Obstetrics and Maternal-Fetal Medicine

01Purpose and scope

• This manual supports the course Obstetrics and Maternal-Fetal Medicine. It describes how obstetric care is actually delivered, from the first prenatal visit through the early postpartum period, with extra attention to pregnancies that need closer watching. The intended readers include obstetric residents, midwives, labor and delivery nurses, maternal-fetal medicine fellows, sonographers, and the charge staff who coordinate them. It is written as a working reference, so it focuses on tasks, decisions, and the records that follow from them rather than on underlying physiology, which textbooks cover in depth.
• The scope covers antepartum care for low-risk and high-risk pregnancies, fetal surveillance, intrapartum management, operative and nonoperative delivery, obstetric emergencies such as hemorrhage and hypertensive disorders, and postpartum recovery. It does not set the protocols for any single hospital. Local policy, the scope of practice granted to each clinician, and the rules of the regulator in your jurisdiction decide what is permitted where you work. This guidance does not replace qualified professional judgment, approved procedures, or the authorization required before a procedure or medication is given.

02Core principles

• Care in this field serves two patients at once, and the mother's condition usually determines the fetus's status first. A sustained drop in maternal blood pressure can reduce placental perfusion within minutes, so the team watches the mother as closely as the fetal monitor.
• Risk is dynamic. A pregnancy classified as low risk at intake can change category after a bleeding episode, a new blood pressure reading, or a change in the fetal heart rate pattern. Reassessment at defined points is part of routine work, not an exception to it.
• Decisions are shared. Patients receive information about options, expected benefits, and risks in language they can follow, and their stated preferences are recorded. The clinician still owns the medical recommendation, and the chart should show both the recommendation and the patient's response.
• Communication must be structured. Standard handoff formats, closed-loop orders, and read-back of critical values reduce the chance that an important finding stays with only one person. Communication breakdowns appear repeatedly in reviews of serious obstetric events, which is why these habits are emphasized in every workflow below.

03Planning and preparation

• Planning starts before the patient arrives. Units should know the current staffing, operating room readiness, blood bank supply, emergency medication stock, and the nearest level of maternal and neonatal intensive care. Ask whether the unit can manage the expected case mix. If it cannot, know the transfer pathway, the transport team contact, and the typical transport time.
• At intake, confirm gestational age using the best available dating information, such as an early ultrasound measurement when one exists. Record blood type, antibody screen, infectious disease screening results, obstetric history, surgical history, current medications, and allergies. Any missing item should be flagged with an owner and a due time so it does not sit unnoticed.
• Prepare the patient's plan in advance where possible. For a planned cesarean, confirm the consent discussion and the surgical date. For a trial of labor after a prior cesarean, confirm the type of prior uterine incision and the facility policy governing that decision. For any labor with a known risk factor, define in writing the findings that would trigger a change in plan.
• Equipment checks matter as much as paperwork. Fetal monitors, pulse oximeters, infusion pumps, blood pressure cuffs, and the hemorrhage cart should be tested on a set schedule, with the date and the name of the checker logged. A monitor that drifts or a pump with a stale drug library can cause harm even when the clinician is skilled.

04Recommended workflow

1. 1
   : Complete intake and risk stratification. Take the history, record vital signs, and order initial laboratory tests. Assign a risk category using the unit's tool, and document the assignment in the chart within the time window set by local policy.
2. 2
   : Schedule antepartum visits by gestational age and risk category. Review glucose screening results, growth scans, and any fetal surveillance testing that applies to the case. Adjust the plan as results return, and tell the patient what changed and why.
3. 3
   : Perform the admission assessment for labor or induction. Confirm membrane status, perform a cervical examination, establish the fetal heart rate baseline, and characterize contractions. Record maternal vital signs at intervals that the protocol specifies for the stage of labor.
4. 4
   : Maintain ongoing intrapartum surveillance. Interpret each fetal heart rate tracing using the NICHD three-tier system or the equivalent scheme your unit uses, and document the tier and any change over time. After each intervention, such as repositioning, intravenous fluid, oxygen, or a change in oxytocin, reassess and record the result.
5. 5
   : Decide on the route of delivery with the patient. Document the indication, the options discussed, the risks and benefits explained, and the patient's response. For an urgent cesarean, record the decision time and the urgency category used by your hospital, and obtain consent unless a documented emergency exception applies under local law.
6. 6
   : Deliver and provide immediate care. Record the names and roles of the delivery team members, confirm that a neonatal resuscitation team is present when indicated, and follow the uterotonic plan. Measure blood loss quantitatively and examine the placenta before it leaves the room.
7. 7
   : Support postpartum recovery and discharge. Monitor vital signs, bleeding, pain control, urine output, and mood. Check blood pressure according to protocol for patients with hypertensive disorders, provide written discharge instructions, schedule follow-up, and screen for postpartum depression with a validated tool.

