent phase of labor, hypotonic uterine contraction pattern; 1. Induction of labor. ACOG Practice Bulletin No. 107. August 2009, • no contraindications to augmentation of labor; Reaffirmed 2016. American College of Obstetricians and Gynecologists. • the fetal presentation is cephalic; and 2. ACOG/ACP Guidelines for Perinatal Care, Seventh Edition. Washington • the absence of a Category III FHR tracing . DC, October 2012. Explain to the patient the planned procedures and/or medications, including risks, benefits, and alternatives, and document the patient’s agreement in the medical record .

AFTER THE INITIATION OF OXYTOCIN (See Guideline 16.) The patient should be monitored for effect, including: • contractions either electronically or by palpation, with a goal of avoiding uterine tachysystole (hyperstimulation); • fetal status (continuous electronic fetal monitoring is mandated, brief interruptions are acceptable); • the progress of the patient’s labor; • monitoring the dose of oxytocin (adequate documentation of clinical reasoning is required and intrauterine pressure (IUPC) may be considered when oxytocin infusion rates rise above 20 mu/min); and • when external monitoring is problematic, consider applying the IUPC for monitoring uterine contractions . All of these monitoring activities should be recorded in the medical record .

INSTITUTIONAL RESPONSIBILITY Each obstetrical unit shall develop guidelines for the use of oxytocin (see Guideline 16). The institution is responsible for ensuring that enough controlled infusion devices for administration of oxytocin are maintained and available to meet the needs of the patient population . © 2017 CRICO CRICO CLINICAL GUIDELINES FOR OBSTETRICAL SERVICES 19

GUIDELINE 18

Operative Vaginal Delivery1,2

Thevacuum extractor or forceps should only be used if all of the instrument is planned . The consultant shall document his or following conditions are met: her obstetrical evaluation and recommendation in the patient’s medical record (see Guideline 4). 1 . The delivering clinician has clinical privileges to use a vacuum extractor or forceps . Sequential use of vacuum extractor and forceps has been 2 . Capability to perform an emergency cesarean delivery is associated with an increased risk of neonatal complications available if unexpected difficulties are encountered . and should not be routinely used . A trial of operative vaginal delivery should be attempted only when the likelihood of 3 . Informed consent has been obtained and the patient agrees success is high, with the operator prepared to abandon the to the procedure . attempt if appropriate descent does not occur . If a trial of 4 . The fetal head (exclusive of any caput) has reached at least vacuum or forceps is unsuccessful, prompt cesarean delivery is +2 cm (scale: -5 to +5) and clinical pelvimetry indicates that indicated unless vaginal delivery is imminent . delivery without fetal or maternal trauma can reasonably be expected . The clinician shall record a detailedoperative note which should include: 5 . Thecervix is completely dilated and the membranes ruptured . • the station and position of the fetal head, 6 . The delivering clinician has assessed the station, position, and • the fetal status at the time of application of vacuum attitude of the fetal head as appropriate to permit an accurate extractor or forceps, cephalic application of the forceps blades, or vacuum cup . • indications, and 7 . Adequate analgesia is provided . • clinical rationale and substantive risks discussed with 8 . Urinary bladder is empty . the patient . For use of the vacuum extractor: For vacuum extractions, the note must also include: 1 . Gestational age must be 34 weeks or greater . • the instrument used and pressure settings, 2 . Careful pelvic examination to rule out any maternal tissue • number of attempts, and trapped between the vacuum cup and fetal head . • duration of the procedure . 3 . Vacuum extraction and commitment to vaginal delivery For forceps delivery, the note must also include: should be reevaluated in the event of: • failure of descent of the vertex with the first • confirmation of fetal position after the placement of the traction effort, forcep blades, and • delivery that is not imminent after four traction efforts, or • the number of pulls applied (with a qualitative assessment of • vacuum cup detachment that occurs three times . the degree of effort) . If the vacuum extractor or forceps fails to accomplish delivery If the operative note is dictated, then the delivering clinician should document the operative procedure in the patient’s despite proper application and technique, then a subsequent trial with the alternate instrument is appropriate only in medical record immediately following the delivery . carefully selected cases . If possible, a second opinion from another physician is recommended if a trial with the alternate 1. ACOG/ACP Guidelines for Perinatal Care, Seventh Edition. Washington DC, October 2012.

GUIDELINE 19

Prevention of Retained Sponges and Needles Following Vaginal Delivery

Retained foreign objects after surgeries or procedures are • If there is a discrepancy in the needle count and careful considered serious reportable events, one of the 28 events inspection of the vagina and search of the delivery area do identified in the Commonwealth of Massachusetts’ uniform not locate the needle, then diagnostic X-ray is expected to non-payment policy 1. Retained foreign objects following vaginal ensure that the missing needle is not retained in the patient . delivery and obstetrical surgery procedures are events that can • The nurse should record the final status of the sponge and usually be prevented by implementing the following steps: needle counts on the Labor and Delivery patient flow record • Two qualified personnel, including the primary nurse, will and the obstetrical provider should similarly document in the perform sponge and needle counts before and after each delivery note . delivery . The counts should be documented in themedical • Purposeful placement and retention of vaginal sponges record . If a pre-delivery sponge count is not possible, as with or packing in the vagina, as in the setting of post partum a precipitous delivery, then sponges shall not be utilized hemorrhage, necessitates a reliable method of tracking until after the delivery, when a count can be systematically and communicating such with members of the obstetrical performed prior to their use . care team . • All sponges used in deliveries should be radio-opaque . • If there is a discrepancy in the sponge count at the completion of the delivery, then manual search of the vagina 1. HealthyMass Serious Reportable Events Task Force, Policy Guidelines. should be performed and findings documented by the Available at: http://www.mass.gov/eohhs/docs/eohhs/healthymass/sre- guidelines.pdf. Accessed June 20, 2013. delivering obstetrical provider . If the discrepancy persists, then the further search of the delivery area should be performed and findings documented in themedical record . A diagnostic X-ray of the patient may be considered to ensure missing sponges are not retained in the vagina .

GUIDELINE 20

Management of Breech Presentations1,2

EXTERNAL CEPHALIC VERSION 4 . During the Procedure 1 . Patient Selection Monitor the fetal heart rate, at minimum, every 30 seconds External cephalic version is precluded in anyone with a during the procedure . contraindication to vaginal delivery or evidence of fetal 5 . Following the Procedure compromise . • observe the patient for at least one hour; 2 . Education/Consent • continuously monitor the fetal heart rate and pattern A discussion with the patient should precede the via electronic fetal monitor apparatus for a minimum performance of the procedure and include: of one hour; • pregnancy management after a successful or • confirm aCategory I fetal heart rate tracing post- unsuccessful version, procedure, prior to discharge; • success rate of attempted version, • administer RhoGAM if indicated; • risks and benefits of the procedure, and • instruct the patient about follow-up plans, and advise • when to call following the procedure . whom to call in the event of any issues; See Appendix E for a sample consent form for this procedure . • give the patient a written discharge instruction sheet . This, or a reasonable facsimile, should be reviewed with and 6 . Documentation of the Procedure signed by the patient prior to the procedure . The details on the procedure should be recorded in the 3 . Prior to the Procedure patient’s medical record, including: • arrange a location in close proximity to the delivery unit; • gestational age; • confirm that an immediatepre-procedure non-stress test • Rh blood type; is reactive; • results of pre-procedure testing; • perform an immediate pre-procedure sonogram to • medication administered; confirm presentation and that there is normalamniotic fluid volume; • details on the version attempt, whether it was successful or unsuccessful; • perform a formal fetal anatomy survey (if one has not been performed previously) to evaluate the possibility of • post-procedure testing; and significant congenital anomalies; • future plans . • consider a tocolytic agent (tocolytics are relatively contraindicated in patients with heart disease); and • consider regional anesthesia if the procedure is to be performed in the operating room .

Guideline 20 continued

DELIVERY OPTIONS: BREECH SINGLETON In this circumstance: Cesarean delivery is the most usual method for delivery of a breech singleton living fetus without any significant congenital • the obstetrician must be skilled in vaginal breech delivery or anomalies . Assessment of the fetal presentation should be have adequate back-up consultants available; performed immediately prior to a scheduled cesarean . • the adequacy of the pelvis must be assessed; the estimated Planned vaginal delivery of a term singleton breech may be fetal weight, type of breech, and fetal attitude shall be reasonable under hospital-specific protocol for both eligibility determined; and management of labor (including use of oxytocin) 1,2. If the • labor dysfunction of any type warrants delivery by patient opts for a vaginal breech delivery, a detailed written cesarean; and informed consent shall be obtained and placed in the medical • breech delivery should be permitted to occur spontaneously, record . Women should be informed that the risk of perinatal or by assisted breech delivery maneuvers as indicated . or neonatal mortality or short-term serious morbidity may be higher than for cesarean delivery .

1. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. July 2006, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

2. External cephalic version. ACOG Practice Bulletin No. 161. February 2016. American College of Obstetricians and Gynecologists.

GUIDELINE 21

Management of Twins

AFTER VAGINAL DELIVERY OF THE FIRST TWIN The clinician and the patient should have a discussion about the delivery options during the antenatal period and that discussion 1 . When monitoring indicates a Category I or II intrapartum should be documented in the medical record . An example of a fetal heart rate, there is no urgency to deliver the second specific writtenconsent is available in Appendix G. twin (delivery interval does not appear to affect perinatal outcome) . However, if there is a monochorionic placentation, TIMING OF DELIVERY attention should be paid to the length of the intertwin Uncomplicated dichorionic twin pregnancies should usually delivery interval (increasing interval increasing the chance of be delivered between 37 and 38 weeks gestational age . acute intrapartum twin to twin transfusion) . Uncomplicated monochorionic diamniotic twins may be 2 . If the second twin is not in a vertex presentation, an delivered between 34 and 37 weeks gestational age . Prior obstetrician skilled in external cephalic version or internal assessment of fetal lung maturity is not required for such cases 1. podalic version should be available . INTRAPARTUM CONSIDERATIONS 3 . Total breech extraction, assisted breech delivery, cesarean delivery, and attempted external cephalic version are all 1 . The obstetrical care provider should evaluate and document acceptable approaches to the delivery of a breech second fetal lie and presentations . twin . Vaginal breech delivery is not recommended in 2 . Continuously monitor (via EFM) both fetuses throughout significantly preterm twins or in the presence of significant active labor and delivery . discordance (i .e ., second twin larger than first) . Previous 3 . Intravenous access should be established . ultrasound (within 2–4 weeks of labor) can be valuable in 4 . Pain relief remains the patient’s choice . determining discordance . 5 . Sufficient personnel should be available to care for the mother and each baby . 6 . An ultrasound should be available throughout the delivery to 1. Multifetal gestations. ACOG Practice Bulletin No. 169. October 2016 American College of Obstetricians and Gynecologists. confirm lie and presentation and, if necessary, to document the fetal heart rate . 7 . Cesarean delivery is indicated for twin pregnancies with a non-vertex presenting twin unless vaginal delivery is imminent .

