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DESCRIPTION OF ROTATION: OBSTETRICS
PRECEPTORS: FP Faculty and WMH Obstetricians
DURATION: Two Months (PG1 and PG2), and One Month (PG3)
GOALS/OBJECTIVES OF ROTATION:
Obstetrics
- Pre-pregnancy planning and counseling
- Prenatal care, including risk assessment
- Labor and delivery
- Postpartum care
- Care of the normal newborn
- Common neonatal problems
- Analgesia and anesthesia for labor and delivery
- Indications for cesarean delivery
- Obstetric complications and emergencies
- Lactation
Consultation and referral:
- The role of the obstetrician/gynecologist and subspecialist
- Women's health care delivery systems
- Regionalized perinatal care for high-risk pregnancies
- Collaboration with other health care providers (e.g., nutritionist/dietitian, lactation consultant, etc.)
CRITERIA FOR SUCCESSFUL COMPLETION:
- Active participation in the responsibilities listed above with completion of all call days required.
- A minimum of two evaluations by attendings which indicate on the evaluation that the resident has successfully completed the rotation.
- Successful completion of ALSO testing prior to completion the academic year containing the rotation block (for graduation a total of 5 tests utilizing ALSO criteria is required).
ORIENTATION:
On the first day of the block, a meeting will be held between the OB Curriculum coordinator and the oncoming residents. This will be an opportunity to orient new residents to the rotation as well as discuss advancement and goals for residents with prior experience. At this time the orientation packet will be given to new residents.
To ensure an effective orientation, any resident coming on service for the first time should not be placed on call for the first day. New residents should be allowed to observe an experienced on call resident for 4 to 6 hours.
EXPECTATIONS:
After initial assessment and triage by Nursing, the resident is called to make an assessment of the patient and then discuss with the nurse any concerns regarding management. The resident then calls the attending physician to finalize a management plan within 30 minutes after arrival of the patient to L&D. If the resident or nurse feels a change in plan is needed (e.g., starting Pitocin, AROM, scalp electrode, or IUPC placement) or there is a suggestion of non-reassuring fetal status, the resident will review the situation and discuss it with the attending as rapidly as possible. The attending should be notified by the resident whenever a significant change occurs, when active labor ensues, rapid progress is noted, or any problems arise. All attending call-backs to L&D should be directed to the resident whenever possible, especially if a change in management is anticipated. Please review the L&D communication protocol appended.
Since the workload will vary on the floor and it will not always be possible for the resident to manage all patients, the resident must decide which patients they can reasonably manage. This should be based on the number and complexity of patients on the floor and not the time of the day. If the resident decides it is not possible to communicate directly with the attending, the resident should indicate this to the nurse who will then assume that responsibility. For any urgent or emergent situation, the resident should always assume responsibility unless the nurse notes the resident is occupied with another, equally important situation from which the resident is unable to break free.
The responsibilities for PG1, PG2, and PG3 residents are the same; however, nursing involvement and attending discussions must be tailored to the level of the resident's experience. All NST/CST strips will be reviewed by the resident with non-reassuring or equivocal studies being discussed with the attendings by the resident.
A form is available for admission H&P's on patients admitted to L&D; WFPC patients can have H&P’s completed on Logician. Patients on L&D must be followed closely; monitoring vital signs; fetal monitor strips; cervical dilatation, effacement, and station; and labor pattern. Residents are encouraged to monitor labor using Friedman curves. For patients in labor, write brief progress notes approximately every two hours (but no less frequently than every 4 hours) recording the above data. Check on patients in active labor about every hour, more frequently if there are problems. The resident is expected to stay near the nursing station rather than in the call room to carefully monitor the status of laboring patients. Nursing staff should know the location of the resident at all times. The resident should be present for all deliveries; the resident’s level of involvement with deliveries and repairs will be dependent on the attending, but the resident’s experience and rapport with the attending will play the largest role in your ability to do procedures. Attendings who feel the resident have paid close attention and given good care to their patients are more likely to involve the resident. Ask permission from the attending to perform as many deliveries (spontaneous and instrumented), laceration repairs, placement of fetal scalp electrodes, intrauterine pressure catheters, and amniotomies as possible. Staffing is sufficient for simple procedures, but more complex procedures and all deliveries must be directly supervised.
The resident is expected to assist on all emergency C-sections and, if possible, scheduled C-sections.
When needed, the resident should resuscitate to the newborn and assess for post-partum complications in the mother. The resident is responsible for notifying the resident on pediatrics when a pediatrician/NNP should be present for delivery or if there is an emergency C-section.
The resident should advise attendings that they would like to perform circumcisions, as well as alert the nursery to call when attendings arrive to do circumcisions.
