OB/GYN

Referrals continue to be primarily via email. The email is mfmperinatal@cumc.columbia.edu. It's managed by the first year MFM fellows, who are usually PGY5s, and who staff concerns with the MFM attendings. The reason for the email referral is the MFM team also fields many consultations from outside our institution
The fellows are expected to document any recommendations or any guidance given via email in Epic as well as via email. This is a new expectation of them, and the OB dept is requesting feedback as to whether it is happening. If recommendations are not documented in Epic, please inform me and Dr. Berenyi for follow up with the MFM team.

Scheduling C-sections at CHONY: As you may have noticed when making scheduling requests for CHONY, there are two teams, Blue and Green. Green is routine L+D, and Blue is MFM / perinatal. For patients that require MFM at delivery (eg patients with BMI >50, or patients with placenta accreta syndrome, or any other high risk concern) please request they be scheduled with the Blue team. In general, when making a delivery request for CHONY:

The more information that is available in the scheduling request, the better they can schedule the patient
We are asked not to provide c section scheduling information to the patient, as that can lead to the patient being scheduled for clinically inappropriate timing of delivery

Scheduling postpartum visits: most postpartum visits are scheduled from the hospital, after delivery. To facilitate timely postpartum video visits, please discuss postpartum care with the patients and schedule the postpartum visit prior to delivery when feasible. F

Whenever scheduling an induction or c-section, also request a postpartum visit.
- This may be a video visit 1-2 weeks after delivery
- This may also be a dyad care visit if the patient wishes to be seen with their infant in Dyad clinic
Also cancel any OB visits that are after the expected delivery date

Requesting multiple appointments: Creating continuity for prenatal care is both a challenge and ultimately rewarding. It is especially challenging currently due to overall access issues and last minute scheduling changes.

Please continue to request multiple future OB visits whenever possible, to ensure patients have visits scheduled and to allow the PFA team to schedule them with the patient's continuity provider whenever possible

RSV vaccine (Abrysvo): Please offer this vaccine to our prenatal patients, as we are in season and currently have the vaccine available at Farrell. The recommended GA for patients to receive the vaccine is between 32 and 36 weeks GA. The purpose of the vaccine is to allow the passive transfer of antibodies to the fetus, with the ultimate goal of reducing RSV illness in the newborns. RSV is a major cause of infant hospitalization, so that is what I discuss with my patients when offering the vaccine. There is an alternate option to administer the antibodies directly (nirsevimab) to the infant either after their birth or at a follow up visit.

Nurse-family Partnership: Finally, I wanted to make sure everyone is aware of this resource for our patients that Dr. Chacko shared with me. The Nurse-Family Partnership provides individual nursing support for first time parents for are eligible for Medicaid or WIC. They must be referred prior the 3rd trimester (so 28 weeks or less) so be sure to refer early. The Healthy Steps team knows about this resource but you can refer patients or share this information with them as clinicians as well

From the NYC DOH website: Nurse Family Partnership
Referral form: nfp-client-referral-form.pdf

Prenatal Updates 11.21.23

Hi Farrell team,

It has been too long since the last OB updates. Please see below and attached for important updates regarding prenatal, postpartum, and gyn care at Farrell. There are many individual (generally unrelated) updates and reminders below. It includes RSV vaccine info; update on Farrell OB/GYN services; a reminder on genetic carrier screening; info on support for perinatal mental health from Project TEACH; a reminder on a Farrell study on postpartum experiences; a reminder on Rhogam ordering; Preop testing; the MyCare app for prenatal patients; and a physician reference for pediatric gynecology when needed.

#RSV vaccines: Pfizer has released a new RSV vaccine that is approved for patients older than 60 years and for prenatal patients. We currently have the vaccine available at Farrell and are able to offer it to our prenatal patients! The gestational age range for prenatal patient is 32w0 to 36w6d. The clinical rationale for the vaccine is to prevent RSV related illness in the newborn, rather than for maternal protection; this is especially important in the winter months when RSV is rampant. See below for guidance from the CDC and the AAFP (via the ACIP) regarding the vaccine; I've also attached the AAFP article as it requires logging in.