GUIDELINE 22

Prolonged Pregnancy

MANAGEMENT OF LATE-TERM PREGNANCY Many descriptive labels are applied to pregnancies that go beyond the expected date of delivery (EDD) . CRICO Guidelines CRICO recommends the following approach to managing supports ACOG’s classifications 1. pregnancies that go beyond the completion of the 41st gestational week . Late-term: 410/7 weeks of gestation through 416/7 weeks of gestation . If the cervix is: Post-term: 420/7 weeks of gestation and beyond . 1 . favorable for oxytocin induction (patient is nullipara or multipara), then induction is preferred; fetal surveillance is an Post-term pregnancies are at risk for adverse outcomes that acceptable alternative; include an increased incidence of perinatal and neonatal morbidity and mortality, uteroplacental insufficiency,meconium 2 . not favorable for oxytocin induction and the patient is aspiration, macrosomia, and intrauterine infection . Late-term multipara, then induction or fetal surveillance are acceptable pregnancies may also be at risk for an increased incidence alternatives; or of perinatal and neonatal morbidity . Accurate assessment of 3 . not favorable for oxytocin induction and the patient is gestational age is of paramount importance for management nullipara, then induction or fetal surveillance are acceptable of pregnancy, interpretation of test results, and timing of alternatives . interventions . (See Guideline 7.) If fetal surveillance is chosen, then twice-weekly fetal testing RISKS OF INDUCTION VS. EXPECTANT MANAGEMENT should begin by 7–9 days after the EDD . This should include an ultrasonographic assessment of amniotic fluid volume to detect Clinicians should be familiar with the acceptable alternative oligohydramnios . methods of management of late-term and post-term pregnancies . Whichever method is chosen, the prenatal record MANAGEMENT OF POST-TERM PREGNANCY must indicate that a discussion regarding management of Steps should be initiated to obtain consent and proceed to pregnancy exceeding 41 weeks gestation occurred between the deliver the patient by induction or cesarean delivery as soon obstetrical provider and the patient . as is feasible . The risks of induction include: failed induction, possibly leading to a cesarean delivery, and complications related to the use of oxytocin or prostaglandin administration, 1. Definition of term pregnancy. ACOG Committee Opinion No. 579. such as uterine tachysytole (hyperstimulation) and fetal November 2013, Reaffirmed 2015. American College of Obstetricians intolerance of contractions .2 The risks of continued expectant and Gynecologists. management include but are not limited to: intrauterine fetal 2. Induction of labor. ACOG Practice Bulletin No. 107. August 2009, demise, perinatal death, meconium aspiration syndrome, Reaffirmed 2016. American College of Obstetricians and Gynecologists. and dysmaturity syndrome . Maternal risks include increased 3. Management of late-term and post-term pregnancies. ACOG Practice frequency of severe perineal lacerations, cesarean delivery, Bulletin No. 146. August 2014, Reaffirmed 2016. American College of infection, and post-partum hemorrhage 3. Obstetricians and Gynecologists.

GUIDELINE 23

Macrosomia1

INTRAPARTUM COUNSELING For the purposes of these Guidelines, fetal macrosomia implies growth beyond 4,500 grams (approximately 1 percent of live The responsible intrapartum clinician should confirm that born infants achieve this birth weight) . Risks for morbidity the patient understands the risks and document this in the for mother and baby increase significantly beyond this weight intrapartum record . compared to the general population . Clinical palpation and DELIVERY OPTIONS sonography are similar in their ability to estimate the presence of macrosomia . If the estimated fetal weight is 5,000 grams or greater (4,500 grams or greater for infants of diabetic mothers), then PRENATAL COUNSELING prophylactic cesarean delivery may be considered . When macrosomia is clinically suspected, patients should be Induction of labor for macrosomia is not recommended because informed of the potential risks and such discussion should be it does not improve maternal or fetal outcomes . documented in the prenatal record . Maternal risks include:

• increased likelihood of cesarean delivery, 1. Fetal macrosomia. ACOG Practice Bulletin No.173. November 2016. American College of Obstetricians and Gynecologists. • vaginal lacerations, and • postpartum hemorrhage . Fetal risks include: • shoulder dystocia, • fractured clavicle, and • injury to the nerves of the brachial plexus producing symptoms ranging from temporary upper extremity weakness to permanent paralysis . Most infants delivered vaginally with birth weight > 4,000 grams and a brachial plexus nerve injury do not have a permanent paralysis .

GUIDELINE 24 GUIDELINE 25

Management of Patients with Previous Shoulder Dystocia Cesarean Delivery1,2

EVALUATION Diagnosis of shoulder dystocia is made when the practice of gentle downward guidance of the fetal head fails to accomplish Make an effort during the pregnancy to document the type delivery of the anterior shoulder requiring the need for of prior incision made in the uterus, and the indication(s) additional obstetrical maneuvers for the delivery of the for the prior cesarean delivery . The maternal pelvis should be fetal shoulders 1. clinically evaluated . A plan for the use of maneuvers to alleviate the shoulder Contraindications to a trial of labor after cesarean: dystocia and obtaining assistance by additional members • prior cesarean delivery involving the upper contractile of the obstetrical team should be in place since shoulder portion of the uterus (classical uterine incision), dystocia is most often an unpredictable and unpreventable • prior T incisions on the uterus, obstetrical emergency . • prior uterine surgery involving the upper contractile portion DOCUMENTATION of the uterus with significant disruption of the uterine wall or If a shoulder dystocia occurs, this event and the details used entering of the uterine cavity, to resolve it must be entered into the medical record as an • prior uterine rupture or dehiscence, operative report and dictated (or the electronic equivalent • more than two consecutive cesarean deliveries and no prior completed) immediately after the delivery . or interval vaginal deliveries, This information should include: • a too small or “contracted” pelvis, and • time of delivery of the fetal head and the time of complete • other contraindication to vaginal delivery . expulsion of the body, If the previous operative note cannot be located, an unknown • maneuvers used, scar is not a contraindication to trial of labor . • Apgars of the newborn, COUNSELING • maternal complications, Discuss with eligible patients the risks and benefits of atrial of • infant complications, and labor after cesarean versus a scheduled repeat cesarean delivery . • names of staff in attendance at the delivery . This discussion should occur after all past obstetrical history is The clinician’s hospitalrisk management unit should be notified obtained and should, ideally, occur early in the pregnancy . Issues of all cases of infant complications . that may be important in this decision include: • success rates of a trial of labor; INSTITUTIONAL RESPONSIBILITY • perinatal morbidity and mortality; Each obstetrical institution is responsible for developing a plan for obstetrical safety drills to prepare staff in the event of high • maternal morbidity, including infection, operative injury, acuity, low frequency emergent events such as shoulder dystocia . hysterectomy, transfusion; • uterine rupture; • recovery and hospital stay; and 1. Shoulder dystocia. ACOG Practice Bulletin No. 178. May 2017. • risk of additional cesarean deliveries . American College of Obstetricians and Gynecologists. A consent form should be used as documentation of this discussion in the medical record (see Appendix F).

GUIDELINE 26

Cesarean Delivery on Maternal Request

SCHEDULED REPEAT CESAREAN DELIVERY Cesarean delivery on maternal request is defined as aprimary Patients for whom labor is contraindicated, such as those cesarean performed at patient request without medical with previous classical uterine incision or myomectomy in the indication . Each physician may decide to support the patient upper contractile portion of the uterus, should be delivered by request or not on a case-by-case basis . Primary cesarean delivery a scheduled repeat cesarean delivery . Timing of delivery will be on maternal request without medical indication should not be determined by clinical circumstances . scheduled before seven days prior to the EDD (see Guideline 14). If a physician agrees to perform a primary cesarean delivery Patients with lower uterine segment incisions, who decline a upon patient request, then detailed written informed consent trial of labor, can be scheduled for a repeat cesarean delivery by should be obtained . A sample consent form for this procedure is or after seven days prior to the EDD . Alternately, the patient available (see Appendix H). and the clinician may choose to await the onset of labor .

TRIAL OF LABOR AFTER CESAREAN DELIVERY 1 . A physician who has credentials to perform an emergent cesarean delivery should be immediately available throughout active labor . 2 . Anesthesia and nursing/operating room personnel should be available for emergent performance of a cesarean delivery . 3 . Continuous electronic fetal monitoring should be instituted no later than the institution of the use of epidural or oxytocin . According to ACOG, most authorities recommend continuous electronic monitoring during labor . 4 . Intravenous access should be obtained in all patients with a prior cesarean delivery . 5 . Oxytocin may be used for augmentation of labor in the absence of disproportion . 6 . Oxytocin may be used for cervical ripening or induction after a discussion with the patient of the increased risk of uterine rupture associated with its use . 7 . Prostaglandins (including Misoprostol) should not be used for third trimester cervical ripening or the induction of labor after a prior cesarean delivery or major uterine surgery . After a successful vaginal delivery, exploration of the prior uterine scar is not necessary in the absence of symptoms of uterine rupture, such as bleeding .

1. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 115. August 2010, Reaffirmed 2017. American College of Obstetricians and Gynecologists.

