Evidence-Based Tools

Educational Stages

Adapted from:  Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com)


Seizure DDx

Differential diagnosis is broad, but consider these conditions which may mimic epileptic seizures:

  • Possible Seizures in Stroke Patients: The elderly population that is at the highest risk of stroke and TIA is also at risk for many of the conditions that can mimic seizures (see below)1
  • Syncope: Is often confused with seizures, due to the presentation of a stiff backward fall and short tonic and clinic manifestations. Syncope is most often distinguishable from epilepsy by examining the history immediately preceding the seizure. Syncope can be accompanied by lightheadedness, vertigo, warmth, nausea, diaphoresis, or prolonged sitting/standing. Often, syncope will occur from an upright position. It can also be accompanied by chest pain, palpitations, or be exercise-related - as well as micturition/defacation or pain1,2
  • Migraine: Migraines can be distinguished from seizures by their more gradual, often visual, warning and longer duration. Can be confused with potential seizures due to auras at onset and potential loss of consciousness1
  • TIAs: Some have remarked that seizures can be differentiated from TIAs because they produce "positive" symptoms (shaking, stiffening, hallucinations) while TIAs produce "negative" symptoms (weakness, sensory loss). That being said, there are "limb-shaking" TIAs that can be confused with seizures. They can be differentiated from seizures by their postural character (usually occurring on promptly on standing), and their involvement of arm, leg, or both - sparing facial muscles and cognition1
  • Sleep Disorders (Narcolepsy/cataplexy/parasomnias/REM Behavior Disorder): Differentiated from seizures in that eyes are usually closed, and that subject can be awakened with stimulation. However, parasomnias are often difficult to differentiate from nocturnal seizures - that being said, the onset of these is rare during adulthood and so it can be valuable to evaluate the patient's history. REM Behavior Disorder is distinguished from seizures by its often purposeful actions and facial actions1.
  • Psychogenic Nonepileptic Seizures: Most common in young adults - especially women. Typically longer, more waxing and waning, display less stereotypy, and have nonphysiologic progression. Eyes tend more often to be closed during unresponsive periods, and environmental precipitants are more likely. Those with psychiatric history are at higher risk3
  • Intracranial Pressure: Can result in temporary alteration in awareness and focal neurologic dysfunction, like seizures. Very often associated with headaches, and are associated with cranial masses masses or injuries1
  • Also consider hyperventilation syndrome and post-hypoxic myoclonus

References 

1. Steven Schater. Differential Diagnosis. Epilepsy Foundation. 2004. Differential Diagnosis | Epilepsy Foundation

2. Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com)

3. Steven Schater. Wrong Diagnosis. Epilepsy Foundation. 2008. Wrong Diagnosis | Epilepsy Foundation

 

 

This ultrasound shows a normal lung with sliding.

  • You can observe freer lung movement, as well as the two pleural lines shimmering just under the subcutaneous tissue. There is also an "ants marching" shimmering effect, which is indicative of normal sliding movement. On the pneumothorax US, there was no shimmering and highly restricted movement.
  • B-lines are present in this ultrasound (vertical shimmering lines beneath pleura), whereas they were absent in the pneumothorax US. In pneumothorax, B-lines are obstructed by the highly reflective surface created by the gas interface. 
  • There is decreased clarity of A-lines (horizontal lines deep to the pleural surface) in this ultrasound. In pneumothorax US, the clarity of these lines is accentuated

Source: Pulmonary — TPA (thepocusatlas.com)

Potential Cause

How to Identify

Treatments

Hypovolemia

Rapid heart rate and narrow QRS on ECG; other symptoms of low volume

Infusion of normal saline or Ringer’s lactate

Hypoxia

Slow heart rate

Airway management and effective oxygenation

Hydrogen ion excess (acidosis)

Low amplitude QRS on the ECG

Hyperventilation; consider sodium bicarbonate bolus

Hypoglycemia*

Bedside glucose testing

IV bolus of dextrose

Hypokalemia

Flat T waves and appearance of a U wave on the ECG

IV Magnesium infusion

Hyperkalemia

Peaked T waves and wide QRS complex on the ECG

Consider calcium chloride, sodium bicarbonate, and an insulin and glucose protocol

Hypothermia

Typically preceded by exposure to a cold environment

Gradual rewarming

Tension pneumothorax

Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing

Thoracostomy or needle decompression

Tamponade – Cardiac

Rapid heart rate and narrow QRS complexes on the ECG

Pericardiocentesis

Toxins

Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms

Based on the specific toxin

Thrombosis (pulmonary embolus)

Rapid heart rate with narrow QRS complexes on the ECG

Surgical embolectomy or administration of fibrinolytics

Thrombosis (myocardial infarction)

ECG will be abnormal based on the location of the infarction

Dependent on extent and age of MI

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

 

Source: Hs and Ts - ACLS Medical Training

Rapid Sequence Intubation

Rapid Sequence Intubation (RSI) is an airway management technique that creates the optimal conditions for intubation. It induces immediate unresponsiveness through an induction agent and muscular relaxation through a neuromuscular blocking agent1-3. It is generally seen as the fastest and most effective means of controlling the emergency airway.


Indications for Intubation

  • Airway protection and patency1
  • Respiratory failure, increased FRC, decreased WOB, secretion management/pulmonary toilet, facilitate bronchoscopy, decreased LOC1
  • Minimize oxygen consumption and optimize oxygen delivery (e.g. sepsis)1
  • Unresponsive to pain, terminate seizure, prevent secondary brain injury1
  • Temperature control1
  • Humanitarian reasons (e.g. procedures) and safety during transport (e.g. psychosis)1

In this scenario, RSI was indicated by decreased LOC (which increases the risk for airway deterioration) and by the upcoming patient transfer, where it would enhance safety during transport. 


Indications and Contraindications for RSI1

For

  • Lack of airway protection despite patency (swallow, gag, cough, positioning) hypoxia
  • Hypoventilation
  • Need for neuroprotection (target PaCO2)
  • Impending obstruction (e.g. airway burn, penetrating neck injury)
  • Prolonged transfer
  • Combativeness
  • Humane reasons (e.g. trauma involving multiple interventions)
  • Cervical Spine Injury (diaphragmatic paralysis)

 

Against

  • Urgent need to OT and theatre is available
  • Anatomically or pathologically difficult
    airway (e.g. congenital deformity, laryngeal fracture)
  • Close proximity to OT
  • Pediatric cases (Esp. <5 yrs old)
  • Hostile environment 
  • Poorly functioning team
  • Lack of skills among team
  • Emergency surgical airway is not possible (e.g. neck trauma, tumour)

 


Administer


Administer RSI: The 9 (or 10) Ps

  1.  Plan​​​​​​: Share your plan A and plan B (for potential difficult intubation) with your team4
  2. Preparation: Prepare oxygen, medications, suction, monitors, equipment, IV access, personnel4
  3. Protect the cervical spine: Maintain C-Spine immobilization throughout the entire intubation process4
  4. Positioning: Ear above the sternum (head flexion and neck extension). In some cases, hyperelevation may be beneficial (ramped position is preferred in obese)4
  5. Preoxygenation: Tight-fitting NRB mask to deliver 10-15L/min for at least 3 mins5
  6. Pretreatment: First medications should reduce patient's adverse response to subsequent meds and laryngoscopy - Atropine, Lidocaine, Fentanyl, Defasiculating agents4
  7. Paralysis and Induction: Administer induction agent to render patient unconscious and unresponsive, paralytic to eliminate muscle tone and prevent vomiting and aspiration4
  8. Placement with proof: Pass the tube and confirm with end-tidal CO24
  9. Post-intubation management: Secure tube, administer sedation and analgesia, place patient on ventilator4
  10. Pressure on cricoid: This is seen by many as optional1. Pressure is used to prevent air insufflation during positive pressure ventilation and passive regurgitation. Overcompressing can have severe consequences and should be avoided.4  

Planning for RSI - Equipment and Roles

Roles: Should be a minimum of 3 people - Airway proceduralist, Airway assistant, Drug administrator (Team leader can perform one of the above, but ideally should be in a separate standalone role)1

Other Roles: Person to perform MILS if indicated, Person to perform cricoid pressure (if necessary), Scribe1

Preparation requires control over: Self, Patient, Others, Environment

Mnemonics to assist with preparation1

O2 MARBLES SOAPME
  • Oxygen
  • Masks (NP, NRB, BVM) + Monitoring
  • Airway adjuncts (OPA, NPA, LMA); Ask for help and airway trolley
  • RSI drugs, Resus drugs
  • BVM, Bougie
  • Laryngoscopes; LMA
  • ETTs; ETCO2
  • Suction; State plan
  • Suction: at least one working suction, place between mattress and bed
  • Oxygen: NRBM and BVM attached to 15LPM O2 preferably w/ nasal prongs
  • Airways: 7.5 ET tube with stylet fits most adults. Stylet placed inside ET for rigidity,
    bend it 30 deg. Mac 3 or 4 blade for adults. Curved Miller 3 or 4 blade.
    Have backup surgical cric kit available. Laryngoscope, LMA, bougie at bedside
  • Preoxygenate: 15 LPM NRBM
  • Monitoring equipment and medications
  • End tidal CO2

Drugs: Premedication, Induction, Neuromuscular Blockers 

Premedication - Note: There is little evidence that these are beneficial clinically, outside of atropine in children. 