05Quality checks, risk controls and compliance

• This is a regulated, high-risk field. Rules for consent, scope of practice, mandatory reporting, medication handling, and maternal death review depend on jurisdiction and on the setting. Use your regulator, your hospital's governing body, and the current guidance from recognized professional bodies as the authoritative sources, and check that you are reading the current version. This guidance does not replace qualified professional judgment or the approved procedures of your facility.
• Hemorrhage is a leading area for risk control. Many units use a bundle that includes early recognition thresholds, quantitative blood loss measurement by weighing drapes and pads, pre-defined escalation steps, and periodic drills. Drill results should be reviewed for time to first intervention and for whether each role was filled.
• Hypertensive disorders need a second set of controls. Severe-range blood pressure should be confirmed and treated within the time frame set by local protocol. Magnesium sulfate requires a dosing sheet, a monitoring schedule that includes reflexes, respiratory rate, and urine output, and a clear plan for toxicity. Oxytocin infusions require a standard concentration, a documented rate, and an independent double check at each change, because both are high-alert medications.
• Fetal monitoring policies often require periodic review of tracings by a second clinician or by a central reviewer. Where a policy exists, follow it, and record the reviewer and the time. Compliance records should also cover credentialing for procedures, informed consent documentation, privacy of records, and any reporting to surveillance systems that your jurisdiction requires, including reporting of severe maternal morbidity or maternal death.

06Collaboration and documentation

• Obstetric care involves obstetricians, maternal-fetal medicine specialists, anesthesia staff, neonatology, nursing, pharmacy, social work, lactation support, and interpreters. Each role should be named in the chart for high-risk cases so that anyone reading the record knows who to call. Consultations should state the question being asked and the answer received, with the time of each.
• Documentation should be timed, factual, and specific. Record the observed finding, the action taken, and the reason for the decision, and avoid speculation about intent or blame. Late entries must be labeled as late and must not overwrite the original. An addendum is the correct way to correct an error, and the rule for addenda should be written into local policy.
• Handoffs are a common failure point. Use a structured format such as SBAR at shift change, at unit transfer, and at any escalation. The handoff should cover the current situation, relevant background, the latest assessment, and a specific recommendation. For patients with a high-risk diagnosis, a brief team huddle at the start of each shift keeps the plan visible to everyone.

07Measures and continuous improvement

• Useful indicators include the proportion of hemorrhages that reach a defined treatment step within the target time, the time from a decision for urgent cesarean to delivery, the share of severe-range blood pressures treated within protocol time, documentation completeness for high-risk patients, concordance of tracing interpretation on audit, and unplanned transfers to higher-level care. Track severe maternal morbidity cases reviewed in unit conferences as a separate measure.
• No single indicator is safe to use alone. The cesarean rate, for example, can fall because clinicians avoid necessary operations, and it can rise for reasons unrelated to quality such as case mix changes. Pair each rate with outcome data, a case review, and a note about what the unit served that year. Small units produce numbers that swing sharply with a few cases, so pooled or multi-period data gives a more stable picture.
• Continuous improvement usually runs through regular case-based morbidity and mortality conferences, root cause analysis for serious events, and simulation debriefs after drills. The output should be a specific change, an owner, and a date for review. Protocols that reduce variation can slow care for atypical patients, so every new protocol should include a route for clinical exceptions that is reviewed afterward.

08Common mistakes and how to prevent them

• Anchoring on the initial risk category is common. A patient labeled low risk at intake may still need reassessment after a bleed or a new finding. Prevent this by writing reassessment triggers into the plan and by revisiting the category at each handoff.
• Reading a tracing in isolation is another mistake. The fetal heart rate pattern should be interpreted alongside maternal vital signs, medications, contraction pattern, and the time since the last intervention. Prevent this by requiring a short maternal check each time the tracing is reviewed.
• Delayed escalation to the attending often happens because staff hesitate to call. Written escalation criteria and a unit norm that calling early is expected both reduce this problem. Recording the time the attending was notified also makes gaps visible in review.
• Medication errors cluster around magnesium, oxytocin, and insulin. Incomplete reconciliation, undocumented rate changes, and missing independent double checks are the usual causes. Prevent them with pump reconciliation at each shift, a documented rate history, and a standard concentration in the unit.
• Estimating blood loss by eye alone leads to underestimation. Weighing drapes and pads, and recording the totals in the chart, gives a more reliable trend. Prevent the habit by making the weighing step part of the delivery checklist.
• Vague, after-the-fact notes are a documentation problem that surfaces during disputes. Timed entries written at the bedside, with the specific finding and action, are far more useful to the next clinician and to any reviewer.

09Practical checklist

• Confirm gestational age, blood type, antibody screen, and infectious disease results at intake, and flag any missing item with an owner and due time.
• Assign and document a risk category, and set a written list of triggers for reassessment.
• Check that monitors, pumps, blood pressure cuffs, and the hemorrhage cart were tested on schedule and that the logs are current.
• Reassess the fetal heart rate tracing with a maternal check each time it is reviewed, and document the tier and any change.
• Document the delivery route decision, the options discussed, the patient's response, and consent status or the emergency exception used.
• Name the members of the delivery team and confirm neonatal resuscitation presence when indicated.
• Measure blood loss quantitatively and record totals in the chart at set intervals.
• Double check magnesium and oxytocin doses and rate changes, and document each change with the time and the second checker.
• Use a structured handoff at every shift change and at every transfer, and record the time the attending was notified of any escalation.
• Screen postpartum patients for depression and hypertensive complications, and schedule follow-up before discharge.

★Learning sources

• Micro Degree: Obstetrics and Maternal-Fetal Medicine
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support