Obstetrics
Primary Obstetrical Care
QGH has a group practice of full-time family physicians providing primary obstetrical care. Antenatal care is by CHNs in the community health centres until 35 weeks and by the GP OBS group clinic in Iqaluit.
Overview of Responsibilities
24 hour shifts: 8 am to 8 am
The on-call OB is responsible for doing OB Clinic and for the OB ward (both intra-partum, post-partum and newborn care).
The OB MD on-call may also receive pages from remote community nurses about OB issues “up island” and possible medevacs.
At start of shift (before 10:30 clinic starts) be prepared to do inpatient OB and newborn rounds and discharges for those who are ready to go home as soon as babies’ blood-work results available.
It is our standard of care to do a comprehensive handover every morning at 08:00 shift change, either by phone or in person on ward. This should be staff person to staff person
Early Pregnancy Assessment Clinic
Patients with early pregnancy complications commonly present to the QGH emergency department (ED). There has been an early pregnancy assessment clinic operating in the outpatient antenatal clinic since 2017.
Please note that if you are unsure about a particular course of action, please contact the obstetrics physician on call and they can assist you in the management and disposition of your patient.
When?
Every Monday-Friday in the Antenatal clinic at 10:00 a.m. There is one 30-minute slot available daily.
Where?
Clinic area (Prenatal clinic area). Patients register with the Obstetrics LPN and are seen by the Obstetric physician on-call for that day.
Who?
Stable pregnant patient with 1st trimester pregnancy complications that require follow up.
How?
Patients can be booked in Meditech into the obstetrics clinic by the referring emergency physician. This is done by booking the patient in the 10:00 obstetrics EPA slot on a particular day in Meditech and then giving the patient an appointment card.
The schedule is found at IQ.OBS.
During business hours, you can phone the Obstetrics LPN at extension 5427 and have them book the patient.
It is mandatory for there to be an EMR note in the system indicating what was done and why the patient is being sent to the early pregnancy clinic.
Booking follow-up ultrasounds may require a discussion with the ultrasound technician or booking clerk. The Iqaluit on-call obstetrics physician can also assist you if needed.
What should be referred to the general surgeon or obstetrics physician on call from the emergency department?
Patients with unstable vital signs
Ectopic pregnancies requiring surgical management
Spontaneous abortions requiring dilatation and curettage.
Septic spontaneous abortions
Hyperemesis gravidarum patients requiring admission
Missed abortions (fetal demises) after 12 weeks gestational age
Threated preterm labour patients after 20 weeks gestational age
Patients with spontaneous abortions requesting surgical management
Molar Pregnancies (need to discuss transfer with Gyne/Gyne-Onc in Ottawa)
Patients who may be unreliable to present for follow up
What is an appropriate referral to obstetrics?
Stable patients with pregnancy of unknown location (PUL) by formal ultrasound.
Follow-up on patients after medical management of spontaneous abortion.
Follow-up on patients after medical management of ectopic pregnancy. (provided MTX has been given and outpatient labs have been entered with clear instructions in Meditech and clear instructions for patient on when to present to ER)
Stable patients after outpatient ultrasounds.
Follow-up of stable patients with threatened, inevitable, incomplete or completed
spontaneous abortions
Stable missed abortions prior to 12 weeks GA to discuss management
Please note: if an US is required before the f/u and needs to be booked within 1-2 days you will need to speak with the US department in person to book this. US referrals in Meditech can take weeks to be booked.
What is an inappropriate referral to obstetrics?
Acute/chronic conditions not related to pregnancy
Complications that are already being followed by a family physician
Infections
Outpatient Post-Partum and Newborn Care
Iqaluit patients are seen at home by a Public Health nurse within 1-2 days of discharge. They provide newborn care, lactation support etc. They do all the subsequent well-baby care, vaccinations, and developmental assessments throughout childhood at the Public Health Clinic. They attend our OB rounds. In addition, newborns are usually seen in OB MD clinic at 7 – 10 days of age (booked at discharge from hospital) and again routinely at 6-8 weeks of age. Moms are routinely seen for a post-Partum check at 6-8 weeks post-partum.
Occasionally a baby needs a follow-up bilirubin level after discharge. This can be done during outpatient lab hours and followed by the OB MD on-call with appropriate OB MD handover from day to day. When the lab is closed on weekends, an OB MD can order the outpatient Bili and arrange for the baby to come into the ER for the lab to draw the Bili (no need to see ER MD but make sure ER nurses know about it). The results should be followed by the OB MD on-call that day.