  • Lidocaine: 1mg/kg. Suppresses cough response, protects from increased ICP, attenuates hypertensive and tachycardia response to intubation6
  • Atropine: Minimum dose 0.1mg, dose 0.01mg/kg. Important in children to prevent reflex bradycardia. Dries secretions. Can worsen tachycardia.6
  • Fentanyl: 3mcg/kg.1
  • Defasiculating Agent: Use 1/10th the paralyzing dose of any paralytic. Use in patients who are at risk of adverse effects of succinylcholine.6

Induction1

  • Ketamine: 1.5-2mg/kg IV. Onset 60-90s, 10-20min Duration. Use in any RSI, especially if hemodynamically unstable or if reactive airways disease. Drawbacks are increased secretions, laryngospasm (rare), raised intra-ocular pressure, caution if cardiovascular disease.
  • Thiopentone: 3-5mg/kg IV. Onset 30-45s. 5-10min Duration. Use in any RSI if hemodynamically stable, status epilepticus. Drawbacks are histamine release, myocardial depression, vasodilation, hypotension. Must NOT inject intra-arterially due to risk of distal ischemia. 
  • Propofol: 1-2.5mg/kg IBW + (0.4TBW). Onset 15-45s. Duration 5-10min. Use in hemodynamically stable patients, reactive airways disease, status epilepticus. Drawbacks are hypotension, myocardial depression, reduced cerebral perfusion, pain on injection, variable response, very short-acting.
  • Fentanyl: 2-10mcg/kg TBW. Onset <60s. Duration dose-dependent. May used in a ’modified’ RSI approach in low doses or titrated to effect in cardiogenic shock and other hemodynamically unstable conditions. Drawbacks are respiratory depression, apnea, hypotension, slow onset, nausea and vomiting, muscular rigidity in high induction doses, bradycardia, tissue saturation at high doses.
  • Midazolam: 0.3mg/kg TBW. Onset 60-90s. Duraton 15-30min. Use not usually recommended for RSI, some practitioners use low doses of midazolam and fentanyl for RSI of shocked patients. Drawbacks are respiratory depression, apnea, hypotension, paradoxical agitation, slow onset, variable responses. 
  • Etomidate: 0.3mg/kg. Onset 10-15s. Suitable for most situations including haemodynamically unstable, other than sepsis or seizures. Drawbacks are adrenal suppression, myoclonus, pain on injection.

Paralytic Agents1

  • Succinylcholine/Suxamethonium: 1.5mg/kg IV and 4mg/kg IM (in extremist). Onset 45-60s. 6-10min duration. Widely used unless contra-indicated, ideal if need to extubate rapidly following an elective procedure or to assess neurology in an intubated patient. Drawbacks are that there are numerous contra-indications (hyperkalemia, malignant hyperthermia, >5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations. 
  • Rocuronium: 1.2mg/kg IV IBW. Onset 60s. Can be used for any RSI unless contra-indication or require rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e. immobile patient for cricothyroidotomy) – can be reversed by sugammadex. Some are allergic, though this is rare. 
  • Vecuronium: 0.15mg/kg IV. Onset 120-180s. Duration 45-60min. Generally not recommended for RSI, unless no suxamethonium or rocuronium cannot be used – can be reversed by sugammadex. Drawbacks are the possibility for allergic reactions, slow onset, and a long duration. 

References

1. Nickson C (2020). Rapid Sequence Intubation (RSI). Life in The Fast Lane. Rapid Sequence Intubation (RSI) • LITFL • CCC Airway
2. Rapid Sequence Intubation (RSI). Westchester Medical Centre Health Network. RSI Information Margaretville only 2.28.17.pdf (hahv.org)
3. Smith C (2001). Rapid Sequence Intubation in Adults: Indications and Concerns. Clinical Pulmonary Medicine. 8(3) pp147-165. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovfte&NEWS=N&AN=00045413-200105000-00004.
4. Braude D (2007). Ten Ps of Rapid Sequence Intubation. Emergency Medicine News. 29(1) pp8,12. doi: 10.1097/01.EEM.0000264634.15897.25
5. Szyld D (2010). Paucis Verbis card: Rapid Sequence Intubation. ALiEM. Paucis Verbis card: Rapid Sequence Intubation (aliem.com)
6. Vafier J (2008). Rapid Sequence Intubation. Virginia Department of HealthMicrosoft PowerPoint - RSI.ppt (virginia.gov)

Acute Respiratory Failure

Respiratory Distress: Dyspnea, tachypnea (RR > 20), decreased respirations (RR < 10) or wheezing, labored breathing, nasal flaring, grunting, accessory muscle use, retractions, cyanosis, respiratory arrest

Hypoxemic

Hypercapnic

Known as: Type I ARF, Lung Failure, Oxygenation Failure, Respiratory Insufficiency

Known as: Type II ARF, Pump Failure, Ventilatory Failure

Definition: The failure of the lungs and heart to provide adequate O2

Definition: The failure of the lungs to eliminate adequate CO2

Criteria:

PaO2 < 60mmHg on FiO2 > .50  

OR

PaO2 < 40mmHg on any FiO2
SaO2 < 90

OR

SpO2 < 91% on room air

OR

P/F ratio (PO2/FiO2)< 300
(SpO2 can be used as surrogate if PO2 unavailable)

Criteria:

paCO2 > 50mmHg w/ pH < 7.35

OR

If baseline known, paCO2 = baseline + 10-15mmHg

References: 

1. Pinson & Tang. Acute Respiratory Failure - All there is to Know. Pinson and Tang. September 2017. Acute Respiratory Failure - All There Is To Know | Pinson & Tang (pinsonandtang.com)

Potential Cause

How to Identify

Treatments

Hypovolemia

Rapid heart rate and narrow QRS on ECG; other symptoms of low volume

Infusion of normal saline or Ringer’s lactate

Hypoxia

Slow heart rate

Airway management and effective oxygenation

Hydrogen ion excess (acidosis)

Low amplitude QRS on the ECG

Hyperventilation; consider sodium bicarbonate bolus

Hypoglycemia*

Bedside glucose testing

IV bolus of dextrose

Hypokalemia

Flat T waves and appearance of a U wave on the ECG

IV Magnesium infusion

Hyperkalemia

Peaked T waves and wide QRS complex on the ECG

Consider calcium chloride, sodium bicarbonate, and an insulin and glucose protocol

Hypothermia

Typically preceded by exposure to a cold environment

Gradual rewarming

Tension pneumothorax

Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing

Thoracostomy or needle decompression

Tamponade – Cardiac

Rapid heart rate and narrow QRS complexes on the ECG

Pericardiocentesis

Toxins

Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms

Based on the specific toxin

Thrombosis (pulmonary embolus)

Rapid heart rate with narrow QRS complexes on the ECG

Surgical embolectomy or administration of fibrinolytics

Thrombosis (myocardial infarction)

ECG will be abnormal based on the location of the infarction

Dependent on extent and age of MI

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

 

Source: Hs and Ts - ACLS Medical Training

Cushing's Triad: Cushing's Triad is a set of three primary signs that often indicate an increased ICP. They are: a change in respirations - often irregular and deep, a widening pulse pressure, and bradycardia. 

Clinical Findings Indicating Elevated ICP in Children:

  • Headache
  • Vomiting
  • Altered Mental Status
  • Papilledema
  • Hypertension w/ bradycardia or tachycardia
  • Transtentorial herniation: Headache, Pupillary Changes, Altered LOC, Abnormal breathing, Localization of Noxious Stimuli
  • Foramen Magnum Herniation: Downbeat Nystagmus, Bradycardia, Bradypnea, Hypertension - May worsen with neck flexion and improve with extension
  • Subalcine Herniation: Uni- or Bilateral Weakness, Loss of Bladder Control, Coma
  • Other Findings (Less Common): Natural preference for knee-Chest position, Seizures, Spontaneous upper eyelid closing when an abrupt increase in CVP is transmitted, Transient (5-15min) epidermal flushing involving upper chest, face, or arms during deterioration

Reference

1. Robert C Tasker. Elevated Intracranial Pressure (ICP) in Children: Clinical Manifestations and Diagnosis. UpToDate. 13 Feb 2020. Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis - UpToDate

EARLY INVOLVEMENT OF A NEUROSURGEON SHOULD OCCUR FOR ALL CHILDREN WITH SIGNS OF INCREASED ICP OR HERNIATION, IF POSSIBLE

General Measures for Stabilization and Management of Increased ICP

1. Secure the airway with RSI (using C-Spine immobilization in trauma patients) for the following:

  • Signs of herniation
  • Refractory hypoxia
  • Hypoventilation
  • GCS < 8 or < 12 and rapidly declining
  • Loss of airway protective reflexes

Maintain PaCO2 at 35 to 40mmHg in intubated patients, unless signs of herniation

2. Rapid treatment of hypoxia, hypercarbia, hypotension, maintain normal oxygenation
3. Check for, and treat, hypoglycemia + Maintain hemoglobin >70g/L
4. Elevate head 15-30 degrees and keep head midline
5. Aggressively treat fever using antipyretics or cooling blankets
6. Maintain paralysis and control shivering using muscle relaxants (vecuronium, rocuronium)
7. Administer prophylactic anticonvulsants (levetiracetam, phenytoin, phenobarbital) to those who are at high risk of seizure (severe TBI, depressed skull fracture, parenchymal abnormalities)
8. Maintain adequate analgesia (to blunt response to noxious stimuli) and sedation 

9. For Intubated Patients: 

  • Maintain head midline position and tape (instead of tying) endotracheal tubes to face
  • Avoid high PIP and PEEP as long as oxygenation and ventilation are maintained
  • Administer lidocaine 1mg/kg IV before suction of the endotracheal tube

 References

1. Robert Tasker. Elevated Intracranial Pressure (ICP) in Children: Management. UpToDate. 4 January 2021. Elevated intracranial pressure (ICP) in children: Management - UpToDate

Indications for Intubation1

This is a clinical decision, there is no lab value that will define a need to intubate

  1.  Progressive exhaustion/fatigue with altered mental status
  2. Severe VQ mismatch
  3. Acute Asphyxial Asthma
  4. Need for transport to another centre 

Initial Ventilator Settings1

Hypercapnia is preferable to hyperinflation, and is tolerable in many cases to avoid more serious lung/airway trauma and complications.