2. Induction of labor. ACOG Practice Bulletin No. 107. August 2009, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

GUIDELINE 27

Obstetrical Surgery Safety Communication

Each institution will develop guidelines for communication placenta previa, multiple previous surgeries, known previous prior to, during, and immediately after obstetrical surgery 1-3. adhesions, fibroid uterus); Guidelines should include specific items to be communicated by • anticipated need for pediatric providers for the birth; the surgical team, which may include the obstetrician, surgical • anticipated need for blood products; assistant, scrub nurse or scrub tech, circulating nurse, and the anesthesiologist . Communication should be ongoing and may • anticipated need for special or additional equipment; include a preoperative briefing of the surgical team in addition • other planned procedures, such as tubal ligation; and to the formal time-out (surgical pause) and post-operative sign • other existing pathology that should be evaluated at the time out/debrief . of the procedure (such as a previously noted ovarian cyst) .

BRIEFING In an emergency, when any delay is inadvisable, the staff should The purpose of a briefing is to gather the care team together cover as many of these items as possible while preparing or in prior to moving to the operating room in order to introduce the initial phases of the case . members of the team, confirm that the correctdocumentation In general, surgical marking is seldom required in obstetrical is present (e .g ., history and physical, consents) and to procedures . If unilaterality in approach and planned procedure ensure that the team has a shared mental model regarding exists, institutional guidelines should be established in order to the planned procedure . All team members should introduce standardize surgical marking . themselves by name and role . SIGN OUT/DEBRIEF TIME-OUT The purpose of a sign out/debrief is to confirm the procedure, The purpose of atime-out is to confirm correct patient and specimens, counts, and plans for post-operative care . procedure immediately prior to initiation of the procedure/ Debrief checklist items to consider, include: surgery . A standardized, scripted, interactive time-out should be performed before each obstetrical procedure, including but 1 . name of procedure verified; not limited to: cesarean delivery, external cephalic version, 2 . appropriate labeling of specimens confirmed; peripartum hysterectomy, and dilation and evacuation . The 3 . estimated blood loss and fluid management; time-out should be documented in the patient’s record . Content 4 . team concerns discussed; and timing of the time-out should be addressed in the institutional guidelines . 5 . pain management plan; 6 . sponge, needle, and instrument counts correct; and Items that should be considered for inclusion for communication during the briefing and thetime-out: 7 . equipment issues/problems addressed . • confirmation of patient identity from two sources; • confirmation of planned procedure(s); 1. Obstetrical surgery includes, but may not be limited to, cesarean delivery, cerclage placement, postpartum tubal ligation, hysterectomy and dilation • confirmation of patientallergies; and evacuation (D&E).

• confirmation of completed consent; 2. Patient safety in the surgical environment. ACOG Committee Opinion • confirmation of antibiotic request or administration: No. 464. September 2010, Reaffirmed 2014. American College of Obstetricians and Gynecologists. prophylactic, otherwise, or none needed; • factors that may significantly affect the length of time for 3. WHO Surgical Safety Checklist. www.who.int the surgical procedure (such as, but not limited to, BMI,

GUIDELINE 28

Anesthesia in Obstetrics

This guideline has been adapted from thePractice Guidelines • An anesthesia care provider must perform a focused for Obstetrical Anesthesia and the Guidelines for Regional pre-anesthesia evaluation which should include, but Anesthesia in Obstetrics as approved by the American Society of is not limited to, maternal health history, anesthesia- Anesthesiologists 1. It applies to obstetrical patients receiving related history, an airway exam, and baseline vital signs . major neuraxial anesthesia (spinal, epidural, combined spinal- Examination of other organ systems should be performed epidural); general anesthesia; or monitored anesthesia care as indicated . Laboratory testing should be performed (MAC) for labor analgesia or operative procedures . when appropriate indications exist . 1 . Regional anesthesia should be initiated and maintained only • A physician credentialed to perform an operative vaginal in locations in which appropriate resuscitation equipment or cesarean delivery must be available . and drugs are immediately available to manage procedure- • An intravenous infusion should be established and related problems . Resuscitation equipment should include, maintained throughout the duration of the regional but is not limited to: anesthetic . Whenever possible, this should be an 18 gauge • sources of oxygen and suction; canula, or larger bore if indicated . • equipment to maintain an airway and perform • A pre-procedure verification/time-out should endotracheal intubation; be performed . • a means to provide positive pressure ventilation; 5 . During routine regional anesthesia for labor, maternal vital • drugs and equipment for cardiopulmonary resuscitation; signs and the fetal heart rate should be monitored and documented . Additional monitoring of the parturient or • a protocol for the management of failed endotracheal fetus should be employed when indicated . intubation; 6 . Patients who receive extensive regional block, MAC, or • adjunctive devices for the management of failed general anesthesia must be monitored, according to the ASA intubation such as LMA, video-laryngoscope, and/or standards for anesthesia, by a qualified anesthesia personnel fiberoptic intubation devices, bougie, or stylets;2-4 and present in the room who is monitoring the patient’s • lipid rescue therapy 5. oxygenation, ventilation, and circulation, and temperature 2 . Surgical airway management must be available . when indicated . 3 . Anesthesia should be initiated and maintained by, or under 7 . The primary responsibility of the primary anesthesiologist the medical supervision of, a physician with appropriate is to provide care to the mother . Qualified personnel, other privileges . Other anesthesia care providers should be than the primary anesthesiologist attending the mother, credentialed to manage obstetrical anesthesia under the should be immediately available to assume responsibility for medical direction of a physician as appropriate . resuscitation of the newborn . 4 . Prior to the initiation of anesthesia for labor or operative obstetrical procedures: • The patient must be examined by an appropriate obstetrical care provider .

Guideline 28 continued

8 . A physician with appropriate privileges to administer 10 .Whenever possible, pregnant patients with co-morbid obstetrical anesthesia shall be available in the medical conditions that may pose an increased anesthesia risk should facility from the initiation of an anesthetic until the patient’s be evaluated by an anesthesia care provider prior to labor post-anesthesia condition is satisfactory and stable . Should so that a multi-disciplinary care plan can be created . Such this physician become unavailable for reasons that would patient conditions include, but are not limited to: not permit timely return to the patient (such as surgery), he • morbid obesity, or she must provide the nursing staff with the name of an • significant cardiac or intracranial lesions, alternate clinician who: • a personal or family history of major adverse reaction to • agrees to assume responsibility for the care of the patient, anesthesia (such as malignant hyperthermia), • is readily available, and • coagulopathy, • is capable of intervening in emergency circumstances . • history of difficult intubation, and 9 . All patients recovering from routine regional anesthesia • significant back surgery (e .g . lumbar scoliosis repair) that for labor should receive appropriate post-anesthesia care . might preclude the use of regional anesthesia . Following extensive regional blockade, MAC, or general anesthesia, the ASA standards for post-anesthesia care should be applied: 1. Practice Guidelines for Obstetric Anesthesia: An Updated Report • A post-anesthesia care recovery area (PACU) should by the America Society of Anesthesiologists; Anesthesiology. be available to receive patients . The design, equipment, 2016;124(2):1–31.

and staffing should meet requirements of the facility’s 2. Maassen R, et al. A comparison of three videolaryngoscopes: the accrediting and licensing agencies . Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesthesia and • Obstetric units must develop a policy for the management Analgesia. 2009;109:1560–65. of patients in the PACU . This policy should describe who 3. Mushambi M, et al. Obstetric Anaesthetists’ Association and Difficult is responsible for the care of patients in the PACU, how Airway Society guidelines for the management of difficult and failed they will be monitored, and the process for discharge . tracheal intubation in obstetrics. Anaesthesia. 2015;70:1286–1306.

Specifically, it must address whether patients will be 4. Aziz M, et al. A retrospective study of the performance of video discharged by a nurse according to protocols, or signed out laryngoscopy in an obstetric unit; Anesthesia and Analgesia. 2012; by an independent licensed practitioner . The protocol for 115 (4). discharge must be delineated . 5. Bern S, Weinberg G. Local anesthetic toxicity and lipid resuscitation in pregnancy. Current Opinion in Anesthesiology. 2011;24:262–267. • When a site other than the PACU is used, equivalent post-anesthesia care should be provided .

GUIDELINE 29

Placental Pathology Evaluation

The decision to submit the placenta to the hospital’s 2 . Peripartum Conditions Department of Pathology for gross and microscopic • temperature greater than 100 .4º F (intrapartum) examination should be based upon a reasonable likelihood that • suspected or proven infection such an examination will: • bleeding, of magnitude beyond “show” (e .g ., suspected • facilitate the diagnosis of maternal-fetal conditions associated abruption placenta, placenta previa, vasa previa) with adverse outcomes; and • oligohydramnios or polyhydramnios • provide information salient to, or allow prognosis for, future pregnancies and their outcomes . 3 . Fetal/Neonatal Conditions • still birth (antenatal, or intrapartum) or neonatal death in The American College of Obstetricians and Gynecologists the delivery or operating room (ACOG) offers no formal guidelines recommending placental examination based on specific clinical conditions with the • multiple births exception of stillbirth 1. ACOG regards placental examination as • all major or minor congenital anomalies “an essential component” of stillbirth evaluation . Some clinicians • fetal growth restriction have advised that all placentas be submitted to pathology for • hydrops fetalis or an edematous placenta examination;2,3 however, there is a lack of consensus for routine • meconium (thin or thick), noted on admission or examination . occurring in labor CONDITIONS FOR PLACENTAL EXAMINATION 4 . Immediate Neonatal Course Individual judgment is warranted concerning the • Apgar scores of 5 or less at 5 minutes appropriateness of submitting the placenta, with as much • suspected neonatal infection umbilical cord as is feasible, for pathologic evaluation . Consider submitting the tissue for any level of concern . CRICO supports • suspected encephalopathy placental examination under the following non-exclusive list of • cord pH< 7 .1 maternal or fetal clinical conditions: 5 . Gross Placental Anomalies 1 . Maternal Conditions • diabetes

• hypertension 1. Management of stillbirth. ACOG Practice Bulletin No. 102. March 2009, Reaffirmed 2016. American College of Obstetricians and Gynecologists. • maternal substance abuse • prematurity (less than completion of 37th gestational 2. Salafia CM, Vintzileos AM. Why all placentas should be examined by a pathologist in 1990. American Journal of Obstetrics and Gynecology. week) 1990;163:1282–93.