CALL TURNOVER:
Each shift is a maximum of 24 hours beginning at 7:00 a.m. The departing resident previously on call should review all patients with the oncoming resident. The departing resident will do postpartum rounds prior to the attendings’ arrival; the oncoming resident will see any laboring patients with immediate issues or pending delivery, then do postpartum rounds on any patients that (s)he has previously delivered. The surgical schedule should be checked for routine C-sections.
If there are only 2 residents on call for the month, there will be no floor coverage on Wednesdays and a maximum of 2 Saturdays and 2 Sundays (each) call coverage will be taken.
WORK-UPS/WRITE-UPS:
For obstetricians’ patients, a brief H&P may be recorded on the standard form to include prenatal course, past OB history, significant PMH, and admission physical exam (including speculum exam if necessary). It is important to remember that this is a worksheet and does not take the place of a dictated H&P. For WFPC patients, the OB hospital admission form from Logician should be completed. This DOES replace a dictated H&P. Write progress as described in paragraph 2. After delivery, the resident is expected to write a brief delivery note, and to dictate a full note which will include total length of Stages 1, 2, and 3; medications and monitoring used; complications; APGARS and infant weight; laceration/episiotomy and repair; and estimated blood loss. Some attendings may want to dictate their own delivery notes.
OTHER EDUCATIONAL EXPECTATIONS:
ALSO testing is required each month, and is a REQUIREMENT FOR ADVANCEMENT AND GRADUATION. The senior resident will be expected to test the junior residents, and the senior resident will be tested by Dr. Fay or Dr. Ginn. In addition, PG1 residents will attend the ALSO course.
Perinatal Clinic with Drs. Kuhlman or Wigton occur on Monday (8:00-4:30), Tuesday (8:00-4:30), Wednesday afternoon (2:30-4:30), Thursday (8:00-4:30), and Friday (8:00-4:30, contact Women’s Health Services (544-2595) as the times tend to change frequently. PG2 and PG3 residents should attend when Dr. Kuhlman is seeing consults at Women's Health Center (if labor and delivery is quiet or the resident is not on call). When three residents are on service, the senior resident should plan on attending the clinic even when not on call. The resident should call ahead to find out when patients will be seen. The perinatologists are willing to teach basic ultrasound relative to labor and delivery (placental position and fetal presentation).
OB Ultrasound clinic with Drs. Fay and Ginn occurs once or twice weekly in the WFPC. The senior resident should expect to attend one clinic per month. Basic labor and delivery ultrasound (fetal life, fetal presentation, and placental position) will be taught. Practice with biometry and limited anatomic surveys can be included.
The resident should be able to make most meetings unless in delivery; therefore the resident is expected to attend all the standard noon conferences as well as Family Practice morning report. Every other month the Women and Children's Services meeting is held, and the resident is expected to attend this as well.
Perinatology Conference (3rd Fridays of odd numbered months at 7:30 a.m. except during quarterly business meetings).
On months when there are three residents, the senior resident will act as team leader to orient PG1 residents to the rotation, ensure that all residents are maintaining their responsibility to patient care in labor and delivery, and to focus the team on educational issues. The latter includes insuring the teams' preparation for the OB/M & M Conference mentioned below, but also discussing topics such as fetal monitoring, non-stress tests, and other common problems encountered on the floor. To ensure the senior resident has enough time to perform these duties, only two clinic half days will be scheduled per week.
OFFICE SCHEDULE:
Office is scheduled on the 24-hours off-call. (PG1s are scheduled for two half-days per week if 3 residents are on OB or one half-day per week if only 2 residents are on OB).
TIME AWAY:
Residents will have at least 4 days off per month. They will also not have any clinical duties on post call days.
EVALUATION:
At the mid-point of each rotation, the resident will pick three attendings with whom they have worked most closely, who will provide specific feedback and complete the evaluation form that the curriculum coordinator will provide. The resident and attending will sign the form and return it to the curriculum coordinator in the enclosed envelope.
SUGGESTED TEXTS/PREPARATION:
Gabbe Obstetrics – Very readable
Williams' Obstetrics – More in-depth, but more arcane and NOT evidence-based
There are pelvic bones and fetal skull models available in the OB call lounge. The resident is expected to practice applying forceps/vacuum and palpating sutures for position. Also, the resident should practice suturing and knot tying prior to starting. Attendings expect efficiency and some will base further participation on this basic skill.
NOTE: Documentation is critical on this rotation. Be meticulous especially with essential procedures!
CONTACT INFORMATION:
For more information regarding the OB ROTATION, please contact:
Lisa Cerletty, Curriculum Coordinator
lisa.cerletty@phci.org
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