Guidelines
Epidurals
Not routinely and consistently available. We do not have an epidural “service” on demand. Occasionally available when medically indicated and anesthetist is available. Very few of our OB nurses have epidural experience. Epidural nursing policy and procedures exist to support epidural safety. Narcotics (morphine and fentanyl) and Entonox are available in labor.
RH Immune Globulin
Given at 28 weeks for Rh negative patients. Do the antibody screen bloodwork and order the WinRho the day before or morning before the appointment for injection. The OB MD must get signed consent and give the im injection (no RN in clinic to do injections). Specific consent forms are in the OB office and on the OB inpatient ward.
Syphilis
Be aware we have an outbreak of syphilis since 2012. We try to screen prenatal patients 3 times, once per trimester (1st trimester routine bloodwork, 24-to-28-week bloodwork when also doing GDM screen and CBC, and at 36 weeks with CBC, GBS swab and GC&C urine screen). If a positive test: ask one of our local full time OB MDs for resources, what to do, who to consult etc.
Mandatory Consult
Essentially any labor induction decision, augment decision or C-section decision must be reviewed with another OB MD before proceeding. (Of course, if there is an obvious emergency C-section needed, don’t waste valuable time seeking another OB MD consult!) Please feel free to ask another OB MD for help with any complicated cases, labor dystocia, assisted vaginal birth, complicated repairs, PPH etc.
C-Section
The OB MD calls in the surgeon and the anesthetist. The OB nurses will call the OR staff, lab, RT and Peds. It is up to the OB MD to clearly communicate the urgency of the situation to everyone (i.e. Crash/STAT, urgent, semi-urgent etc.) and continue to do so until the surgery has started.
VBAC / TOL requests
There are several unique things to consider about our practice location aside from the usual TOLAC risk considerations. Ideally have a long term OB MD (not a resident or locum) do the risk review and discussion with the patient. (i.e.: only 1 OR available which may be busy during TOL, one-on-one RN intra-partum care may not always be possible, Blizzard conditions may make it difficult to get OR staff in if an emergency C-section needed, C-section decision to delivery time 1 hour at best, etc.)
MSS and NIPT Testing
QGH offers MSS (Maternal Serum Quad Screen) to all pregnant women at 15 to 20 weeks gestation. We do not have IPS (Integrated Prenatal Screen) or eFTS (enhanced First Trimester Screening) available. Our sonographers do not offer first trimester nuchal translucency measurements. NIPT (Harmony test) is available at QGH at no cost for selected patients according to our clinical guidelines.
Inductions
A clipboard with a list of pending inductions is kept on the ward at the OB nurses’ desk. Please add patients as needed and include indication for induction, when induction needed and considerations for prioritizing if multiple patients needing induction same time. All cases will be reviewed in weekly OB rounds
Therapeutic Abortion Referrals
Reproductive choice is an important principle of obstetrical care. Therapeutic abortions (TAs) are provided in Iqaluit up to 13 + 0 weeks. Patients must be transferred to a southern clinic when they are over 13 weeks pregnant.
Iqaluit Referrals
To streamline the experience of women who have TA’s in Iqaluit the referring person should:
Complete the TA referral: in Iqaluit, this is in the electronic record under specialty consults (TA)
The “provider” is “is TA.IQ. (Please note that this is not the name of the physician)
From a health centre, there is a TA referral form (attached).
Meditech has been improved. Under: orders/specialty/physician referral there is now a TA<13 wk and a TA>13 wk option.
It is essential to include contact information in documentation
Order tests: CBC and ABO/Rh and an ultrasound
STI testing: Send a urine sample for GC and Chlamydia
Please note, it must be < first 15cc or lab will reject
If the patient has any current unusual discharge, or has any history of bacterial vaginosis or pelvic inflammatory disease, please also do a vaginal swab for BV and consider an immediate wet mount if you suspect trichomonas
If you suspect trichomonas in a health center, never send a specimen away for Trichomonas. The test will always be negative (the test is dependent on seeing them swimming, but the organism lives only a short while and must be kept at body temp. CHNs can perform these easily immediately after collecting the specimen. Please contact your NIC or the lab for instructions).
If you suspect trichomonas in the hospital/clinic, if you suspect trichomonas, please have the specimen taken immediately to the lab (kept at body temp) and speak to the lab tech to request a wet mount right away.
It is highly recommended that a vaginal C&S and wet mount be performed before sending a patient south for TA as an untreated infection can cause significant delays in treatment or even result in a patient no longer meeting the gestational age cut-off.
Document on the referral the most recent Pap test and result.