• post-maturity (greater than the completion of the 42nd 3. Langston C, et al. Guideline for examination of the placenta: developed gestational week) by the Placental Pathology Practice Guideline Development Task Force of the College of American Pathologists. Archives of Pathology and Laboratory Medicine. 1997;121(5):449–76.

GUIDELINE 30

Maternal Early Warning System (MEWS)1-2

Obstetrical patients may exhibit physiological changes that The initialOB provider for patient assessment should be signify deterioration . credentialed in obstetrics and may be a physician, certified nurse midwife, nurse practitioner, or physician assistant . If no TRIGGERS3 credentialed obstetrics provider is available, each institution • Systolic BP (< 80 or > 160 mm Hg) should specify an appropriate initial bedside responder, while • Diastolic BP (> 105 mm Hg) simultaneously contacting the obstetrical attending physician . • Heart rate (< 50 or > 120 beats per min) At a minimum, a Rapid Response Team (obstetrical attending physician, anesthesiologist covering obstetrics, and charge nurse) • Respiratory rate (< 10 or > 30 breaths per min) should be readily available to assist in stabilizing the patient and • Oxygen saturation % (< 95 room air, at sea level) determining when transfer to a higher level of care is indicated . • Oliguria (< 30 mL for > 2 hours): for catheterized patients INSTITUTIONAL RESPONSIBILITY • Maternal agitation, confusion, unresponsiveness (if any present) Each institution should develop a MEWS (see Appendix C) . Institutional leadership should provide necessary resources • Preeclampsia, with patient reporting non-remitting headache for implementation, including staffing, education, a quality or shortness of breath (if any present) improvement process, and leadership from senior medical and An effective maternal early warning system MEWS( ), with nursing personnel . prompt bedside evaluation may facilitate timely recognition, evaluation, and treatment for obstetrical patients developing critical conditions such as hemorrhage, hypertensive crisis, and 1. Preparing for clinical emergencies in Obstetrics and Gynecology. ACOG sepsis . Committee Opinion No. 590, March 2014, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

2. Mhyre JM. The maternal warning criteria. Obstetrics and Gynecology. 2014;124:782–86. 3. Specific MEWS triggers may evolve as more evidence becomes available.

GUIDELINE 31

Postpartum Care

IN-HOSPITAL CARE AFTER DISCHARGE Patients should be seen each day of their hospitalization Consideration should be given to an early follow-up postpartum by an obstetrical provider . This person assesses for medical visit for women with medical complications or those women at complications and psychosocial issues, addresses any questions risk for postpartum depression, such as: or concerns, and arranges for discharge . • past episodes of depression, Each institution shall have a process or program to instruct each • family history of mood disorder, or patient regarding normal postpartum events . These instructions • unusually stressful life events 1. should include care of the breasts, perineum, bladder, the incision (if appropriate) and signs of complications . Instruction All women, including those with an earlier visit (as above), about infant care, infant feeding (including the benefits of should be advised to have a visit four to eight weeks postpartum . breastfeeding), and subsequent maternal and newborn medical That visit should include a complete review of the pregnancy examinations should also be included . Verbal instructions should and events that occurred during labor, delivery, and the be supplemented with written instructions and reinforced by immediate postpartum period for the outpatient medical providers . The need for and timing of follow up should be record if not already completed . The patient should be asked clearly communicated to the patient . about her recent history and current symptoms . All postpartum women should be assessed for and counseled about postpartum Plans for management or referral of ongoing problems should depression and domestic violence and should be informed about be instituted when appropriate, including evaluation of support services offered through the institution or community 2. problems identified during the pregnancy . Vaccine status should Use of one of the validated screening tools for postpartum be assessed and vaccination for Tdap, influenza, rubella, and depression may be helpful . All appropriate contraceptive varicella should be initiated if indicated . Contraception should methods should be discussed and an initiation plan established . be discussed and a plan established with the patient . An appropriate physical exam should be performed including, at a minimum, vital signs and examination of the breasts, abdomen, pelvis, perineum, and extremities . All pregnancy and post-partum problems needing follow up should be addressed (e .g ., hypertension, diabetes, incomplete vaccination series) .

1. Wisner KL, et al. Postpartum depression. New England Journal of Medicine. 2002;347(3):194–99.

2. Screening for perinatal depression. ACOG Committee Opinion No. 630. May 2015, Reaffirmed 2016. American College of Obstetricians and Gynecologists.

GUIDELINE 32

Therapeutic Hypothermia forNeonates

Each institution shall adopt a process and standardized tool to • prolonged resuscitation at birth, and/or intubation, and/or trigger therapeutic hypothermia when that is determined by a mask ventilation at 10 minutes licensed independent provider to be the appropriate treatment for • pH < 7 .1 from cord or patient blood gas within 60 minutes any neonate at or past 34 weeks gestation with findings of neonatal of birth encephalopathy—or considered at risk for encephalopathy or a seizure • ≤ -10 mEq/L from cord gas or patient blood gas within 60 event (per screening criteria). If the neonate is being considered for minutes of birth therapeutic hypothermia and a definitive decision has not yet been reached, a repeat exam, ideally by the same licensed independent Absolute Exclusion Criteria: provider, should be performed within the first hour to evaluate • gestational age < 34 weeks evolution of neonatal encephalopathy. Relative Exclusion Criteria: When the delivery clinician is concerned about the fetal status (at the discretion of the accepting attending physician at the at delivery, a double-clamped segment of the umbilical cord Level III facility) should be set aside for possible arterial blood gas assessment . If • IUGR < 1,750 grams the neonatal 5-minute Apgar score is 5 or less, or if requested • severe congenital anomalies /genetic syndromes /established by the delivering or newborn provider, umbilical artery blood metabolic disorders should be sent for analysis whenever possible . Blood can be drawn from the clamped segment of cord at any time within an • major intracranial hemorrhage hour of delivery . • overwhelming septicemia • uncorrectable, clinically relevant coagulopathy SCREENING CRITERIA 1 . Neonates ≥ 34 weeks gestational age; and RECOMMENDATIONS 2 . Concern for encephalopathy or seizure event; and For neonates meeting the eligibility criteria for therapeutic 3 . Any one of the following: hypothermia, contact the closest Level III NICU with hypothermia capabilities . Document the discussion and • sentinel event prior to delivery such as uterine rupture, rationale for the decision to offer or not to offer therapeutic profound bradycardia, or cord prolapse hypothermia . • low Apgar scores ≤ 5 at 10 minutes of life

GUIDELINE 33

Newborn Male Circumcision

Circumcision is the surgical removal of the foreskin of the penis . • pain relief: injection anesthetic, such as dorsal penile nerve In the neonatal period, this is an elective procedure performed block or subcutaneous ring block, is expected unless the at the request of the parent(s) . parent declines; should the parent decline injection then use of a topical anesthetic agent may be considered; swaddling, Each institution will develop guidelines for circumcision, oral sucrose and acetaminophen administration may be including: considered for comfort of the newborn during the procedure • contraindications (e .g ., abnormal genital structure, but are not sufficient as a sole method of analgesia;1 prematurity); • documentation; and • requirements for ascertaining normal physical examination of • qualifications of performing clinicians . the infant prior to procedure; Pediatric providers, obstetrical providers, and nurses should all • preparation for procedure, including obtaining consent (using be involved in the development/approval of guidelines . a form specifically forcircumcision); . • time-out (surgical pause) is required prior to the procedure to Each institution will track short-term complications of the confirm the patient and the presence of completed consent; procedure, including the type of complication, the method of circumcision, and the performing clinician .

1. Guidelines for Perinatal Care, 7th ed. October 2012. American College of Obstetricians and Gynecologists.

GUIDELINE 34

Reporting of Adverse Outcomes

MATERNAL COMPLICATIONS Routine screening for adverse outcomes shall be conducted at each institution for the purpose of capturing untoward • Death outcomes, determining trends, developing corrective action, and • Eclampsia providing timely information . The following patient outcomes • Failure to perform planned procedure should be reported to the institution’s risk management and • Hysterectomy quality assurance personnel as soon as possible . • Maternal readmission within two weeks of discharge INFANT CONDITION OR COMPLICATION • Need for return to delivery room or operating room for • Apgar score of 5 or less at five minutes unplanned procedure • Brachial plexus palsy • Retained sponge, instrument, or needle • Congenital deformity or birth injury leading to incapacity or • Surgery done on the wrong person or the wrong organ disability1 • Surgical or delivery injuries, including burns and nerve • Cord pH less than 7 .0 injuries • Fracture of any long bone (excluding clavicle) • Symptomatic uterine rupture • Fractured skull • Unconsented procedure • Infant abduction • Unplanned transfer to intensive care • Intracranial bleed unrelated to prematurity Peer review conducted pursuant to an institution’s bylaws • Meconium aspiration relating to any adverse maternal or fetal outcome is strictly • Neonatal seizures within the first 48 hours confidential by law .