  • Mode: No evidence for one over another. Many start with Volume-Control
  • Tidal Volume: 6-10ml/kg ideal BW
  • Expiratoy Time: 4-5s, want long I:E (from 1:4 to 1:8) to avoid stacking breaths with barotrauma
  • RR: Below physiologic rate for age. Controlled hypoventilation has been shown to be safe
  • PEEP: 0 in acute phase
  • FiO2: Start at 100%, titrate to keep SATs >90%
  • Keep Child adequately sedated
    • Avoid patient-ventilator asynchrony
    • Decrease CO2 production
    • Consider Ketamine
    • Avoid prolonged neuromuscular paralysis if possible
  • Keep Plateau Pressures <30 cmH20
    • Increased risk of barotrauma above this
    • Measured by end-inspiratory pause of several seconds in system w/o leaks

References 

1. Sean M Fox. Mechanical Ventilation for Severe Asthma. Pediatric EM Morsels. 7 November 2014. Mechanical Ventilation for Severe Asthma in Pediatrics (pedemmorsels.com)

1. Disconnect from Ventilator and allow chest to recoil

  • If hemodynamics improve, restart ventilator at lower tidal volume and RR
  • If hemodynamics don't improve, consider other complications

2. Consider Typical complications

  • Dislodged ETT Tube: Verify with End-Tidal CO2 Monitoring, videoscopic laryngoscope, or ultrasound
  • Obstructed ETT Tube: Suction the tube
  • Pneumothorax: Consider x-ray or ultrasound. If confirmed, proceed with needle thoracostomy/chest tube
  • Equipment Failure

3. Other Complications

  • Hypoxemia
    • Exclude right mainstem intubation
    • Exclude pneumothorax and place pleural drain
    • Determine cause - check tube obstruction (kinking, biting of tube, plugging), check settings, reassess frequently, check for bronchospasm
  • Hypotension
    • Exclude other causes like myocardial infarction and sepsis
    • Trial apnea or hypopnea to decrease intrathoracic pressure unless there is unequivocal evidence of pneumothorax (this can be both diagnostic and therapeutic for lung hyperinflation)
    • Decrease RR and adjust to allow for short inspiration and longer expiration
    • Administer fluids
    • Critical hypotension with no identifiable reversible cause is indication for epinephrine
  • Cardiac Arrest
    • Consider pneumothorax early
    • Trial apnea or hypopnea for no more than 30-60s with external compressions and volume challenge. This is therapeutic for lung hyperinflation as a cause of cardiac arrest
    • Consider external chest compressions, volume challenge, and epinephrine

References 

1. Sean M Fox. Mechanical Ventilation for Severe Asthma. Pediatric EM Morsels. 7 November 2014. Mechanical Ventilation for Severe Asthma in Pediatrics (pedemmorsels.com)

2. Barry Brenner, Thomas Corbridge, Antoine Kazzi. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proceedings of the American Thoracic Society. 2009. 6(4) pp371-379. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure | Proceedings of the American Thoracic Society (atsjournals.org)

S

Setting Up

  • Arrange for privacy
  • Involve significant others, sit down, establish rapport, manage time constraints and interruptions
  • What time would suit you and your family members to chat about your results?

P

Perception of condition/seriousness

  • Determine what they know
  • Listen to their level of comprehension, accept denial but do not confront at this stage
  • Explain to me what you understand about your test/results?

I

Invitation from the patient to give information

  • Ask what they want to know about the details of their situation, accept their right not to know
  • Offer to answer questions later
  • Would you like me to explain exactly what your results/tests are/mean?

K

Knowledge: giving medical facts

  • Use language that the patient can understand
  • Give information in small chunks
  • Consider patient background
  • Check if patient understands what you have said, respond to reactions as they occur
  • When we examined your chest x-ray we saw a small visible mass, this is usually an indication of cancer. Is this making sense to you?

E

Explore emotions and empathize

  • Prepare to give an empathetic response
  • Identify emotions expressed by the patient
  • Identify the cause/source of emotion, give the patient time to express their feelings
  • Has this all made sense to you?
  • How are you feeling?

S

Strategy and Summary

  • Close the discussion
  • Ask whether they want to clarify anything else
  • Decide on a strategy going forward/next actions
  • Offer plan for next meeting
  • Has this all made sense?
  • What other questions do you have?

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Empathetic Statements Exploratory Questions Validating Response
“I can see how upsetting this is to you.” “How do you mean?” “I can understand how you felt that way.”
“I can tell you weren't expecting to hear this.” “Tell me more about it.” “I guess anyone might have that same reaction.”
“I know this is not good news for you.” “Could you explain what you mean?” “You were perfectly correct to think that way.”
“I'm sorry to have to tell you this.” “You said it frightened you?” “Yes, your understanding of the reason for the tests is very good.”
“This is very difficult for me also.” “Could you tell me what you're worried about?” “It appears that you've thought things through very well.”
“I was also hoping for a better result.” “Now, you said you were concerned about your children. Tell me more.” “Many other patients have had a similar experience.”

 

Source: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Recognizing an Inferior STEMI on an ECG1,2

  • ST elevation in leads II, III, and aVF 
  • Progressive development of Q waves in II, III, and aVF
  • Reciprocal ST depression in aVL (+ lead I)
  • Hyperacute T waves may precede these changes
  • Associated features:
    • Concommitant right ventricular infarction (40% of patients) 
    • Significant bradycardia due to second or third-degree AV block (20%)
    • Posterior infarction due to extension of infarct area
    • ST elevation in lead III > lead II

Determining which artery is the culprit1

  • 98% of STEMIs are in the right coronary artery (RCA) or left circumflex artery (LCx)
    • RCA - 80%
    • LCx - 18% 
  • The remaining 2% occur in the left anterior descending artery (LAD), producing concomitant inferior and anterior ST elevation

References

1. Ed Burns and Robert Buttner. Inferior STEMI. Life in the Fast Lane. 8 February 2021. Inferior STEMI • LITFL • ECG Library Diagnosis

2. Cardiac Care Network. STEMI Education for Emergency Department. CorHealth Ontario. ND. PowerPoint Presentation (corhealthontario.ca)

3. Huang et al. New ST-segment algorithms to determine culprit artery location in acutre inferior myocardial infarction. The American Journal of Family Medicine. Sep 2016. 34(9). pp1772-1778. https://doi.org/10.1016/j.ajem.2016.06.005

Biochemical Criteria of DKA
Hyperglycemia
  • Blood glucose > 11mmol/L (200mg/dL)
Metabolic Acidosis
  • Either
    • Venous PH < 7.3 
    • Serum bicarbonate <15 mEq/L
Ketosis
  • Either
    • Beta-hydroxybutyrate > 3mmol/L
    • Moderate to large urine ketones
Assessing Severity of Pediatric DKA
Defining Features Severe Moderate Mild
Venous pH <7.1 7.1-<7.2 7.2-<7.3
Serum bicarbonate (mEq/L)* <5* 5-9 10-<15*

*For particularly vulnerable patients like young children or in resource-limited settings, these thresholds may be raised to heighten sensitivity


References

1. Nicole Glaiser. Diabetic Ketoacidosis in Children: Clinical Features and Diagnosis. UpToDate. 30 October 2020. UpToDate

2018 Canadian Diabetes Association DKA Guidelines treatment algorithm, adapted from https://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf


Source: DKA Recognition and ED Management | Emergency Medicine Cases

Generally, you should avoid intubating a DKA patient, for several reasons:

  • Respiratory dynamics of hyperpnea to correct their metabolic acidosis means that the ventilator must match their large tidal volume and RR. This puts them at risk for ventilator-induced lung injury and development of ARDS1
  • Patients with profound metabolic acidosis are at risk of circulatory collapse peri-intubation as periods of apnea during intubation will cause PCO2 to rise rapidly1
  • DKA patients are often compensating for low bicarb with respiratory alkalosis. Difficulties intubating puts patient at risk for extremely high PaCO2 and very low pH2
  • DKA patients may develop gastroparesis and are at risk for aspiration2
  • It is generally impossible/very difficult to generate the same level of respiratory alkalosis on ventilator that a strong non-intubated patient can generate2

Intubate if2:

  • Decision to intubate is a clinical decision
  • Prolonged changes in mental status
  • They are no longer able to protect their airway
  • If close observation and serial evaluation indicate it

When Intubating1:

  • Resuscitate before you intubate
  • Consider ketamine +/- paralytic; continue bagging if paralytic used to avoid any period of apnea
  • Consider antiemetic
  • Consider giving IV bolus bicarb, esp. if serum bicarb <10
  • High tidal volume (8cc/kg) and RR (24-28) to hyperventilate/match pre-intubation RR
  • Consider asking for additional help/anesthesiology consult

References

1. Helman, A. Baimel, M. Sommer, L. Tillmann, B. Episode 146 – DKA Recognition and ED Management. Emergency Medicine Cases. September, 2020. https://emergencymedicinecases.com/dka-recognition-ed-management

2. Josh Farkas. PulmCrit - Four DKA Pearls. PulmCrit (EMCrit). May 2014. PulmCrit - Four DKA Pearls (emcrit.org)

Potential Cause

How to Identify

Treatments

Hypovolemia

Rapid heart rate and narrow QRS on ECG; other symptoms of low volume

Infusion of normal saline or Ringer’s lactate

Hypoxia

Slow heart rate

Airway management and effective oxygenation

Hydrogen ion excess (acidosis)

Low amplitude QRS on the ECG

Hyperventilation; consider sodium bicarbonate bolus

Hypoglycemia*

Bedside glucose testing

IV bolus of dextrose

Hypokalemia

Flat T waves and appearance of a U wave on the ECG

IV Magnesium infusion

Hyperkalemia

Peaked T waves and wide QRS complex on the ECG

Consider calcium chloride, sodium bicarbonate, and an insulin and glucose protocol

Hypothermia

Typically preceded by exposure to a cold environment

Gradual rewarming

Tension pneumothorax

Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing

Thoracostomy or needle decompression

Tamponade – Cardiac

Rapid heart rate and narrow QRS complexes on the ECG

Pericardiocentesis

Toxins

Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms

Based on the specific toxin

Thrombosis (pulmonary embolus)

Rapid heart rate with narrow QRS complexes on the ECG

Surgical embolectomy or administration of fibrinolytics

Thrombosis (myocardial infarction)

ECG will be abnormal based on the location of the infarction

Dependent on extent and age of MI

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

 

Source: Hs and Ts - ACLS Medical Training

S

Setting Up

  • Arrange for privacy
  • Involve significant others, sit down, establish rapport, manage time constraints and interruptions
  • What time would suit you and your family members to chat about your results?

P

Perception of condition/seriousness

  • Determine what they know
  • Listen to their level of comprehension, accept denial but do not confront at this stage
  • Explain to me what you understand about your test/results?