#Farrell OB/GYN Consults: After a long hiatus, we welcome Dr. Swapna Nalgonda back to Farrell. Dr. Nalgonda will resume seeing prenatal patients for consultation as well as gyn consult patients, and will resume working with PGY2 residents. She will also be helping ensure access to care for all of our prenatal patients during periods of time with access challenges, such as the holidays. Appropriate consult cases for Ob/Gyn at Farrell include:

Prenatal patients with history of c section, whether they are interested in TOLAC or repeat C section
Prenatal patients with history of uterine procedures, especially myomectomy for uterine fibroids
Patients interested in gynecological surgery for surgical planning
Patient requiring gyn procedures such as endometrial biopsy

#SMA variant: Some of you have noted that the prenatal genetic carrier screening test is resulting with a new silent variant; thank you to those who brought this to my attention! As a reminder to all, genetic carrier screening results are present in the pathology section of EPIC, and so they do not flag abnormal results. Genetic results must read to determine if they are normal or abnormal! Please review all genetic carrier screening results as they come in, with special attention to the Spinal Muscular Atrophy results

#Project Teach: Project TEACH is an initiative from the Columbia Psychiatry Department to provide training and support to Ob/gyn, pediatric, and family medicine practitioners who care for pregnant, postpartum, and pediatric patient with mental health needs. They have a number of trainings available and support clinical care through phone consultations and linkage and referral support. Please see the attached flyer, which will also be in the resident and preceptor rooms at Farrell, and which contains their phone consult line.

Further trainings can be accessed here: https://projectteachny.org/events/
Look for upcoming didactic sessions on maternal mental health

#Qualitative postpartum research study: Many of you have met Columbia Medical Student Natalie Forbath, who is conducting a qualitative study on postpartum experiences. She is interviewing patients in Dyad Clinic, but is interested in talking to postpartum patients at Farrell more broadly. Please review her 10/25/23 email to the Farrell team and let her know about any patients who may be appropriate for her to interview - the patient receives a $20 visa gift card for participating. I've also attached her flyer as 'Dyad Care Study Flyer'

#Rhogam: as part of routine prenatal care for prenatal patients with Rh negative blood types, we administer Rh immunoglobulin (Rhogam) after 28 weeks to prevent maternal alloimmunization and hemolytic disease of the newborn. Since we don't have Rhogam on site, and since it requires a recent type and screen to order the medication, the workflow can be complex and relies on the expertise and effort of our excellent nursing team. Please close the loop with the RN team, either in person or over secure chat, whenever ordering Rhogam, so they can be aware of the case, counsel the patient, and schedule them for an appropriate return date to administer the medication.

#Pre-op testing and guidance (patient facing forms):

We have new patient facing handouts to help patient prep for their delivery admission (for induction or C section) at either location. These will also be on the website.
COVID testing is necessary prior to both inductions and C sections. Home COVID swab is insufficient - it needs to be a COVID-19 PCR test
- Covid testing needs to be completed at a community site with a written result
- COVID testing should be no less than 5 days (120 hours) old at the time of admission for the delivery
C section patients also need preop testing, specifically with CBC, RPR, and Type and Screen
- Allen patients should have the preop testing done at the Allen hospital specifically
- MSCHONY patients should have preop testing done on the main campus.
  - This includes both Farrell and the phlebotomy site at 161 Ft. Washington
- Preop testing should be within 72 hours of the schedule C section

#MyCare Pregnancy: This is a new patient facing support system for pregnancy within the patient portal app. It contains with pregnancy related guidance, reminders, and general information, It is being pushed out to all prenatal patients without provider input. This is just being shared for your information, but it may be useful to ask patients what their experience is of the app.

If you would like to take the provider survey the link is https://nypisgme.iad1.qualtrics.com/jfe/form/SV_bxe1o6Rp4eAAvga.
If you are interested in providing feedback via a 1:1 interview, please reach out to Sarah Steward at oux9001@nyp.org and Dharaa Rathi at alh9197@nyp.org

Finally,

#Pediatric Gynecology: Occasionally we have need of gynecology referral for our pediatric patients. Dr. Beth Rackow is an Ob/Gyn in Columbia with experience with pediatric patients, for the rare cases where a referral is necessary.

As always, thank you for all your hard work and attention to caring for prenatal, postpartum, and general gyn patients at Farrell.

Prenatal Updates 4.10.23

Hi Farrell clinicians,

I'm writing with two updates around OB care around delivery and postpartum care and with the most recent OB ACN newsletter, which includes a number of excellent resources for our patients. First, an update on pre-induction covid testing. Then an update around short-term disability and a breakdown of the types of leave + disability tour patients take. The newsletter includes information on tours and birth classes. Finally, reminders to please refer appropriate patients to the EMBRACE program and to Dyad clinic at Farrell.