• Respiratory distress syndrome after elective induction or INSTITUTIONAL RESPONSIBILITY elective repeat cesarean delivery Events identified as being serious reportable events SRE( s) • Stillbirth or neonatal death in fetuses > 24 weeks must be reported by the institution to the Commonwealth of or > 500 grams Massachusetts Executive Office of Health and Human Services • Surgical injury, including laceration of infant Department of Public Health 1. • Term infant (> 36 weeks) > 2, 500 grams admitted for Each obstetrical institution is responsible for developing policies > 24 hours to Level II or Level III nursery and procedures for disclosure to patients of adverse events and • Unconsented circumcision outcomes involving their care 2. • Admission/transfer to NICU of a newborn for therapeutic hypothermia (see Guideline 32)

1. Massachusetts Department of Public Health website for reportable incidents. Available at: http://www.mass.gov/dph

2. If an adverse event occurs. CRICO. Available at: https://www.rmf. harvard.edu/Clinician-Resources/Article/2009/What-to-do-After-an- Adverse-Event

GUIDELINE 35

Institutional Responsibilities

When obstetrical services are provided in a CRICO-insured 3 . Support for quality improvement activities (Guideline 1). institution, the following support services, staff training, and 4 . A formal process to resolve disagreements between arrangements are the responsibility of the institution . professional staff about medical management, conduct of FOR EMERGENCY SUPPORT labor, or interpretation of tests of fetal status (Guideline 5). 5 . A standard policy and procedure for establishing gestational 1 . Blood products should be available at all times . age (Guideline 7 ). 2 . Personnel capable of performing an emergent surgical airway 6 . Guidelines for second trimester pregnancy termination must always be immediately available . (Guideline 9). 3 . Obstetrical (maternal) resuscitation guidelines should be 7 . Ensuring that, whenever there is an actively laboring patient readily available by each institution and include: on the labor floor, a physician credentialed to perform an • a designated response team for maternal emergencies in emergency operative delivery is readily available (Guideline 13). Labor and Delivery that includes members familiar with 8 . A system by which alternative clinician coverage (as needed) the physiologic changes of pregnancy and the procedures is clearly communicated and available to all members of the for notification of the response team; and labor and delivery staff (Guideline 13). • a designated response team for obstetrical patients who 9 . Providing and maintaining appropriate fetal monitoring experience emergencies anywhere in the hospital other apparatus to meet the needs of its patients (Guideline 15). than Labor and Delivery . 10 .Convening at least daily multidisciplinary meetings held on 4 . Consultants from other services should be readily available as the Labor and Delivery unit to discuss all patients’ relevant needed . clinical issues and have appropriate clinical and administrative FOR INFANT IDENTIFICATION AND PROTECTION plans agreed upon by the team caring for the patients 1 . Each institution should affirm the identity of thenewborn (Guideline 15). prior to any procedure, testing, and prior to being released to 11 . A standard policy and procedure for scheduling induction of the mother and/or her designee(s) while in the hospital . labor (Guideline 16). 2 . Each institution should establish clear protocols to prevent 12 . A standard policy and procedure for establishing the infant abduction . indication and method for induction of labor, including the preparation and use of oxytocin and use of cervical ripening FOR GENERAL SUPPORT agents (Guideline 16). These responsibilities are imbedded in specific guidelines, 13 . Guidelines for the use of oxytocin (Guideline 17). and repeated here for clarity . CRICO-insured institutions are 14 .Ensuring that enough controlled infusion devices for responsible for: administration of oxytocin are maintained and available to 1 . Adequate resources for record processing and adhering to meet the needs of the patient population (Guideline 17). record keeping standards including compliance with federal 15 . Guidelines for communication prior to, during, and regulations (e .g ., HIPAA) and its mandate for a designated immediately after obstetrical surgery (Guideline 27). institutional compliance officer(Guideline 1). 2 . Accommodations for preserving all electronic fetal monitoring tracings (Guideline 1).

Guideline 35 continued

16 .Ensuring that a physician with appropriate privileges to 22 .Tracking short-term complications of circumcision, including administer obstetrical anesthesia (or a designee) will be the type of complication, the method of circumcision, and available in the medical facility from the initiation of an the performing clinician (Guideline 33). anesthetic until the patient’s post-anesthesia condition is 23 .Identifying and reporting serious reportable events (SREs) satisfactory and stable (Guideline 28). to the Commonwealth of Massachusetts Executive Office of 17 . A policy for the management of patients in the PACU that Health and Human Services Department of Public Health describes who is responsible for the care of patients in the (Guideline 34). PACU, how they will be monitored, and the process for 24 .Policies and procedures for disclosure to patients of adverse discharge (Guideline 28). events and outcomes involving their care (Guideline 34). 18 .A maternal early warning system and providing necessary FOR STAFF COMMUNICATION, EDUCATION, resources for implementation, including staffing, education, AND TRAINING a quality improvement process, and leadership from senior medical and nursing personnel (Guideline 30). 1 . A program to evaluate and document staff competence . 19 .A process or program to instruct each patient regarding 2 . Continuing education for all obstetrical personnel including: normal postpartum events . These instructions should include FHR monitoring, emergency measures for the treatment care of the breasts, perineum, bladder, the incision (if of shoulder dystocia and eclampsia, and forceps or vacuum appropriate), and signs of complications (Guideline 31). application . 20 .A process or program to instruct each patient regarding 3 . Developing a plan for obstetrical safety drills to prepare staff infant care, infant feeding (including the benefits of in the event of high acuity, low frequency emergent events breastfeeding), and subsequent maternal and newborn such as shoulder dystocia . medical examinations (Guideline 31). 4 . All existing and future CRICO-insured institutions and/ 21 . Adopting a standardized neonatal encephalopathy or Departments of Obstetrics/Gynecology will endorse assessment tool—mutually agreeable to both referring and individualized institutional guidelines that define the roles accepting neonatal units— that meets the needs of the and responsibilities and collaborative relationship of Certified providers and patient population served . (Guideline 32). Nurse Midwives and Obstetrician/Gynecologists .

APPENDIX A

Sample Documentation of Delivery with Shoulder Dystocia

Patient identifiers here or upper right hand corner, depending on institution. Shoulder Dystocia Duration: minutes from delivery of head to expulsion of baby:

Maneuvers Performed (check all that apply) McRoberts Fetal rotation (Woods Maneuver, Rubin) Suprapubic pressure Gaskin (hands and knees) Episiotomy Zavanelli Deliver posterior arm Other (describe):

Fetal vertex position: OA LOA ROA | OT LOT ROT | OP LOP ROP Shoulder anterior at time of diagnosis of shoulder dystocia: Left Right Pain relief (check all that apply): None Local Epidural Spinal CSE General Other: Anesthesiology Team alerted: NO YES Pediatric Team alerted: NO YES

Maternal Status Maternal complication: NO YES If YES, describe:

Maternal blood transfusion: NO YES | If YES, # units transfused:

Newborn Status MALE FEMALE Birth weight: lbs oz, or grams Apgar: 1 min | 5 min If 5 min is less than 7, document Apgar score at: 10 min | 15 min | 20 min Arterial and venous cord blood gasses, if 5 min Apgar is 5 or less: Newborn complication known or suspected: NO YES If YES, describe:

Dictated delivery note or its electronic equivalent completed: NO YES

Patient and family informed of complication and given opportunity to ask questions: NO YES

Clinician Name (print)

Clinician Signature Date Time

APPENDIX B

Sample Documentation of Operative Vaginal Delivery

Patient identifiers here or upper right hand corner, depending on institution

Indication(s) for OVD (check all that apply) Fetal intolerance of labor Prolonged 2nd stage Arrest of descent Elective Maternal exhaustion Other (specify):

Patient Counseling (check all that apply) Discussed with patient: Risks: NO YES | Benefits: NO YES | Alternatives: NO YES Patient consent obtained prior to procedure: NO YES If NO, state why:

Maternal-Fetal Assessment Prior to Operative Delivery Maternal bladder empty: NO YES Fetal vertex position: OA LOA ROA | OT LOT ROT | OP LOP ROP Fetal station immediately prior to application of instrument: +2/+5 +3/+5 +4/+5 +5/+5 Fetal heart rate: Category I Category 2 Category 3 Estimated fetal weight: grams Anesthesia (check all that apply): None Local Epidural Spinal Pudendal Other: Anesthesiology Team alerted: NO YES Pediatric Team alerted: NO YES

Details of Procedure Forceps instrument applied Forceps (name): | # of pulls: Rotation of fetal head: None 0–45º 45–90º > 90º Total time instrument applied (minutes): Vacuum instrument applied Vacuum cup: Hard cup Soft cup Other: Pressure setting: | # of pulls: | # of pop offs: Total duration of instrument application (minutes): Was instrument-assisted delivery successful: NO YES If NO, please describe: please describe:

Was instrument-assisted delivery accompanied by shoulder dystocia? NO YES | If YES, also complete shoulder dystocia form.

Maternal Status Episiotomy: NO YES | If YES: Median Mediolateral, right Mediolateral, left

Lacerations: NO YES | If YES: 1st degree 2nd degree 3rd degree 4th degree Other maternal complications: NO YES If YES, describe:

Estimated maternal blood loss: Placenta: Spontaneous Manual extraction

Blood transfusion: NO YES | If YES, # units of blood transfused:

Newborn Status MALE FEMALE Birth weight: lbs oz, or grams Apgar: 1 min | 5 min If 5 min is less than 7, document Apgar score at: 10 min | 15 min | 20 min Arterial and venous cord blood gasses, if 5 min Apgar is 5 or less: Newborn injury: NO YES If YES, check all that apply: Scalp laceration Scalp hematoma Other (describe):

Operative vaginal delivery note and dictation/electronic equivalent entered into chart: NO YES

Clinician Name (print)

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APPENDIX C

Maternal Early Warning System Algorithm

The Maternal Early Warning System MEWS( ) algorithm Any one of the physiologic identifies prompts for bedside assessment by providers with parameters out of range the ability to activate resources required for diagnostic and therapeutic interventions . Escalation of concern may be initiated by any team member at any point in the patient’s care . Nurse verifies parameter(s) persistently out of range

Parameter(s) out of range Parameter(s) in range

Nurse notifiesOB provider Continue appropriate level for prompt bedside of clinical surveillance for evaluation patient

Patient fails to respond Patient responds to or deteriorates treatment

Rapid Response Team Continue regular (RRT)2 notified monitoring of patient

RRT evaluates and treats patient

Patient fails to respond Patient responds to or deteriorates treatment

Consider transfer of patient Continue appropriate level to higher level of care: ICU, of clinical surveillance for L&D, emergency code, the patient external facility transfer

APPENDIX D

About Your Care During Labor and Birth

Having a baby is natural . Most mothers and babies go through it without serious problems . Even so, some situations may arise near the end of your pregnancy, or during labor . These can affect the care you or your baby may need . Many of those situations are described below . Some common practices you might experience at the hospital are also described . Ask your doctor, midwife, or nurse if you have questions .