I

Invitation from the patient to give information

  • Ask what they want to know about the details of their situation, accept their right not to know
  • Offer to answer questions later
  • Would you like me to explain exactly what your results/tests are/mean?

K

Knowledge: giving medical facts

  • Use language that the patient can understand
  • Give information in small chunks
  • Consider patient background
  • Check if patient understands what you have said, respond to reactions as they occur
  • When we examined your chest x-ray we saw a small visible mass, this is usually an indication of cancer. Is this making sense to you?

E

Explore emotions and empathize

  • Prepare to give an empathetic response
  • Identify emotions expressed by the patient
  • Identify the cause/source of emotion, give the patient time to express their feelings
  • Has this all made sense to you?
  • How are you feeling?

S

Strategy and Summary

  • Close the discussion
  • Ask whether they want to clarify anything else
  • Decide on a strategy going forward/next actions
  • Offer plan for next meeting
  • Has this all made sense?
  • What other questions do you have?

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Empathetic Statements Exploratory Questions Validating Response
“I can see how upsetting this is to you.” “How do you mean?” “I can understand how you felt that way.”
“I can tell you weren't expecting to hear this.” “Tell me more about it.” “I guess anyone might have that same reaction.”
“I know this is not good news for you.” “Could you explain what you mean?” “You were perfectly correct to think that way.”
“I'm sorry to have to tell you this.” “You said it frightened you?” “Yes, your understanding of the reason for the tests is very good.”
“This is very difficult for me also.” “Could you tell me what you're worried about?” “It appears that you've thought things through very well.”
“I was also hoping for a better result.” “Now, you said you were concerned about your children. Tell me more.” “Many other patients have had a similar experience.”

 

Source: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

S

Setting Up

  • Arrange for privacy
  • Involve significant others, sit down, establish rapport, manage time constraints and interruptions
  • What time would suit you and your family members to chat about your results?

P

Perception of condition/seriousness

  • Determine what they know
  • Listen to their level of comprehension, accept denial but do not confront at this stage
  • Explain to me what you understand about your test/results?

I

Invitation from the patient to give information

  • Ask what they want to know about the details of their situation, accept their right not to know
  • Offer to answer questions later
  • Would you like me to explain exactly what your results/tests are/mean?

K

Knowledge: giving medical facts

  • Use language that the patient can understand
  • Give information in small chunks
  • Consider patient background
  • Check if patient understands what you have said, respond to reactions as they occur
  • When we examined your chest x-ray we saw a small visible mass, this is usually an indication of cancer. Is this making sense to you?

E

Explore emotions and empathize

  • Prepare to give an empathetic response
  • Identify emotions expressed by the patient
  • Identify the cause/source of emotion, give the patient time to express their feelings
  • Has this all made sense to you?
  • How are you feeling?

S

Strategy and Summary

  • Close the discussion
  • Ask whether they want to clarify anything else
  • Decide on a strategy going forward/next actions
  • Offer plan for next meeting
  • Has this all made sense?
  • What other questions do you have?

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

STOP for 5 Minutes

  1. Thank the team and ask “Is everyone ok?” If YES, continue with debrief

Things to STATE FIRST:

  • We are going to have a 5 minute debrief
  • The purpose is to improve patient care, it is not a blaming session
  • Participation is welcome but not necessary
  • All information discussed here is confidential

S

Summarize the case

  • Collect facts about the case
  • Create common understanding of what happened
  • Can be best if the team leader provides the summary

T

Things that went well

  • Identify what went well
  • All team members can contribute, all opinions valued equally

O

Opportunities to improve

  • Identify areas for improvement, both at a skills/knowledge level and at a hospital systems level
  • All team members should contribute, and all opinions equally valued

P

Points to action and responsibilities

  • Identify points of action going forward, to address opportunities for improvement or simply as next steps
  • Delineate clear responsibilities to address those points to action

Adapted From: Walker CA, McGregor L, Taylor C, Robinson S. STOP5: a hot debrief model for resuscitation cases in the emergency department. Clin Exp Emerg Med. 2020;7(4):259-266. doi:10.15441/ceem.19.086

The following are indicators of Opioid Overdose:

  • Altered mental status ranging from mild euphoria or lethargy to coma
  • Miotic pupils
  • Decreased bowel sounds
  • Low-to-normal heart rate and blood pressure
  • Hypoventilation
  • Possible clonus

Reference: A Stolbach. 2022. Acute Opioid Intoxication in Adults. UpToDate. 

1.  Reviewing the tracheostomy tube and its pieces

 

It is important to collect laryngectomy and tracheostomy history from this patient because:

Laryngectomy History: If the patient has had their larynx removed, the upper airway is not connected to the trachea. Oral ventilation and oral intubation would thus be impossible. They would need to be ventilated and intubated through the stoma. 

Tracheostomy History: If the tracheostomy is less than 7 days old, and the airway is patent (no laryngectomy), then oral intubation of the patient is preferred

1. Total breech extraction should not be performed to deliver singleton breech.
2. Delivery of the breech wit hthe woman in the upright position, or in the all fours position, may reduce the need for intervention
3. Necessity of pushing in second stage of labour should be explained to the woman
4. Provide adequate analgesia. Be aware that dense epidural analgesia will hamper maternal pushing efforts
5. Spontaneous descent and expulsion to the umbilicus should occur with maternal pushing only: DO NOT PULL ON BREECH
6. Episiotomy may be considered once anterior buttock and anus are crowning
7. Spontaneous delivery of enture breech fetus is desirable. Delivery of aftercoming head may be facilitated by adequate maternal pushing efforts, oxytocin augmentation after delivery of fetal body or uterin fundal pressure. Assisted deivery is acceptable if there is delay in delivery. Following manoeuvres may be required:
    a. Pinard's manoeuvre to deliver the fetal legs may be considered once popliteal fossae visible
    b. Lovset's manoeuvre to deliver nuchal arms 
8. Support baby to maintain head in a flexed position and body in a horizontal position. Delivery of the aftercoming head may be achieved with maternal pushing efforts alone. Oxytocin augmentation or uterin fundal pressure can be used to treat expulsive delay after the breech has crowned.
9. Failing these, the Mauriceau-Smellie-Viet manoeuvre, or Piper forceps, may be required to deliver head in flexion

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

1. Insert two fingers along one leg to the knee 
2. Abduct knee away from midline while flexing the leg at the hip
3. This will cause spontaneous flexion of the knee and delivery of the foot
4. Knees of frank breech are hyperextended, and it is important to correctly identify popliteal fossae to avoid further hyperextension

 

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022. 

A1. Grasp fetus by bony pelvis with 2 hands and raise towards maternal pubic symphisis
A2. Turn fetal torso while lowering it to bring shoulder underneath pubic symphisis
B1.  Sweep humerus of posterior arm across chest to release 
A3. Rotate fetal trunk back through a sacrum-anterior position to the other side
B2. Sweep humerus of remaining arm across chest to release 

 

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

 

 

1. Place one hand underneath fetus and palpate the fetal maxilla. Have assistant maintain suprapubic pressure.
2. Apply pressure to fetal maxilla to flex head
3. Grasp fetal shoulders with other hand to apply gentle traction
4. Maintain flexion of head and suprapubic pressure while applying traction to aid delivery

Source
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022. 

1. Elevate fetal body using warm towel
2. Apply left blade of forceps to aftercoming head
3. Apply right blade of forceps with body still elevated
4. With body still elevated, use forceps to deliver head

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

 

Apgar Score
Record score 1-5 mins after birth

Indicator

0 Points

1 Point

2 Points

A

Activity

(Muscle Tone)

Absent

Some tone and flexion

Active motion with flexed muscle tone

P

Pulse

Absent

Less than 100bpm

100+ bpm

G

Grimace

(Reflex irritability)

Floppy, No response to stimulation

Grimacing

Cries, coughs, or sneezes

A

Appearance

(Skin Color)

Pale or blue

Pink but blue extremities

Entirely pink

R

Respiration

Absent

Slow, irregular, weak, or gasping

Crying vigorously

Total Score:
0-3: Low
4-6: Moderately Abnormal
7-10: Normal

 

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

There are two equations that can be used to calculate the anion gap. It is common practice to use the second one, but the first is more accurate:

1. Na+ + K+ - Cl- - HCO3-
2. Na+- Cl- - HCO3-

Normal anion gap when including K+ is 12-20meEQ/L1
When not including K+, normal anion gap is 12 + 41

 

DDx of Elevated Anion Gap - MUDPILES Mnemonic1

M - Methanol, Metformin
U- Uremia
D - DKA
P - Paraldehyde, phenformin
I - Iron, INH, Ibuprofen (large ingestions)
L - Lactic Acidosis
E - Ethylene Glycol
S - Salicylates

Other possibilities: Starvation/ETOH ketoacidosis, Carbon monoxide, CN poisoning, Colchicine, Toluene, Chronic acetaminophen use


References:

1. Fields A, Iacomini P, Cunningham R, Miller CM, Ross J, Lu K, Davey M, Young N, Ostermayer D, Donaldson R. Anion Gap. WikEM. Feb 2021. wikem.org/wiki/Anion_gap

 

 

Inclusion Criteria - Only apply to patients with GCS 13-15 and at least one of the following:

  • Loss of consciousness on injury
  • Amnesia to the head injury event
  • Witnessed disorientation

Exclusion Criteria - If any of the following are true, Canadian CT Head Rules do not apply:

  • Age < 16 years
  • Patient on blood thinners
  • Seizure after injury

Medium Risk Criteria - Presence of one or more indicate medium risk for brain injury on CT

  • Retrograde amnesia to the event > 30 minutes
  • Dangerous Mechanism - e.g. pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from >3 feet or >5 stairs

High Risk - Presence of one or more indicate high risk for brain injury on CT and possible need for neurological

  • GCS <15 at 2 hours after injury
  • Suspected open or depressed skull fracture
  • Signs of basilar skull fracture (hemotympanum, "racoon" eyes, CSF otorrhea/rhinorrhea, battle's sign)
  • Age > 65 years
  • > 2 vomiting episodes

 

Source: MD Calc

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

A table with text and imagesDescription automatically generated

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

A diagram of a baby's head

Description automatically generated

Reference(s): 
Retrieved January 4, 2024 from 
https://www.doctorstock.com/image/I0000pff4Hvr0dFc
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

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A diagram of a baby's breastDescription automatically generated

Reference(s): 
Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/postpartum-hemorrhage/
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Classification of Placental Abruption:

Abruption Definition Management
Mild Abruption with no fetal compromise
  • Conservative managemeent if preterm
  • Initiate delivery if term 
Moderate  Abruption with fetal compromise
  • Emergency delivery (regardless of gestational age)
Severe Abruption with fetal death
  • Initiate delivery (non-emergent)
  • Be vigilant for disseminated intravascular coagulopathy


Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/antepartum-hemorrhage

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Do Not
1. Pull, on the head
2. Push, on the fundus
3. Pivot or rotate the head
4. Panic
ALARMER Mneumonic for Shoulder Dystocia Management
Note: Ask the woman to push after each maneuver. Avoid pushing between contractions while maneuvers are carried out to maximize cerebral perfusion. 
A: Ask for help
  • Appropriate equipment and personnel
  • Cooperate with support person
  • Recognize initial presentation of turtle sign (fetal head delivers and retracts onto the perineum)
L: Lift/Hyperflex legs

McRoberts Maneuver
1. Flatten the head of the bed. 
2. Bring the woman to the end of the bed. 
3. Hyperflex both legs at the hip (knees bent to woman's shoulders to increase the AP pelvic diameter).