If you are referring from Iqaluit, please order an ultrasound (on the computer) that is marked “Dating for TA” so they know it is urgent. Providing information about LMP and exam is very helpful. A current phone number here too is very helpful. The surgical coordinator will order and arrange the dating ultrasound for patients from outside of Iqaluit.
Send the referral to the surgical coordinator’s office in Iqaluit. Her fax # is 867-975-8610 and phone # is 867-975-8600 x 2129. Electronic referrals are automatically distributed.
Time Sensitivity
As the procedure is time sensitive, any obstacles to accessing care should be minimized. CHN’s, CHR’s, NP’s ER nurses and MDs should all refer immediately if requested by a patient. Note that women sometimes self-refer and contact the surgical secretary directly, who then make arrangements for an NP or MD to initiate the referral.
In Iqaluit, patients will be booked for a counseling appointment the day before the procedure. The following morning the TA is done, and women can typically fly home as early as the next day
Southern procedures for women over 16 weeks usually occur over 2 days (sometimes with the counseling day in addition to this).
Southern Referrals
For gestations beyond thirteen weeks, women are sent south (primarily to Ottawa). This must be arranged by the referrer (CHN, NP, community physician). The patient will need an ultrasound before a booking in Ottawa can be made (ORDER THE U/S ASAP).
Care providers should be aware that patients sometimes return from the south without adequate contraceptive plans or without ongoing prescriptions for their contraceptive of choice. You may want to keep this in mind if you are seeing a patient in follow-up after her procedure (and feel free to offer some contraceptive counseling at the time of initiating the referral). IUDs can typically be inserted at the time of the procedure.
If you have questions or need additional help / resources, please feel free to contact the surgical coordinator who can help you directly or help you identify an available abortion provider in Iqaluit.
Booking TA’s in the South
Therapeutic Abortions are transferred outside of Iqaluit when the gestation is > 13 + 0 weeks or if not possible in Iqaluit due to O.R. time or staffing. Currently, abortions may be possible up to 23 weeks in southern facilities.
Contact the southern specialist first. They will require dating information (especially the U/S results including placental location) and they must know about previous caesarian sections. They will also request a faxed referral after you have spoken with them. Appointments can be weeks away, so early referral increases the chance of meeting the gestational age cut- offs.
Start with Ottawa as there is much greater support available there for our patients. If there is no availability or trouble booking with Dr. Feigel or the Women’s Health Clinic, then try the Ottawa Morgentaler Clinic.
If gestation will be over 19 + 2 weeks then Toronto Cabbagetown or Montreal should be contacted.
Southern Contacts
Ottawa
Dr Feigel (male): current gestational age limit is 19+2:
613-728-0474 (main – try first)
613-728-1021 (private line – try second)
613-728-8381 fax
Often they’ll ask you to call the Women’s Health Clinic (M, T, W, F from 07:00 to 11:00 only) where he and others also provide TAs: 613-798-5555 x 13000 (fax 613 761 5366)
Ottawa Morgentaler Clinic: always up to 17 wks; occasionally able up to 19 wks
65 Bank street, 3rd floor, Ottawa K1P 5N2
613-567-3360 for appointments
613-567-9128 fax
Outside of Ottawa
Outside of Ottawa there are no supports or Inuit-specific resources available to patients
(Winnipeg has supports but no TAs are performed in MB beyond 19+6 weeks).
First Choice: Toronto Morgentaler Clinic (up to 19 wks, sometimes a little less)
416-932-0446 - be prepared to be on hold quite a long time
416-932-0837 fax
Cabbagetown Women’s Clinic - Toronto (up to 22 weeks) 302 Gerrard St. E.
416-323-0642 416-323-3099 fax
Please note:
They DO NOT offer 2nd trimester abortions if there is a placenta previa.
They will not offer an abortion if there are BOTH: an anterior placenta and previous c-section (anterior placenta without previous c-section is fine).
They require an operative report detailing scar location if there has been a previous c-section.
It is recommended that a vaginal swab for C&S/wet mount prior to the patient traveling there be collected (and appropriate treatment initiated).
CLSC des Faubourres - Montreal (up to 23 weeks with U/S dates)
514-527-9565 x 3674
Fax 514-847-8662
Montreal Morgentaler Clinic (15 – 20wks)
30 St Joseph’s Blvd #710 (corner of St. Lawrence Blvd), Montreal
888-401-4844 888-844-4844 514-844-7883 fax
If you discover that information included in this form has changed, or if you’d like to provide feedback about encounters with these clinics, please contact the surgical coordinator.