LABOR 1 . A nurse will work with your doctor or midwife to take care of Epidural: A doctor places a thin tube in your back . This takes you . In some hospitals, doctors who are in training (residents) about 20 minutes . You can then get drugs through the tube may also help care for you . that will relieve most of your labor pain . 2 . Other trainees may be involved in caring for you . Students Nitrous oxide: Where available . are always supervised by your doctor, midwife, or a nurse . 9 . If your labor slows down, your doctor or midwife might 3 . You may have a blood test during labor . give you oxytocin through an IV to make your contractions 4 . A nurse may put a monitor on your belly to check your baby’s stronger and closer together . heartbeat . If it is normal, the monitor may be removed . The 10 .Your doctor or midwife may try to help you start (induce) baby’s heartbeat will be checked again during your labor . labor . Some reasons for this are: 5 . If your baby’s heartbeat needs to be checked more closely, • your baby is overdue by more than a week or two, you might wear a monitor for longer . This monitor may be • your baby has not grown well, placed on your skin, or sometimes it is placed on top of the • infection, baby’s head . Sometimes the baby’s heartbeat patterns cause • high blood pressure, concern, even when the baby is fine . These patterns can be • diabetes, or hard to understand . Your chance of a cesarean or vaginal • your water breaks . delivery with vacuum or forceps increases when your baby’s If your cervix is soft and stretchy, you may be given oxytocin pattern raises a concern . Checking your baby’s heartbeat does through an IV . If your cervix is not ready, you may get a not prevent cerebral palsy or birth defects . prostaglandin medication, or a special balloon inserted, to 6 . Sometimes it is possible to change the baby’s heartbeat soften the cervix before using oxytocin . pattern . Your doctor or midwife can place a tube inside your 11 . Sometimes, your labor may be induced for non-medical womb and add fluid around the baby . This added fluid may reasons before your due date . Generally, this cannot be done take pressure off the umbilical cord during your labor . before 39 weeks gestation because babies who deliver before 7 . You may have an intravenous line (IV) in your arm during then can have trouble breathing room air . labor . This is used to give you extra fluids, pain relief drugs, or 12 . The risks of inducing labor include creating contractions antibiotics . that are too strong or frequent . This can cause changes in 8 . Pain you feel during labor can be relieved many ways . You the baby’s heart rate . This risk is usually manageable and the might choose walking, a bath or shower, breathing, massage, contractions can be decreased . It is best to speak with your special pillows, or a combination . Your doctor or midwife can own provider regarding advice for induction; each hospital or offer you other, safe choices: institution will have its own rules regarding the scheduling of Medication: You get pain relief medication by needle (a inductions . “shot”) or through an IV line . You may get sleepy . Allergic reactions are rare .

About Your Care During Labor and Birth continued

VAGINAL BIRTH CESAREAN DELIVERY 1 . Labor contractions slowly open your cervix . When your 1 . About one third of mothers give birth by cesarean . Some are cervix is completely open, contractions, along with your help, planned; some are not . push the baby through the birth canal (vagina) . Usually, the 2 . During cesarean birth, a doctor delivers the baby through an baby’s head comes out first, then the shoulders . incision (cut) in your belly . 2 . About 10–15 percent of mothers need some help getting the 3 . Here are some common reasons you might need a cesarean: baby through the birth canal . A doctor or midwife may apply • your cervix doesn’t open completely, a special vacuum cup or forceps (tongs) to your baby’s head . • your baby doesn’t move down the birth canal, The doctor will then pull while your push the baby out . • your baby needs to be delivered quickly because of a 3 . In approximately one percent of births, the shoulders do problem for mother or baby, not come out easily . This is called shoulder dystocia . If this • your baby is not in a position that allows for a vaginal happens, your doctor or midwife will try to free the baby’s delivery, or shoulders . Shoulder dystocia may cause a broken bone or • you gave birth by cesarean delivery before . nerve damage to the baby’s arm . Most often, these problems 4 . Anesthesia is always used for a cesarean . Most cesareans heal quickly . Shoulder dystocia may cause tears around your are performed using regional anesthesia (spinal, epidural, vaginal opening, and bleeding after birth . or combined spinal-epidural) so that the mother is awake 4 . Many women get small tears around their vaginal opening . during the delivery . Some are performed using general Sometimes a doctor or midwife will cut some vaginal tissue anesthesia and the mother is not awake during the delivery . to make the opening bigger . This is called an episiotomy . 5 . You will lose more blood during a cesarean birth than during 5 . Most women with tears or an episiotomy will need stitches . a vaginal birth . About 12 out of 1,000 mothers who have Your stitches will dissolve over a few weeks during healing . cesareans need a blood transfusion . The area may be swollen and sore for a few days . Rarely, 6 . Infection is more common after a cesarean . Your doctors will infection may occur . Infrequently, a tear or cut may extend to give you medication to help prevent infection . the rectum . Most often this heals with no problem . 7 . A thin tube (catheter) will drain your bladder during a 6 . Normally, the placenta will come out soon after birth . If not, cesarean . It may remain in place for 12–24 hours afterwards . then the doctor or midwife must reach into the womb and remove the placenta . You may need anesthesia . 8 . In less than one percent of cesareans, the mother’s bowel or urinary system is injured . Most of the time these problems 7 . All women lose some blood during childbirth . Some reasons are fixed during the surgery . you might lose a lot are: • the placenta doesn’t pass on its own; 9 . In less than one percent of cesareans, the baby might be • you are having more than one baby, such as twins or injured . Such injuries are usually minor . triplets; or • your labor lasts a very long time . 8 . Oxytocin can help reduce bleeding after birth . If your bleeding is very heavy, you may be given other medications to help contract your uterus . Very few women need a blood transfusion after vaginal birth .

About Your Care During Labor and Birth continued

AFTER BIRTH NEWBORN 1 . Infection of the uterus (womb) 1 . At one minute, and again at five minutes after birth, your • After a vaginal birth = 2–3 percent baby will be given Apgar scores . The scores are based on heart • After a cesarean birth = 20–30 percent . rate, breathing, skin and muscle tone, and vigor . Apgar scores • Drugs (antibiotics) can lower the risk, but don’t guarantee help your pediatrician and the hospital staff care for your you won’t get an infection . baby . 2 . You will have cramps as your womb returns to its normal 2 . About 3 to 4 percent of babies are born with birth defects . size . Cramping gets stronger with each birth . You may notice Many (for example, extra fingers or toes) do not hurt the it more when breastfeeding . baby . Some, such as some heart abnormalities, can be serious . 3 . After a vaginal birth, you will probably have discomfort 3 . Approximately 7 to 10 percent of babies are born prematurely, around your vaginal opening . After a cesarean birth, you will that is before 37 completed weeks of pregnancy . Premature have pain from the incision . Ask your doctor or midwife for babies may require treatment in a special nursery or an pain relief . intensive care unit . Some babies born after 37 weeks also may need special care . 4 . Vaginal bleeding is normal after birth . It will lessen over 1–2 weeks . About one percent of women will need treatment 4 . About 12 to 16 percent of babies pass meconium (the first for heavy bleeding . Sometimes, heavy bleeding can happen bowel movement) into the amniotic fluid before delivery . If weeks after birth . your baby is born with meconium-stained fluid, and is not crying at birth, the pediatrician will suction the meconium 5 . Most women feel tired and may feel sad after birth . For from the nose and mouth . about 10 percent of new mothers, these feelings of sadness linger or get worse . This may be postpartum depression . If 5 . After birth, your baby will be given eye ointment to prevent this happens, ask your doctor or midwife for help . eye infections . Your baby will also get a Vitamin K shot to prevent bleeding . A few drops of blood from his or her heel 6 . When you can leave the hospital will depend on your health, are taken to screen your baby for some diseases . The results your baby’s health, and the help you have at home . are sent to your pediatrician . Your baby’s hearing will be checked while in the hospital . You will be asked if you want your baby protected against hepatitis B before going home . 6 . Three to four of every 1,000 newborns have serious infections of their blood, lungs, and—in more rare cases—the brain and spine . You may be given antibiotics to protect your baby if: • you carry Group B Strep, • you had a previous baby who had a Group B Strep infection shortly after birth, • you develop a fever during labor, or • your membranes (bag of waters) are ruptured for a long time . 7 . If your baby is at risk, your pediatrician may order testing for infection . Your baby may also receive drugs to prevent infection .

About Your Care During Labor and Birth continued

INFREQUENT OR RARE EVENTS SUMMARY The following problems occur infrequently or rarely during Most babies are born healthy . Most mothers go through pregnancy: labor and birth without serious problems . But pregnancy and childbirth do have some risks . Many of the possible problems 1 . A baby is born too early to survive, or with serious medical are frightening, but most are uncommon . The most serious problems . A baby may die inside the womb after 20 weeks events are very rare . gestation (stillbirth or fetal death); or a baby may die shortly after or within one month of birth . Your health care team will do its best to identify any problems 2 . The mother develops blood clots in her legs after giving early and offer you treatment . Your team looks forward to caring birth . This is more likely to occur after a cesarean delivery for you and delivering a healthy baby . than after a vaginal birth . 3 . The doctor must remove the mother’s uterus (hysterectomy) to stop heavy, uncontrollable bleeding . The woman cannot become pregnant again . 4 . The mother has a problem after a blood transfusion such as an allergic reaction, fever, or infection . The chance of contracting hepatitis (from a transfusion) is 1 in 100,000; the chance of contracting HIV is less than 1 in 1,000,000 . 5 . The mother dies during childbirth (less than 1 in 10,000) . Causes might include extremely severe bleeding, high blood pressure, blood clots in the lungs, and other medical conditions . 6 . Women who have a higher body weight (“body mass index”) may be at risk for additional complications related to childbirth (infection, blood clots, cesarean delivery) . Your obstetrician or midwife may recommend preventive medications or other therapy to reduce your risk of complications .

Authorization for Obstetrical Care I have read About Your Care During Labor and Birth. I understand what has been discussed with me, including this form. I have been given the chance to ask questions and have received satisfactory answers. No guarantees or promises have been made to me about expected results of this pregnancy. I am aware that other risks and complications may occur. I also understand that during the remainder of my pregnancy, or during labor, unforeseen conditions may be revealed that require additional procedures. I know that anesthesiologists, pediatricians, resident doctors, and other clinical students/staff may help my doctor or midwife. I retain the right to refuse any specific treatment. All of my questions have been answered.

I consent to obstetrical care during my birthing experience. I understand that some of the procedures described above may occur. I retain the right to refuse any specific treatment. Ongoing discussion(s) about my current status and the recommended steps will be a part of my care.

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I accept blood transfusions in the case of a life-threatening medical emergency. I refuse blood transfusion under any circumstances and have signed a separate form specifically for the refusal of blood products.