A: Anterior Shoulder Disimpaction Abdominal Approach
1. Assistant applies steady or rocking suprapubic pressure with heel of clasped hands from the posterior aspect of the anterior shoulder to dislodge it.
2. Attempt with McRoberts maneuver.

Vaginal Approach (Rubin Maneuver)
1. Advance your index finger, middle finger, or whole hand laterally and apply pressure to the posterior aspect of the anterior shoulder (push the shoulder towards the chest or apply pressure to the scapula of the anterior shoulder). 
2. Adduct the anterior shoulder. 

R: Rotation of the posterior shoulder

Woods Maneuver (Screw-like Maneuver)
1. Apply pressure with whole hand in vagina to the anterior aspect of the posterior shoulder. 
2. Attempt to rotate the posterior shoulder to an anterior position. 
Alternative: Rotate posterior shoulder in the opposite direction with pressure on the posterior aspect to collapse the biacromial diameter.

Note: No fundal pressure or pulling. May combine maneuvers with anterior disimpaction maneuvers.

M: Manual removal of the posterior arm

The arm is usually flexed at the elbow. If the arm is NOT flexed, 
1. Apply pressure to the antecubital fossa and splint the humerus. 
2. Grasp the hand and sweep the arm over the fetal chest.
3. Grasp the wrist/forearm and deliver the arm. 
Note: If the fetal abdomen faces the maternal right, the left hand is grasped (and vice versa). 

Alternate maneuver or if the posterior hand cannot be reached, deliver the posterior shoulder using axillary traction:
1. Assistant gently flexes the fetal head toward the anterior shoulder. 
2. Place your middle finger into the fetus' posterior axillary fold and apply downward traction.
Alternative: Place your middle fingers from both hands (one from anterior and the other from posterior) in the posterior axilla and apply downward traction. 

Note: Once the shoulder has been brought down sufficiently, the posterior arm can be grasped and delivered. These maneuvers may release the anterior shoulder or allow a rotation maneuver to release the anterior shoulder. Fractures of the humerus can heal, however, brachial plexus palsies may be permanent. 

E: Episiotomy Note: An episiotomy may facilitate the Woods maneuver or manual removal of the posterior arm by creating more space. However, shoulder dystocia is NOT caused by obstructing soft tissue, therefore, performing an episiotomy on its own will not relieve a shoulder dystocia. 
R: Roll over onto "all fours"

Gaskin's Maneuver
1. Move the woman onto "all fours" with her back arched.
Objective: Increase pelvic dimensions and shift fetal position. This creates easier access to the posterior shoulder for rotational maneuvers and removal of the posterior arm. 

2. Apply gentle downward pressure on the posterior shoulder of the fetus.
Note: Can do with epidural analgesia (unless the degree of motor block makes turning and maintaining the position impossible).

Last Resort: 
1. Zavanelli Maneuver (Cephalic Replacement): 
Reversing the cardinal movements of labour.
- Rotate the head to the occiput anterior position
- Rotate, flex the head, and push it up
- Rotate the head to the transverse, disengage the head, and perform a cesarean delivery 
2. Symphysiotomy: Surgically remove the cartilage of the symphysis pubis to increase the size of the pelvic outlet. 
3. Break Clavicle: Apply direct upward pressure on the mid-portion of the fetal clavicle. 


Figure retrieved July 2, 2023 from https://www.glowm.com/pdf/aip%20chap13%20shoulder%20dystocia.pdf

Videos: 
Shoulder Dystocia & ALARMER Mnemonic (8.5 min.): https://youtu.be/BvkKMwDaryg
ALARMER Mnemonic (8.5 min.): https://youtu.be/jNmSJDbTARw

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

 

Apgar Score
Record score 1-5 mins after birth

Indicator

0 Points

1 Point

2 Points

A

Activity

(Muscle Tone)

Absent

Some tone and flexion

Active motion with flexed muscle tone

P

Pulse

Absent

Less than 100bpm

100+ bpm

G

Grimace

(Reflex irritability)

Floppy, No response to stimulation

Grimacing

Cries, coughs, or sneezes

A

Appearance

(Skin Color)

Pale or blue

Pink but blue extremities

Entirely pink

R

Respiration

Absent

Slow, irregular, weak, or gasping

Crying vigorously

Total Score:
0-3: Low
4-6: Moderately Abnormal
7-10: Normal

 

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

Signs of Placental Separation

1. Gush of blood 
2. Cord lengthening 
3. Uterine fundus rising in the abdomen 
4. Uterus becoming firmer

Active Management 
  • Oxytocin (10 IU IM or 5 IU by slow IV push over 1-2min or 20-40 IU in 100mL normal saline at 150mL/hour) - after delivery of the anterior shoulder to prevent PPH 
    • Oxytocin not available, use Misoprostol (400mcg SL) 
    • Medications not available, encourage breastfeeding 
  • Controlled cord traction: Traction applied in the axis of the pelvis (45 degrees from horizontal) during a contraction. Apply external counter traction (one hand supporting the uterus above the uterus above the pubic bone). - see Cord Traction Education, Note: Excessive traction may tear the umbilical cord or placenta 
  • Ensure all membranes are delivered 
  • Assess amount of bleeding and fundus (ensure it is well contracted)
    • If the uterus is not contracted, perform uterine massage 
  • Inspect the placenta

 

Drug Name

Characteristics

Side Effects

PPH Usage 

Medication Class: Oxytocics

Oxytocin 

Preferred first line uterotonic 

 

Stimulates muscle of upper uterine segment causing contraction to compress blood vessels 

 

IV: acts immediately 

IM: 3-5 minutes 

Rare: nausea, vomiting, headache, flushing

 

Never give as IV bolus → hypotension, tachycardia & potential cardiovascular collapse possible 

 

Water intoxication with high doses, prolonged infusion, or  hypotonic IV solution → Use normal saline or Ringers Lactate 

Prevention 

Vaginal Delivery:

  • 10 IU IM or 
  • 5 IU IV over 1-2min or 
  • 20-40 IU in 1000 mL, 150 mL/hour 

Cesarean (elective):

  • Bolus 1 IU 
  • Start infusion at 2.5-7.5 IU/hour (0.04-0.125 IU/min) 

Cesarean (intrapartum): 

  • 3 IU over ≥ 30 seconds 
  • Start infusion at 7.5-15 IU/h (0.125-0.25 IU/ min) 

Treatment: 20-40 IU in 1000 mL normal saline, initially wide open 

Carbetocin 

Long-acting oxytocin analogue 

 

Alternative agent if oxytocin is not available or consider if pt. is at high risk of PPH 

Nausea, vomiting, flushing, headache 

Prevention 

Vaginal Delivery: 100 mcg IM 

Cesarean: 100 mcg over ≥ 30 seconds

Treatment: Limited data available 

Medication Class: Ergot Alkaloids

Ergot Alkaloids

Stimulates myometrium of upper AND lower uterine segments 

IM: 2-5 minutes 

IV: acts <1 minute (however, IV not recommended) 

Nausea, vomiting, hypertension 

Contraindicated in all hypertensive disorders of pregnancy 

Prevention: 0.2-0.25 mg IM 

Treatment: 0.2-0.25 mg IM (may repeat at 2h intervals)

Medication Class: Prostaglandins 

Misoprostol 

Prostaglandin E1

Causes vasoconstriction & enhanced contractility of the myometrium 

Fever (most common with >600 mcg) 

Prevention: 400 mcg SL (SL achieves highest serum peak level)

Treatment 
Fastest Acting: 400 mcg SL
Alternate: 800 mcg REC

Carboprost 

Prostaglandin F2α

Causes vasoconstriction & enhanced contractility of myometrium 

Vomiting, diarrhea, fever, bronchospasm

Use with extreme caution if asthma or major cardiovascular, renal, or hepatic dysfunction) 

Treatment
250 mcg IM or intramyometrial q15min (maximum 8 doses, aka 2mg)

Medication Class: Tranexamic Acid 

Tranexamic Acid  

Not a uterotonic 
 

Inhibits fibrinolysis 
 

Consider in pt. at very high risk of PPH 

N/A

Prevention 

Vaginal Delivery: 1 g IV over 10 minutes within 10 minutes after vaginal delivery 

Cesarean: 1 g IV over 10 minutes before skin incision 

Treatment
1 g IV over 10 minutes within 3h of PPH diagnosis 

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Contraindications to planned vaginal delivery breech.

Contraindications to planned vaginal delivery breech.