#Pre-delivery covid testing: All patients with scheduled deliveries (induction or c-section) need pre-delivery covid testing. Unfortunately, the test sites within NYP have recently been closed (Heart Center, CHONY Wintergarden, and Allen). For now, please direct patients to seek out a testing site in the continuity that will provide them with a written result of a covid PCR test.

all patients with planned induction or c-section need a COVID result within the 3 days leading up to their hospital procedure
COVID tests should be performed at a community site, such as a freestanding testing center or pharmacy

#Pregnancy related disability and Family Leave: There are some updates as well as general confusion around short term disability and leave forms for postpartum patients.

The majority of our patients take short term disability. New York State recently updated its guidelines regarding short term disability.
- Short term disability is 6 weeks for vaginal deliveries
- It is 8 weeks for c-sections
- Leave can now start as early as 36 weeks GA (it previously started at delivery)
- There is a patient-facing handout, also attached here, that will be shared with patients during their pregnancies.
- see the NY update here: https://www.wcb.ny.gov/content/main/DisabilityBenefits/employee-disability-benefits.jsp#:~:text=If%20you%20are%20pregnant%2C%20you,from%20your%20medical%20care%20provider.
Patients with medical complications beyond a normal vaginal delivery may qualify for a longer period of disability
This is separate from New York Paid Family Leave (PFL) which our patients may also take. This is a paid benefit for bonding (not disability) that patients may take within 12 months of delivery. Our responsibility as providers is primarily to certify delivery.
- You can find out more at https://paidfamilyleave.ny.gov/ and patients may call the Paid Family Leave Helpline at (844) 337-6303
This is also separate from FMLA, which is a federal benefit with 12 weeks of job protection and continuation of benefits, but which does not provide income. To qualify for FMLA, an individual must:
- Have worked for their employer for at least 12 months; and
- Have worked for their employer for at least 1,250 hours in the 12 months before you are taking leave; and
- Work at a location where their employer has at least 50 employees within 75 miles of their worksite.

This all gets confusing, but the take away is that for the short term disability forms, they can be completed at 36 weeks, should give patients 6 weeks for vaginal deliveries and 8 weeks for c-sections.

Please take a moment to look over the OB ACN Newsletter April 2023 . It includes information on the following resources for our patients:

Birth classes for our patients, the next available on 4/24, followed by 5/22
Postpartum support group (last Wednesday of every month)
Prenatal breastfeeding classes

Finally, a reminder to refer patients to the EMBRACE program when appropriate (flyer attached), and to refer patients who would benefit from Dyad postpartum visits to Dr. Beckman for her Friday Dyad clinic where she sees postpartum patients and their infants for a comprehensive joint visit.

Thanks for all you do for our prenatal, perinatal, and postpartum patients!

Prenatal Updates 2.27.23

Hi Farrell team,

I hope everyone is doing well. I'm writing with a few updates on OB care at Farrell and the ACN, and with a request that you review your patient panels to ensure PCP assignments are appropriate. There are additional reminders at the end regarding scheduling inductions and c-sections and the lab orders that must accompany those requests, as well as an update on self-swabbing for GBS.

#OB extra sessions and OB care continuity:

As many of you have noticed, we have a something of a crunch with regards to access for patient visits at Farrell at the moment. To ensure access for our OB patients, members of the OB-gyn department will generously be staffing additional weekly sessions at Farrell specifically for OB follow up. Providers include Dr. Nalgonda and Dr. Emmanuel, sessions will be scheduled within the FRL OBGYN department in EPIC, and will occur approximately weekly.

This affects all of you directly because OB patients who cannot be scheduled with their PCP or follow up of choice will be then scheduled for a visit within these tallies. While this is very beneficial for access, it has the potential to disrupt continuity of care if we are not proactive. To that end, I ask that everyone do the following:

review patients that you have either seen recently or are PCP for to ensure accuracy of that information
- when appropriate, please do assign yourself as PCP
- it may be necessary to reach out to other Farrell providers to establish who is the PCP for patient, if they've seen multiple providers
proactively work to schedule patients for whom you are continuity maternity care provider
- this may be with yourself or, if appropriate, with a team member who also is familiar with the patient

The attached patient lists should be helpful in this regard. There are columns for PCP as well as for most recent visit provider and 2nd most recent provider. Please prioritize patients who don't have a PCP!