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APPENDIX E

Breech Version or External Cephalic Version

If your baby is in the breech (buttocks down) position late in If successful, turning your baby head down reduces the chance your pregnancy, the following explains a procedure your doctor of a cesarean . But it is associated with a number of risks . or midwife may try to turn the baby to a head down position . • During the turning, your baby’s heart rate may fall . This is About 4 out of 100 babies are in the breech position after 37 not uncommon . The heart rate usually returns to normal weeks . This increases some risks for the baby . Breech babies have quickly . a slightly higher than average chance of birth injury . The mother • The procedure may start your labor or cause your water to has a high chance of cesarean delivery . For these reasons, you break . For this reason, the attempt to turn the baby is usually and your doctor or midwife may try to turn your baby . done within a few weeks of the due date . By then, the baby This procedure is carried out in the hospital . An ultrasound is should be mature . used to see the baby’s position . This helps the doctor or midwife • In less than 1 out of 100 cases, the baby can be entangled in decide how to push on your belly . Your baby’s heartbeat is the umbilical cord during the turning . checked during the procedure . A drug may be given to help • In less than 1 out of 200 of cases, the placenta may separate your uterine muscles relax (it may make your heart beat faster) . from the wall of the uterus . If this happens, the blood flow to Then, the doctor or midwife will push on the baby through your the baby is reduced . That can be dangerous for the baby . abdominal wall in an attempt to turn it . • If a problem does occur, an emergency cesarean delivery may After the procedure, your baby’s heartbeat is checked again . If be needed . Rarely, a problem will happen hours or days after you are Rh negative, then Rh immune globulin is usually given the version . at this time . • In very rare instances, the baby can die . About half the time, the baby can be turned into the head down position . Usually, once turned, the baby will stay head down . Sometimes, the baby turns back to breech .

Authorization for Breech Version or External Cephalic Version I have read Breech Version or External Cephalic Version. I understand what has been discussed with me, including this form. I have been given the chance to ask questions and have received satisfactory answers. No guarantees or promises have been made to me about expected results of this pregnancy. I know that anesthesiologists, pediatricians, resident doctors, and other clinical students/staff may help my doctor or midwife. I retain the right to refuse any specific treatment. All of my questions have been answered.

I consent to breech version (external cephalic version). Ongoing discussion(s) about my current status and the recommended steps will be a part of my care.

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APPENDIX F

Delivery Following a Previous Cesarean Delivery

HOW SUCCESSFUL IS A TRIAL OF LABOR? If you have had one baby by cesarean delivery, you may have some questions about what happens in the next pregnancy . First, 1 . From 60 to 80 percent of women who try labor give birth you must discuss the situation with your doctor or midwife . vaginally . Even after two cesareans, the success rate is You will have to plan for another cesarean, or to try for a “trial relatively high . of labor” and a vaginal delivery . If you want to try for a vaginal 2 . Women with bigger babies have a lower success rate . So do delivery, the following explains the risks and benefits . women whose previous cesarean was done because her labor slowed or stopped . IS A TRIAL OF LABOR RIGHT FOR YOU? 1 . During your previous cesarean(s), a cut was made in your WHAT ARE THE BENEFITS AND RISKS OF A VAGINAL belly and uterus (womb) . If the cut was in the lower part of BIRTH? your uterus—and sideways—then it is usually strong . The 1 . The mother usually has a faster recovery time, shorter risk of the scar tearing during labor is low . hospital stay, and less discomfort . You have less chance of 2 . If you had a low, sideways cut, then you can safely attempt blood transfusion and postpartum infection . You avoid the labor and a vaginal delivery . If you have had more than one risks of surgery (cesarean) . Vaginal birth also lowers your cesarean, you can consider vaginal delivery, but the risk of baby’s risk of breathing difficulty in the first few hours of life . rupture of the scar during labor goes up with each previous 2 . If your trial of labor is not successful, you will need an cesarean . “unplanned” cesarean . An unplanned cesarean has more risk 3 . If your cesarean cut was in the lower part of your uterus—but for you and your baby than a planned cesarean . This includes up and down—then the risk of your scar tearing is higher a higher chance of infection, blood transfusion, and a uterine than if it was sideways . tear . 4 . If your cesarean cut was in the upper part of your uterus and 3 . After a previous cesarean, a uterine rupture (tear) can up and down (a classical cesarean delivery), then a vaginal occur during a future pregnancy or labor . If you have a low, birth is not recommended . sideways cut, the risk is less than one percent . If your uterus 5 . Your doctor or midwife will need to know the type of cut does tear, you will need an emergency cesarean . Your baby you had in your previous cesarean(s) . If your records are not may be injured or die from a uterine rupture . Occasionally, available, the two of you will have to talk and decide if a the uterus cannot be repaired and a hysterectomy (removal of trial of labor is right for you without having the information the uterus) may be needed . Rarely, other organs such as the about your previous cesarean(s) . bladder or bowel may be injured from a uterine rupture or emergency cesarean . WHAT ELSE IS NEEDED FOR A TRIAL OF LABOR? 4 . The risk for rupture of the scar also goes up if your labor is • Your pelvis should be judged adequate . induced, especially if your cervix is not ready for labor . • You should have no other uterine scars . 5 . The safety of a vaginal birth (after cesarean) with twins, • An obstetrician and other medical team members must be breech babies, or after more than one previous cesarean, is immediately available if you need an emergency cesarean . less well studied .

WHAT ARE THE BENEFITS AND RISKS OF A 8 . Having one baby delivered by cesarean increases the chance SCHEDULED REPEAT CESAREAN DELIVERY? of a cesarean for your next pregnancy . Each cesarean increases 1 . A repeat cesarean can be planned and the date chosen . You the risk of scarring and may increase the difficulty of the next avoid any chance of a long labor . The risks of attempting cesarean surgery . There is also an increased risk for rupture of vaginal delivery are avoided . the uterus in future pregnancies if labor is tried . 2 . If a repeat cesarean is planned more than seven days prior to 9 . Rarely, infertility may result from internal scar tissue . your due date, then your baby has more risk for problems . 10 .Rarely, a hysterectomy (removal of the uterus) can be 3 . The infection rate is higher in women who are delivered by required . cesarean than for women who have vaginal births . WHO SHOULD NOT TRY LABOR AND VAGINAL 4 . Blood loss is usually more with a cesarean than with a vaginal DELIVERY? delivery . Approximately 12 in 1,000 of all women who have cesareans require blood transfusion . Trying labor and a vaginal delivery following a previous cesarean is not recommended when the risks are greater than the benefits . 5 . Injury to the urinary system occurs in less than 1 in 200 women . These problems are usually identified and fixed at the • You’ve had a previous cesarean delivery with an up and down time of birth . cut in the upper part of your uterus (a classical cesarean 6 . Injury to the bowel (the intestines, colon, or rectum) is very delivery) . rare, occurring in fewer than 1 in 1,000 cesareans . If an injury • You’ve had some previous uterine surgery, including some to the bowel occurs, it will usually be recognized and fixed at myomectomies (fibroid removal) . the time of birth . • You’ve had more than two consecutive (back to back) 7 . Occasionally, the placenta in a future pregnancy can implant cesareans and no prior or interval vaginal deliveries . over the old scar . This increases the risk of bleeding and • You’ve had a prior uterine rupture or tear . premature delivery in that pregnancy . The chance of the • Your pelvis too small . placenta implanting in the wrong place increases with each • Medical or obstetrical problems prevent vaginal delivery . cesarean .

Authorization for Delivery Following a Previous Cesarean Delivery I have read Delivery Following a Previous Cesarean Delivery. I understand what has been discussed with me, including this form. I have been given the chance to ask questions and have received satisfactory answers. No guarantees or promises have been made to me about expected results of this pregnancy. I know that anesthesiologists, pediatricians, resident doctors, and other clinical students/staff may help my doctor or midwife. I retain the right to refuse any specific treatment. All of my questions have been answered.

I have chosen to attempt a trial of labor and vaginal delivery. Ongoing discussion(s) about my current status and the recommended steps will be a part of my care.

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APPENDIX G

The Delivery of Twins

If you are having twins, the following explains possible events • vaginal delivery of the first baby, breech vaginal delivery of and risks related to your labor and delivery . the second baby; or

TIMING OF DELIVERY • vaginal delivery of the first baby, cesarean delivery of the second baby (uncommon) . • About 40 percent of twin pregnancies begin labor early . Each option has risks . • Sometimes, medical problems require an early delivery . • Vaginal delivery poses risks for the second baby, including • Almost all women with twins give birth before or by their birth trauma (rare) . due dates . • A cesarean includes the risk of bleeding, infection, and ROUTE OF DELIVERY surgical injury to the bowel or bladder . The recommended route of delivery depends in large part on Vaginal breech delivery of the second twin is not recommended how the babies are presenting . when: • Both heads are down: vaginal delivery for both babies . • the second baby is estimated to be much larger than the first, • The first baby is not head down: cesarean is most often • the mother’s pelvis is judged to be too small to allow the baby recommended . to deliver safely, or • The first baby is head down, the second baby is buttocks • the baby is very small (less than 4 pounds) or very early (less down or sideways, the options are: than 32 weeks) . • cesarean delivery of both twins; • vaginal delivery of the first baby, attempt to turn the second baby for vaginal delivery;

Authorization for the Delivery of Twins I have read The Delivery of Twins. I understand what has been discussed with me, including this form. I have been given the chance to ask questions and have received satisfactory answers. No guarantees or promises have been made to me about expected results of this pregnancy. I know that anesthesiologists, pediatricians, resident doctors, and other clinical students/staff may help my doctor or midwife. I retain the right to refuse any specific treatment. All of my questions have been answered.

I understand that some of the procedures described above may occur. I retain the right to refuse any specific treatment. Ongoing discussion(s) about my current status and the recommended steps will be a part of my care.