  • Cord presentation
  • Footling breech presentation (one or both hip(s) extended)
  • Hyperextended fetal head
  • Clinically inadequate maternal pelvis
  • Fetal anomaly incompatible with vaginal delivery
  • Fetal macrosomia (EFW >4000g)
  • Fetal growth restriction (EFW <2800g)

Breech Delivery Technique Notes

Delivery Technique

  • Total breech extraction, where a hand is reached into the uterus and fetus delivered, should not be used for term singleton breech delivery.
  • Note on analgesics: Dense epidural analgesia will impact maternal effort.
  • Delivery with the woman upright or on her hands and knees may assist the delivery.
  • Spontaneous or assisted breech delivery is acceptable.
  • Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. Do not pull on the breech.
  • Rotation to a sacrum anterior position usually occurs spontaneously and is desired.
  • If the fetus appears to be rotating to a sacrum posterior position, grasp the fetal pelvis and gently rotate to a sacrum anterior position.
  • Spontaneous delivery of the entire breech fetus is desirable. Assisted breech delivery is acceptable if there is a delay in delivery, and the following maneuvers may be required:
  • Pinard’s maneuver once the popliteal fossae are visible,
  • Nuchal arms may be reduced by the Bickenbach or Løvset’s maneuvers.
  • For expulsive delay after the breech has crowned, power from above is likely safer than traction from below.
  • Techniques to maximize power from above include effective maternal effort and hands and knees posture. Fundal pressure and oxytocin augmentation can be used after the fetus has crowned.
  • Support the fetus to maintain the head in a flexed position and the body in a horizontal position.
  • If the above maneuvers fail, the Mauriceau-Smellie-Veit maneuver or Piper forceps may be required to deliver the head in flexion.

In the rare circumstance of a trapped aftercoming head or irreducible nuchal arms perform a symphysiotomy or Zavanelli maneuver.

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Pinard’s Maneuver: deliver fetal legs once the popliteal fossae are visible.

1. Insert two fingers along one leg to the knee.
2. 
Abduct the knee away from midline while simultaneously flexing the leg at the hip (This causes spontaneous flexion of the knee and delivery of the foot).

Note: The knees of a frank breech are hyperextended at this point. It is important to correctly identify the popliteal fossae to avoid further hyperextension and damage to the fetal knee.

Bracht’s Maneuver: suprapubic pressure with the extension of the fetal neck.
After delivery of the arms, have an assistant apply suprapubic pressure while the fetus is grasped by the hips and lifted with two hands toward the mother’s stomach, without traction, allowing the neck to pivot around the symphysis.

Bickenbach Maneuver: reduction of the nuchal arms.

Release of the posterior arm.
1. 
Grasp the legs at the ankles and raise them briskly until the fetal body is near vertical.
2. 
Reach a vaginal hand into the sacral hollow and sweep the humerus from posterior to anterior across the fetal chest.

Release of the anterior arm.
1. 
Lower the fetal body briskly toward the floor until the axilla appears at the introitus.
2. Reach a vaginal hand behind the pubic symphysis and sweep the humerus from posterior to anterior across the fetal chest.

Løvset’s Maneuver: reduction of the nuchal arms.

Release of the posterior arm.
1. 
Grasp the fetus by the bony pelvis with two hands and raise it towards the maternal pubic symphysis.
2. Turn the fetal torso while lowering it to allow the fetal humerus to be swept out under the pubic symphysis.

Release of the first arm brings the other arm posteriorly.
1. Rotate the fetal trunk back through a sacrum-anterior position to the other side to allow the remaining arm to similarly be swept out under the pubic symphysis. 

Mauriceau-Smellie-Veit Maneuver: delivery of the aftercoming head.

Note: As the fetal head is being delivered, flexion of the head is maintained by suprapubic pressure provided by an assistant, and simultaneously by pressure on the maxilla (inset) by the operator as traction is applied.

Piper forceps: delivery of the aftercoming head.

Note: The blue arrows show the direction of movement. The fetal body is elevated using a warm towel and the left blade of the forceps is applied to the aftercoming head. The right blade is applied with the body still elevated.

Videos: 
Breech Delivery Technique (4 min): https://youtu.be/d9pU_6LDVUM
In-depth Technique Explanations (12 min) – Includes Piper Forceps Delivery: https://youtu.be/xOqWT06qVS8

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

FHR Pattern (VEAL) Cause (CHOP) Management (MINE)
V Variable Deceleration C Cord Compression M Maternal Repositioning
E Early Deceleration H Head Compression I Identify Labour Progress
A Acceleration O Okay! N No Intervention
L Late Deceleration P Placental Insufficiency E Evaluate (reposition, fluids, oxygen, emergency delivery).

 

A pink and blue medical chart

Description automatically generated

Retrieved July 17, 2023, from Melbourne University Obstetrics and Gynecology Society (Facebook)


Norwitz E. R. (2022). Eclampsia. In Barss V (Ed.), UpToDate. Retrieved July 4, 2023, from https://www.uptodate.com/contents/eclampsia

Brandt-Andrews Maneuver (preferred): an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord.

Reference(s): 
Anderson, Janice M, and Duncan Etches. 2007. Prevention and Management of Postpartum Hemorrhage. www.aafp.org/afp. (October 12, 2023).

FHR Pattern (VEAL) Cause (CHOP) Management (MINE)
V Variable Deceleration C Cord Compression M Maternal Repositioning
E Early Deceleration H Head Compression I Identify Labour Progress
A Acceleration O Okay! N No Intervention
L Late Deceleration P Placental Insufficiency E Evaluate (reposition, fluids, oxygen, emergency delivery).

 

A pink and blue medical chart

Description automatically generated

Retrieved July 17, 2023, from Melbourne University Obstetrics and Gynecology Society (Facebook)

Important Notes Regarding Pharmacological use in Labour: 

  • Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
  • No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
  • Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
  • A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
  • When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
  • Action should be taken to prevent toxicity with all local anesthetics.
  • Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

  • Opioids 
    • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
    • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
      • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
    • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

Stage of Labour

Nulliparous

Parous 

Latent Stage:

IM/SC Morphine 

IM/SC Morphine

Early Active Stage: 

IM/SC or IV Morphine

IV Morphine or Fentanyl

Late Active Stage:

IV Morphine or Fentanyl

IV Fentanyl

Second Stage: 

IV Fentanyl

IV Fentanyl 

  • Nitrous Oxide 
    • Has been shown to provide mild analgesia, but high patient satisfaction.
      • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
    • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
    • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
    • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
    • It must be self-administered for safety reasons via a demand-valve.
    • Should be used in a well-ventilated room for workplace safety.
      • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
    • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
  • Peripheral Nerve Blocks 
    • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
    • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
    • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
  • Neuraxial Anesthesia 
    • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
    • Quite common in Canada and remains the most effective form of labour analgesia
    • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
    • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s): 

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Important Notes Regarding Pharmacological use in Labour: 

  • Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
  • No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
  • Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
  • A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
  • When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
  • Action should be taken to prevent toxicity with all local anesthetics.
  • Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

  • Opioids 
    • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
    • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
      • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
    • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

Stage of Labour

Nulliparous

Parous 

Latent Stage:

IM/SC Morphine 

IM/SC Morphine

Early Active Stage: 

IM/SC or IV Morphine

IV Morphine or Fentanyl

Late Active Stage:

IV Morphine or Fentanyl

IV Fentanyl

Second Stage: 

IV Fentanyl

IV Fentanyl 

  • Nitrous Oxide 
    • Has been shown to provide mild analgesia, but high patient satisfaction.
      • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
    • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
    • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
    • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
    • It must be self-administered for safety reasons via a demand-valve.
    • Should be used in a well-ventilated room for workplace safety.
      • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
    • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
  • Peripheral Nerve Blocks 
    • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
    • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
    • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
  • Neuraxial Anesthesia 
    • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
    • Quite common in Canada and remains the most effective form of labour analgesia
    • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
    • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s): 

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Important Notes Regarding Pharmacological use in Labour: 

  • Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
  • No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
  • Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
  • A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
  • When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
  • Action should be taken to prevent toxicity with all local anesthetics.
  • Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

  • Opioids 
    • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
    • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
      • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
    • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

Stage of Labour

Nulliparous

Parous 

Latent Stage:

IM/SC Morphine 

IM/SC Morphine

Early Active Stage: 

IM/SC or IV Morphine

IV Morphine or Fentanyl

Late Active Stage:

IV Morphine or Fentanyl

IV Fentanyl

Second Stage: 

IV Fentanyl

IV Fentanyl 

  • Nitrous Oxide 
    • Has been shown to provide mild analgesia, but high patient satisfaction.
      • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
    • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
    • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
    • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
    • It must be self-administered for safety reasons via a demand-valve.
    • Should be used in a well-ventilated room for workplace safety.
      • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
    • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
  • Peripheral Nerve Blocks 
    • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
    • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
    • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
  • Neuraxial Anesthesia 
    • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
    • Quite common in Canada and remains the most effective form of labour analgesia
    • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
    • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s): 

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Date and Time

ID 

  • Age
  • GxPx - see below.
  • Gestational Age (GA)
  • Estimated Date of Delivery (EDD)
  • EDC 
  • Group B Strep (GBS) 
  • Rh status

CC

  • Contractions
  • Per Vag (PV) blood loss: amount, pain, Rh Status
  • Ruptured membranes
  • Fetal movement
  • Infection: fever, pain, GBS status
  • Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions 

  1. Contractions 
  • Since when 
  • How close together (q x min) 
  • How long (x sec) 
  • How painful 
  1. Bleeding 
  • Since when 
  • How much (pads) 
  • Colour (pinky vs. brownish vs. bright red) 
  • Pain 
  • Last ultrasound 
  • Trauma/intercourse 
  1. Fluid (Rupture of Membranes - ROM)
  • Since when 
  • Large gush vs. trickle 
  • Soaked pants 
  • Clear vs. green vs. red 
  • Continuous 
  1. Fetal Movement (FM) 
  • As much as usual?
  • Time since last movement 
  • Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

  • Antenatal screening (genetic screening, Rh status, serology) 
  • Previous U/S
  • Biophysical profile (BPP) score 
  • Growth 
  • Estimated Fetal Weight (EFW) 
  • Presentation 
  • Last Vaginal Exam 
  • Complications  
  • Gestational Diabetes (GDM) 
  • Group B Strep (GBS) result
  • HTN
  • Infection
  • Twins 