#Regarding scheduling inductions / IOLs, please take into account the following:

If a patient is being scheduled for IOL/Cesarean and is COVID recovered, please send Rosita Grant a secure message stating this. If not she will assume that the order was omitted and contact you for it.
A friendly reminder that all lab orders should NOT be entered with class code “Clinical draw”. All lab orders that are to be conducted at the Allen should always have class code entered as “Internal Draw ” with a comment “ Process As Stat”. The Allen lab department will not draw any labs that have “Clinical Draw”.
Reminder that patients scheduled for inductions/ cesarean sections at CHONY are not given appointments for preop labs/ COVID swabs. They must walk in at the Heart Center 2-3 days prior to their scheduled appointment.

#GBS exam and self swabbing

Routine Group B strep testing is routinely performed at 36 weeks GA or later, usually by the provider with the patient in lithotomy position. An acceptable alternative is patient self collection of the GBS swab, if that is their preference. The attached guide - for patients and providers - may be of use when explaining the collection process to patients.

Prenatal Updates 1.13.23

Hi Farrell team,

I hope this email finds you well. I'm writing with a few updates and reminders for prenatal care at Farrell. There is info below on childbirth classes, changes to obesity recommendations, patient support persons on L+D, referrals within Farrell, and Ob/gyn referrals outside of Farrell.

#Childbirth education classes for the Allen: Attached is a flyer for childbirth education classes, oriented to the Allen. The next three classes are 1/16, 1/23, and 2/1. Please share the flyer and phone number for registration with interested prenatal patients.

#Change to anesthesia consultation indications: it is no longer necessary or recommended for prenatal patients with BMI between 40 kg/m2 and 50 kg/m2. Obesity based anesthesia consultation is now only indicated for BMI > 50. Relatedly, any patient with a BMI > 45 is indicated for delivery at MSCHONY, not the Allen. Anesthesia consultations for other indications in pregnancy, such as prior complication of anesthesia or scoliosis, remain valid. Please see the updated guideline attached.

#Support persons in labor: While the number of support people allowed on labor and delivery had been limited when covid hospitalizations were high, patients on L+D are again allowed two support people. The guidelines are linked here.

https://infonet.nyp.org/Attach/COVID19_VisitationGuidelines.pdf

#High risk OB consultation/ transfer/ comanagement: Please continue to use the mfmperinatal@cuimc.columbia.edu email for questions about comanagement of high risk OB patients, whether for fetal or maternal indications. This email is run by the Maternal Fetal Medicine fellows, who are the primary outpatient providers of care. Feel free to include me on any correspondence. Outcomes may include transfer of care to perinatal clinic, email based comanagement, or brief consultation at perinatal clinic prior to return to our low risk clinic. Please continue also to use the .ambob smartphrases for generic guidance based on patient diagnosis.

#Consultation / support systems available at Farrell: A quick rundown / reminder of the

Group prenatal visits: These are monthly group prenatal visits run by Dr. Urmi Desai. Ideal time for referral is 20 weeks GA, although the referral can be made any time by email or SHM to Dr. Desai
EMBRACE / postpartum doula: This referral is for patients with social determinant risk factors for poor outcomes at birth or postpartum, such as limited support networks, housing instability, teen pregnancy, etc. It includes antenatal community health worker support and postpartum doula visits (not intrapartum doula). The referral is through an epic order to the MAC-IMP program.
Dyad visits: early postpartum visits are being offered as a joint maternal / fetal dyad visit on Friday mornings with Dr. Beckman. These are being offered to patients after delivery, but if you have a patient who intends to continue care for themselves and their infant at Farrell after delivery, please discuss this visit type and inform Dr. Beckman if the patient is interested.

#Consultation policies within OB/Gyn: The following guidance is from our colleagues and leadership within the OB/gyn department, which has been steadily transitioning the mode for consultation to orders in Epic. Guidance on urgency of consultation is below; most consultations to OB (indications may include evaluation for removal of fibroids, permanent sterilization, urogynecological concerns, to name a few).

Emergency: Use if delay in consultation of more than 3 days from the date of the referral could result in the patient requiring care in the emergency department or prolonged suffering or pain. ALSO, reach sub-specialist by secure chat or by phone (may consider asking the PFA/Registrars at the sites to assist with reaching out by phone)
Urgent: Delay in consultation more than 2 weeks from the date of the referral request could result in increased health risk or increased suffering to the patient. The appointment should be scheduled within two business days.
Routine: For an appointment as soon as possible and the patient should be seen within no more than 3 months from the date of the referral request.
Elective: May not be medically necessary and scheduling would be initiated by the patient as needed

GBS SELF SWABBING INSTRUCTIONS

gbs_swab_sheet21.pdf