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APPENDIX H

Primary Cesarean Delivery on Maternal Request

THE BENEFITS AND RISKS OF A SCHEDULED 7 . A cesarean delivery can result in serious problems in ELECTIVE PRIMARY CESAREAN DELIVERY subsequent pregnancies . Occasionally, the placenta in a 1 . A cesarean delivery can be planned; the date can be chosen . future pregnancy implants over the old cesarean scar, which 2 . You may not experience labor . is usually near the cervix (the opening of the womb to the birth canal) . This increases the risk of bleeding and premature 3 . The most common problems with cesarean delivery are delivery . The chance of the placenta implanting in the wrong hemorrhage (uncontrolled bleeding) and infection . Both are place increases with each additional cesarean . higher risk for cesarean deliveries than for vaginal births . 8 . Having had one cesarean increases the chance of having 4 . For the mother, blood loss is usually greater with a cesarean another one . Each cesarean increases the risk of scarring than with a vaginal delivery . Approximately 12 in 1,000 of all afterwards and may increase the difficulty of future surgeries . women having a cesarean need a blood transfusion . There is also a small but increased risk for rupture of the 5 . Injury to the urinary system (the bladder and drainage to and uterus during labor for women who have had a previous from the bladder) occurs in less than 1 in 200 women who cesarean . deliver by cesarean . These problems are usually identified and 9 . Rarely, the inability to get pregnant, or chronic pelvic pain, repaired at the time of the cesarean . Vaginal delivery does not may result from scar tissue (adhesions) that may form after eliminate risk of injury to the urinary system . cesarean delivery . 6 . Injury to the mother’s bowel (intestines, colon, or rectum) is 10 .Rarely, a hysterectomy (removal of the uterus) may be needed rare at the time of cesarean . It occurs in less than 1 in 1,000 for the treatment of uncontrollable bleeding . cesareans . Such an injury will usually be recognized and fixed at the time of the cesarean . Injury to the mother’s bowel almost never happens after a vaginal delivery .

Authorization for Primary Cesarean Delivery on Maternal Request I have read Primary Cesarean Delivery on Maternal Request. I understand that I have the option for vaginal delivery and that I do not have specific medical indications for cesarean delivery. I understand the risks and benefits of an elective primary cesarean delivery as explained above and as explained by my clinician. I am aware that other risks and complications may occur. I understand what has been discussed with me, including this form. I have been given the chance to ask questions and have received satisfactory answers. No guarantees or promises have been made to me about expected results of this pregnancy. I am aware that other risks and complications may occur. I also understand that during the remainder of my pregnancy, or during labor, unforeseen conditions may be revealed that require additional procedures. I know that anesthesiologists, pediatricians, resident doctors, and other clinical students/staff may help my doctor or midwife. I retain the right to refuse any specific treatment. All of my questions have been answered.

I request and consent to elective primary cesarean delivery. Ongoing discussion(s) about my current status and the recommended steps will be a part of my care.

Patient Name (print) DOB or Patient ID#

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IndexRed page numbers indicated topic-specific guideline.

A abruption 31 clinical discord 2, 6 Foley catheter 17 ACOG 1, 27, 31 clinician coverage 4, 13 forceps 3, 16, 19, 38 adverse outcome 11, 13, 24, 31, 36 coagulopathy 30, 34 fractured clavicle 25 allergies 8, 28 communication 2–4, 6, 28 congenital anomalies 21, 31, 34, 36 G amniotic fluid 21, 24 genetic screening 6, 8, 9 consultation 5, 10, 11, 37 amniotomy 17, 18 glucose screening 9 corticosteroids 11 ampicillin 12 gonorrhea 9 CRICO 1, 2, 24, 37 anaphylaxis 12 Group B Strep 9, 12 anesthesia 10, 21, 27, 29 D antenatal care 3, 8, 14 dehiscence 26 H handoffs: See transfer of patient care antenatal corticosteroids 11 depression 8, 9, 33 hepatitis B 6, 8, 9 antenatal record 2 dexamethasone 11 HIV 6, 8, 9 antenatal testing 11 diabetes 6, 9, 31, 33 houlder dystocia 38 antibody screen 8 discharge 21, 30, 33, 36 hyperstimulation 18, 24 Apgar 16, 26, 31, 34, 36 documentation 2, 3, 5–8, 10, 14, 15, 17–21, 23, hypertension 6, 31, 33 arterial blood gas 16, 34 25, 26, 28, 29, 35 hysterectomy 26, 28, 36 ASA 29, 30 domestic violence 6, 8, 33 augmentation 18, 27 dysmaturity syndrome 24 I auscultation 14 dystocia 2, 16, 25, 26, 38 incident reports 2, 6 induction of labor 10, 13, 17, 24, 25, 27, 36 B E informed consent 2, 3, 9, 14, 19, 21–23, 27, betamethasone 11 eclampsia 16, 32, 36 28, 35, 36 birth injury 36 elective delivery 13 intensive care (ICU) 36 bladder 19, 33, 38 electronic fetal monitoring 2, 14–16, 18, 21, 27 intracranial hemorrhage 34, 36 breastfeeding 9, 33 electronic health record 2 intrapartum antibiotics 12 breasts 8, 33 encephalopathy 31, 34 intrapartum temperature 12, 31 breech 3, 14, 21, 23 endotracheal intubation 29 epidural 27, 29 L C Level III nursery 34, 36 cardiopulmonary resuscitation 29 erythromycin 12 estimated date of delivery (EDD) 7, 8, 13, case load 13 M Category I 14, 21, 23 24, 27 macrosomia 24, 25 Category III 15, 18 extensive regional block 29, 30 malignant hyperthermia 30 cervical cytology 9 external cephalic version 3, 9, 21, 23, 28 maternal early warning system 32 cervical dilation 14, 15 meconium 14, 15, 24, 31, 36 F cervical ripening 10, 17, 27 fetal assessment 9, 11, 14, 15 medical record 2, 3–7, 15–26, 28, 33, 37 cervix 17, 19, 24 fetal demise 24 midwifery 6, 15, 32 cesarean 2, 3, 16, 17, 19, 22–25, 28, 29, 36 fetal lung maturity 7, 13, 17, 23 Misoprostol 27 cesarean delivery on maternal request 3, 27 fetal status 6, 14–19, 34, 37 multipara 24 chlamydia 9 fetal weight 11, 14, 22, 25 circumcision 3, 9, 35 first trimester 7, 8

N R neonatal sepsis 12 regional anesthesia 21, 29, 30 neuraxial anesthesia 29 resuscitation 29, 34, 37 newborn 9, 26, 29, 33–37 retained sponges and needles 20 NICU 11, 34, 36 Rh 8, 9, 21 non-stress test 11, 17, 21 risk management 6, 25, 26, 36 non-vertex presenting twin 3, 23 rubella 6, 8, 33 nullipara 24 rupture of the membranes 11, 12, 14, 19

O S oligohydramnios 24, 31 shoulder dystocia 2, 16, 25, 26, 38 operative delivery 13 signs of complications 33 operative injury 26 sonography 21, 24, 25 operative note 2, 19, 26 sponge count 20, 28 operative vaginal delivery 2, 19, 29 spontaneous rupture 14 oxytocin 11, 15, 17, 18, 22, 24, 27, 37 surgical pause 28, 35 syphilis 9 P PACU 30 T pain 14, 15, 23, 28, 35 telephone consultation 5 peer review 36 therapeutic hypothermia 16, 34, 36 penicillin 12 time-out 28, 29, 35 perinatal morbidity 22, 24, 26 tocolytics 3, 14, 21 placental pathology 31 transfer of patient care 4, 5 placenta previa 28, 31 transfusion 23, 26 planned cesarean delivery 12, 13 trauma 9, 19 postpartum care 9, 33 triage 14 postpartum depression 33 trial of labor 3, 26, 27 pre-anesthesia evaluation 29 twins 3, 23 preconception care 6 pregnancy termination 10 U ultrasound 2, 7, 9, 10, 13, 23 prenatal record 24, 25 umbilical artery blood 16, 34 prenatal visit 9 urine toxicology screening 9 pre-procedure 21, 29 uterine rupture 26, 27, 34, 36 preterm labor 9, 12 uterine tachysystole 17, 18, 24 previous cesarean 6, 14, 17, 26 primary cesarean 27 V prior pregnancies 14 vacuum 16, 19, 38 prolonged pregnancy 24 varicella 6, 9, 33 prostaglandin 17, 24, 27 ventilation 29, 34 protraction of labor 18 vertex 14, 19, 23

Acronyms and Definitions Below is a list of words, phrases, and acronyms used throughout the Guidelines that may be ambiguous or unfamiliar to some providers of obstetrical service.

ACOG • accelerations: absence of induced EDD American College of Obstetricians and accelerations after fetal stimulation Estimated date of delivery determined Gynecologists • periodic or episodic decelerations by a combination of historical, clinical, • recurrent variable decelerations and laboratory criteria. ACTIVE LABOR accompanied by minimal or moderate The second part of first stage labor, baseline variability FETAL DEMISE when the cervical dilation rate is • prolonged decelerations more than 2 In utero deaths occurring at 20 or maximal. minutes but less than 10 minutes more weeks gestation, or when the • recurrent late decelerations with fetal weight is 350 grams or greater. CATEGORY I moderate baseline variability FETAL HEART RATE (FHR) • variable decelerations with other FETAL LUNG MATURITY characteristics such as slow return to A pattern defined as: Fetal lungs have developed to the point baseline, overshoots, or “shoulders” • baseline FHR: 110–160 beats per that respiratory distress syndrome is not expected. minute, CATEGORY III FHR • baseline FHR variability: moderate, Includes either: • late or variable decelerations: absent, INFORMED CONSENT • early decelerations: present or absent, • absent baseline FHR variability and any A process for informing patients of the and of the following: risks, benefits, and alternatives involved • accelerations: present or absent. • recurrent late decelerations in the provision of specific medical care. • recurrent variable decelerations CATEGORY II FHR • bradycardia MEWS Includes all FHR tracings not • sinusoidal pattern Maternal early warning system categorized as Category I or Category CRICO III such as: MIDWIFE Controlled Risk Insurance Company, • baseline FHR For these Guidelines, the term refers the provider of medical professional • bradycardia not accompanied by to a certified nurse midwife working liability insurance for Harvard-affiliated absent baseline variability in a collaborative relationship with an physicians, hospitals, and their • tachycardia attending obstetrician. employees. • baseline FHR variability OPERATIVE DELIVERY • minimal • absent with no recurrent Non-spontaneous vaginal and cesarean decelerations deliveries. • marked