OBHx: Outcomes of previous pregnancies 

  • Year
  • Term/premature
  • Miscarriages/abortions 
  • Vaginal or C-section delivery 
  • Use of vacuum or forceps 
  • Size of babies
  • Length of labours
  • Complications

PMHx

  • Medications (dose & route of admin) 
  • Allergies (include reactions) 
  • Surgical history 
  • Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

  • Maternal Vitals
  • Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
  • Uterine Activity Characteristics (frequency, duration, intensity, resting tone) 
  • Position of Baby - Leopold’s Maneuvers 
  • Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation) 
  • Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test 
  • Ultrasound
  • Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL 

G = Gravidity → total # of pregnancies 
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity total # of pregnancies 
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks) 
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age) 

  • Induced (therapeutic) & spontaneous (misscarriage) 

L = number of living children 

 

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy. 
This can be described as: G4P2 in GxPx format or  G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

  • First: to determine which fetal part is lying furthest away from pelvic inlet 
  • Second: to determine the location of the fetal back 
  • Third: to determine which fetal part is lying above the pelvic inlet 
  • Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

  1. Fetal Lie
  2. Fetal Presentation 
  3. Fetal Position 
  4. Fetal Attitude 
  5. Station 
  6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus 

  1. Longitudinal (0 degrees) - most common 
  2. Transverse (45 degrees) 
  3. Oblique (90 degrees) 

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis) 

Cephalic (head down in pelvic inlet) - most common 
Breech (bum of feet) 
- Frank breech - bum presenting, knees extended (pike position)  
- Complete - cannon ball position 
- Single footling breech 
- Double footling breech 

Compound (more than one part presenting - e.g., cephalic or breech + extremity  
Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis 

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down)
- Left OA - fetal back faces left, anterior fontanelle faces right (most common position)
- Right OA - fetal back faces right, anterior fontanelle faces left  
Occiput Posterior (OP) - fetal occiput towards sacral promontory 
Sacrum - direction of fetal sacrum in breech presentation 
Mentum - (chin) in extended cephalic (aka face) presentation 

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common) 
Forehead/Military - partial flexion 
Brow - partial extension 
Face - maximum extension 
- Mentum anterior - chin to pubic symphysis 
- Mentum posterior - chin to coccyx

*spontaneous vaginal delivery possible in all attitudes  

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine 
Positive (+) = below ischial spine 
0 = at level of ischial spine 
Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged 

6. Synclitism: Parallelism between pelvic plane and plane of fetal head 

Synclitism - posture in which the 2 parietal bones are at the same level
Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head
- Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible
- Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section 

Date and Time

ID 

  • Age
  • GxPx - see below.
  • Gestational Age (GA)
  • Estimated Date of Delivery (EDD)
  • EDC 
  • Group B Strep (GBS) 
  • Rh status

CC

  • Contractions
  • Per Vag (PV) blood loss: amount, pain, Rh Status
  • Ruptured membranes
  • Fetal movement
  • Infection: fever, pain, GBS status
  • Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions 

  1. Contractions 
  • Since when 
  • How close together (q x min) 
  • How long (x sec) 
  • How painful 
  1. Bleeding 
  • Since when 
  • How much (pads) 
  • Colour (pinky vs. brownish vs. bright red) 
  • Pain 
  • Last ultrasound 
  • Trauma/intercourse 
  1. Fluid (Rupture of Membranes - ROM)
  • Since when 
  • Large gush vs. trickle 
  • Soaked pants 
  • Clear vs. green vs. red 
  • Continuous 
  1. Fetal Movement (FM) 
  • As much as usual?
  • Time since last movement 
  • Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

  • Antenatal screening (genetic screening, Rh status, serology) 
  • Previous U/S
  • Biophysical profile (BPP) score 
  • Growth 
  • Estimated Fetal Weight (EFW) 
  • Presentation 
  • Last Vaginal Exam 
  • Complications  
  • Gestational Diabetes (GDM) 
  • Group B Strep (GBS) result
  • HTN
  • Infection
  • Twins 

OBHx: Outcomes of previous pregnancies 

  • Year
  • Term/premature
  • Miscarriages/abortions 
  • Vaginal or C-section delivery 
  • Use of vacuum or forceps 
  • Size of babies
  • Length of labours
  • Complications

PMHx

  • Medications (dose & route of admin) 
  • Allergies (include reactions) 
  • Surgical history 
  • Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

  • Maternal Vitals
  • Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
  • Uterine Activity Characteristics (frequency, duration, intensity, resting tone) 
  • Position of Baby - Leopold’s Maneuvers 
  • Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation) 
  • Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test 
  • Ultrasound
  • Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL 

G = Gravidity → total # of pregnancies 
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity total # of pregnancies 
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks) 
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age) 

  • Induced (therapeutic) & spontaneous (misscarriage) 

L = number of living children 

 

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy. 
This can be described as: G4P2 in GxPx format or  G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

  • First: to determine which fetal part is lying furthest away from pelvic inlet 
  • Second: to determine the location of the fetal back 
  • Third: to determine which fetal part is lying above the pelvic inlet 
  • Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

  1. Fetal Lie
  2. Fetal Presentation 
  3. Fetal Position 
  4. Fetal Attitude 
  5. Station 
  6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus 

  1. Longitudinal (0 degrees) - most common 
  2. Transverse (45 degrees) 
  3. Oblique (90 degrees) 

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis) 

Cephalic (head down in pelvic inlet) - most common 
Breech (bum of feet) 
- Frank breech - bum presenting, knees extended (pike position)  
- Complete - cannon ball position 
- Single footling breech 
- Double footling breech 

Compound (more than one part presenting - e.g., cephalic or breech + extremity  
Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis 

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down)
- Left OA - fetal back faces left, anterior fontanelle faces right (most common position)
- Right OA - fetal back faces right, anterior fontanelle faces left  
Occiput Posterior (OP) - fetal occiput towards sacral promontory 
Sacrum - direction of fetal sacrum in breech presentation 
Mentum - (chin) in extended cephalic (aka face) presentation 

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common) 
Forehead/Military - partial flexion 
Brow - partial extension 
Face - maximum extension 
- Mentum anterior - chin to pubic symphysis 
- Mentum posterior - chin to coccyx

*spontaneous vaginal delivery possible in all attitudes  

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine 
Positive (+) = below ischial spine 
0 = at level of ischial spine 
Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged 

6. Synclitism: Parallelism between pelvic plane and plane of fetal head 

Synclitism - posture in which the 2 parietal bones are at the same level
Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head
- Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible
- Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section 

Date and Time

ID 

  • Age
  • GxPx - see below.
  • Gestational Age (GA)
  • Estimated Date of Delivery (EDD)
  • EDC 
  • Group B Strep (GBS) 
  • Rh status

CC

  • Contractions
  • Per Vag (PV) blood loss: amount, pain, Rh Status
  • Ruptured membranes
  • Fetal movement
  • Infection: fever, pain, GBS status
  • Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions 

  1. Contractions 
  • Since when 
  • How close together (q x min) 
  • How long (x sec) 
  • How painful 
  1. Bleeding 
  • Since when 
  • How much (pads) 
  • Colour (pinky vs. brownish vs. bright red) 
  • Pain 
  • Last ultrasound 
  • Trauma/intercourse 
  1. Fluid (Rupture of Membranes - ROM)
  • Since when 
  • Large gush vs. trickle 
  • Soaked pants 
  • Clear vs. green vs. red 
  • Continuous 
  1. Fetal Movement (FM) 
  • As much as usual?
  • Time since last movement 
  • Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

  • Antenatal screening (genetic screening, Rh status, serology) 
  • Previous U/S
  • Biophysical profile (BPP) score 
  • Growth 
  • Estimated Fetal Weight (EFW) 
  • Presentation 
  • Last Vaginal Exam 
  • Complications  
  • Gestational Diabetes (GDM) 
  • Group B Strep (GBS) result
  • HTN
  • Infection
  • Twins 

OBHx: Outcomes of previous pregnancies 

  • Year
  • Term/premature
  • Miscarriages/abortions 
  • Vaginal or C-section delivery 
  • Use of vacuum or forceps 
  • Size of babies
  • Length of labours
  • Complications

PMHx

  • Medications (dose & route of admin) 
  • Allergies (include reactions) 
  • Surgical history 
  • Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

  • Maternal Vitals
  • Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
  • Uterine Activity Characteristics (frequency, duration, intensity, resting tone) 
  • Position of Baby - Leopold’s Maneuvers 
  • Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation) 
  • Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test 
  • Ultrasound
  • Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL 

G = Gravidity → total # of pregnancies 
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity total # of pregnancies 
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks) 
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age) 

  • Induced (therapeutic) & spontaneous (misscarriage) 

L = number of living children 

 

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy. 
This can be described as: G4P2 in GxPx format or  G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

  • First: to determine which fetal part is lying furthest away from pelvic inlet 
  • Second: to determine the location of the fetal back 
  • Third: to determine which fetal part is lying above the pelvic inlet 
  • Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

  1. Fetal Lie
  2. Fetal Presentation 
  3. Fetal Position 
  4. Fetal Attitude 
  5. Station 
  6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus 

  1. Longitudinal (0 degrees) - most common 
  2. Transverse (45 degrees) 
  3. Oblique (90 degrees) 

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis) 

Cephalic (head down in pelvic inlet) - most common 
Breech (bum of feet) 
- Frank breech - bum presenting, knees extended (pike position)  
- Complete - cannon ball position 
- Single footling breech 
- Double footling breech 

Compound (more than one part presenting - e.g., cephalic or breech + extremity  
Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis 

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down)
- Left OA - fetal back faces left, anterior fontanelle faces right (most common position)
- Right OA - fetal back faces right, anterior fontanelle faces left  
Occiput Posterior (OP) - fetal occiput towards sacral promontory 
Sacrum - direction of fetal sacrum in breech presentation 
Mentum - (chin) in extended cephalic (aka face) presentation 

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common) 
Forehead/Military - partial flexion 
Brow - partial extension 
Face - maximum extension 
- Mentum anterior - chin to pubic symphysis 
- Mentum posterior - chin to coccyx

*spontaneous vaginal delivery possible in all attitudes  

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine 
Positive (+) = below ischial spine 
0 = at level of ischial spine 
Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged 

6. Synclitism: Parallelism between pelvic plane and plane of fetal head 

Synclitism - posture in which the 2 parietal bones are at the same level
Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head
- Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible
- Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section 

Date and Time

ID 

  • Age
  • GxPx - see below.
  • Gestational Age (GA)
  • Estimated Date of Delivery (EDD)
  • EDC 
  • Group B Strep (GBS) 
  • Rh status

CC

  • Contractions
  • Per Vag (PV) blood loss: amount, pain, Rh Status
  • Ruptured membranes
  • Fetal movement
  • Infection: fever, pain, GBS status
  • Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions 

  1. Contractions 
  • Since when 
  • How close together (q x min) 
  • How long (x sec) 
  • How painful 
  1. Bleeding 
  • Since when 
  • How much (pads) 
  • Colour (pinky vs. brownish vs. bright red) 
  • Pain 
  • Last ultrasound 
  • Trauma/intercourse 
  1. Fluid (Rupture of Membranes - ROM)
  • Since when 
  • Large gush vs. trickle 
  • Soaked pants 
  • Clear vs. green vs. red 
  • Continuous 
  1. Fetal Movement (FM) 
  • As much as usual?
  • Time since last movement 
  • Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

  • Antenatal screening (genetic screening, Rh status, serology) 
  • Previous U/S
  • Biophysical profile (BPP) score 
  • Growth 
  • Estimated Fetal Weight (EFW) 
  • Presentation 
  • Last Vaginal Exam 
  • Complications  
  • Gestational Diabetes (GDM) 
  • Group B Strep (GBS) result
  • HTN
  • Infection
  • Twins 

OBHx: Outcomes of previous pregnancies 

  • Year
  • Term/premature
  • Miscarriages/abortions 
  • Vaginal or C-section delivery 
  • Use of vacuum or forceps 
  • Size of babies
  • Length of labours
  • Complications

PMHx

  • Medications (dose & route of admin) 
  • Allergies (include reactions) 
  • Surgical history 
  • Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

  • Maternal Vitals
  • Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
  • Uterine Activity Characteristics (frequency, duration, intensity, resting tone) 
  • Position of Baby - Leopold’s Maneuvers 
  • Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation) 
  • Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test 
  • Ultrasound
  • Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL 

G = Gravidity → total # of pregnancies 
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity total # of pregnancies 
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks) 
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age) 

  • Induced (therapeutic) & spontaneous (misscarriage) 

L = number of living children 

 

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy. 
This can be described as: G4P2 in GxPx format or  G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

  • First: to determine which fetal part is lying furthest away from pelvic inlet 
  • Second: to determine the location of the fetal back 
  • Third: to determine which fetal part is lying above the pelvic inlet 
  • Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

  1. Fetal Lie
  2. Fetal Presentation 
  3. Fetal Position 
  4. Fetal Attitude 
  5. Station 
  6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus 

  1. Longitudinal (0 degrees) - most common 
  2. Transverse (45 degrees) 
  3. Oblique (90 degrees) 

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis) 

Cephalic (head down in pelvic inlet) - most common 
Breech (bum of feet) 
- Frank breech - bum presenting, knees extended (pike position)  
- Complete - cannon ball position 
- Single footling breech 
- Double footling breech 

Compound (more than one part presenting - e.g., cephalic or breech + extremity  
Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis 

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down)
- Left OA - fetal back faces left, anterior fontanelle faces right (most common position)
- Right OA - fetal back faces right, anterior fontanelle faces left  
Occiput Posterior (OP) - fetal occiput towards sacral promontory 
Sacrum - direction of fetal sacrum in breech presentation 
Mentum - (chin) in extended cephalic (aka face) presentation 

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common) 
Forehead/Military - partial flexion 
Brow - partial extension 
Face - maximum extension 
- Mentum anterior - chin to pubic symphysis 
- Mentum posterior - chin to coccyx

*spontaneous vaginal delivery possible in all attitudes  

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine 
Positive (+) = below ischial spine 
0 = at level of ischial spine 
Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged 

6. Synclitism: Parallelism between pelvic plane and plane of fetal head 

Synclitism - posture in which the 2 parietal bones are at the same level
Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head
- Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible
- Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section 

Date and Time

ID 

  • Age
  • GxPx - see below.
  • Gestational Age (GA)
  • Estimated Date of Delivery (EDD)
  • EDC 
  • Group B Strep (GBS) 
  • Rh status

CC

  • Contractions
  • Per Vag (PV) blood loss: amount, pain, Rh Status
  • Ruptured membranes
  • Fetal movement
  • Infection: fever, pain, GBS status
  • Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions 

  1. Contractions 
  • Since when 
  • How close together (q x min) 
  • How long (x sec) 
  • How painful 
  1. Bleeding 
  • Since when 
  • How much (pads) 
  • Colour (pinky vs. brownish vs. bright red) 
  • Pain 
  • Last ultrasound 
  • Trauma/intercourse 
  1. Fluid (Rupture of Membranes - ROM)
  • Since when 
  • Large gush vs. trickle 
  • Soaked pants 
  • Clear vs. green vs. red 
  • Continuous 
  1. Fetal Movement (FM) 
  • As much as usual?
  • Time since last movement 
  • Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

  • Antenatal screening (genetic screening, Rh status, serology) 
  • Previous U/S
  • Biophysical profile (BPP) score 
  • Growth 
  • Estimated Fetal Weight (EFW) 
  • Presentation 
  • Last Vaginal Exam 
  • Complications  
  • Gestational Diabetes (GDM) 
  • Group B Strep (GBS) result
  • HTN
  • Infection
  • Twins 

OBHx: Outcomes of previous pregnancies 

  • Year
  • Term/premature
  • Miscarriages/abortions 
  • Vaginal or C-section delivery 
  • Use of vacuum or forceps 
  • Size of babies
  • Length of labours
  • Complications

PMHx

  • Medications (dose & route of admin) 
  • Allergies (include reactions) 
  • Surgical history 
  • Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

  • Maternal Vitals
  • Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
  • Uterine Activity Characteristics (frequency, duration, intensity, resting tone) 
  • Position of Baby - Leopold’s Maneuvers 
  • Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation) 
  • Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test 
  • Ultrasound
  • Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL 

G = Gravidity → total # of pregnancies 
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity total # of pregnancies 
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks) 
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age) 

  • Induced (therapeutic) & spontaneous (misscarriage) 

L = number of living children 

 

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy. 
This can be described as: G4P2 in GxPx format or  G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

  • First: to determine which fetal part is lying furthest away from pelvic inlet 
  • Second: to determine the location of the fetal back 
  • Third: to determine which fetal part is lying above the pelvic inlet 
  • Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

  1. Fetal Lie
  2. Fetal Presentation 
  3. Fetal Position 
  4. Fetal Attitude 
  5. Station 
  6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus 

  1. Longitudinal (0 degrees) - most common 
  2. Transverse (45 degrees) 
  3. Oblique (90 degrees) 

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis) 

Cephalic (head down in pelvic inlet) - most common 
Breech (bum of feet) 
- Frank breech - bum presenting, knees extended (pike position)  
- Complete - cannon ball position 
- Single footling breech 
- Double footling breech 

Compound (more than one part presenting - e.g., cephalic or breech + extremity  
Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis 

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down)
- Left OA - fetal back faces left, anterior fontanelle faces right (most common position)
- Right OA - fetal back faces right, anterior fontanelle faces left  
Occiput Posterior (OP) - fetal occiput towards sacral promontory 
Sacrum - direction of fetal sacrum in breech presentation 
Mentum - (chin) in extended cephalic (aka face) presentation 

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common) 
Forehead/Military - partial flexion 
Brow - partial extension 
Face - maximum extension 
- Mentum anterior - chin to pubic symphysis 
- Mentum posterior - chin to coccyx

*spontaneous vaginal delivery possible in all attitudes  

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine 
Positive (+) = below ischial spine 
0 = at level of ischial spine 
Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged 

6. Synclitism: Parallelism between pelvic plane and plane of fetal head 

Synclitism - posture in which the 2 parietal bones are at the same level
Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head
- Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible
- Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section 

Compress the uterus against the anterior part of the cervix with a hand in the vagina and a hand on the fundus. 

Retrieved July 20, 2023 from Bromberek, Elaine & Smereck, Janet. (2017). Evaluation and Treatment of Postpartum Hemorrhage. 10.1007/978-3-319-54410-6_8.

Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

FHR Pattern (VEAL) Cause (CHOP) Management (MINE)
V Variable Deceleration C Cord Compression M Maternal Repositioning
E Early Deceleration H Head Compression I Identify Labour Progress
A Acceleration O Okay! N No Intervention
L Late Deceleration P Placental Insufficiency E Evaluate (reposition, fluids, oxygen, emergency delivery).

 

A pink and blue medical chart

Description automatically generated

Retrieved July 17, 2023, from Melbourne University Obstetrics and Gynecology Society (Facebook)

Assessing Contraction Pattern 

Methods of Assessment 

Palpation by Hand

  • Can assess frequency & duration of contractions
  • Estimate intensity & resting tone

Tocodynamometer (external)

  • Assesses relative frequency & duration 
  • Cannot measure intensity or resting tone

Internal Intrauterine Pressure Catheter (IUPC) 

  • Most accurate 
  • Invasive - use if uterus not easily palpated or external provide inadequate info  

Characteristics of Contractions 

Frequency

Duration

Intensity

Resting Tone 

# of contractions in 10 minutes, averaged over 30 minutes 

Normal: ≤ 5 in 10 mins

# of seconds from beginning to end of contraction 

Normal: <90 s

Strength of contraction  

By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented)

Normal (IUPC): 25-75 mmHg above baseline  

Firmness between contractions 

Palpation: soft or firm
IUPC: in mmHg

Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion 

Normal (IUPC): 7-25 mmHg 

Abnormal Contraction Pattern 

Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) 

Characteristics: 

>5 contractions per 10-min period averaged over 30 mins and/or 
Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or 
Prolonged contraction lasting >90s 

Impact: Can reduce placental perfusion & result in fetal hypoxemia 
Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ) 

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Reference(s): 
Society of Obstetricians