OB Rotation: Month 1

Before Your Rotation Begins:

❏       Review the weekly schedule

❏     Review expectations for rotation and initial schedule

❏       Ensure access to scrubs (burgundy scrubs, in- hospital use only)

Call room 5-4-3 (do not share)

Staff restroom and nurses lounge (with microwave and fridge) 2-1-5-4

Schedule updated by Dr. Grandelis. Scroll to the appropriate month

https://docs.google.com/document/d/1WjorsZ8V4Brv3FTMgIGByG5FW__7iW0a_trSCaxRqq8/edit?usp=sharing 

L&D DAY:

1. Arrive to L&D 7:20AM and review Labor board list. Rounds start promptly at 7:30am

   • Labor and Delivery Expectations:

     • Triage and Admissions:

       • Efficiently assess and triage pregnant patients presenting with various obstetric complaints. 

       • Assess patients presenting for rule out labor as well monitor labor progress through reliable cervical exams. 

       • Evaluate patients for membranes rupture, vaginal discharge, and HSV lesions via speculum examination, with attention paid to proper technique and patient comfort

       • Estimate fetal weight using Leopold’s maneuvers 

       • Perform basic ultrasound for fetal presentation

       • Obtain informed consent for procedures and interventions and clarify consent for blood product

     • Labor Management

       • Understand and manage the stages of labor, including normal and abnormal labor patterns. 

       • Be familiar with medications used in labor induction and augmentation, such as oxytocin and prostaglandins. 

       • Monitor and interpret fetal heart tracings. 

         • Intrapartum management of category II fetal heart rate tracings: towards standardization of care 

       • Appropriately coach patients during the second stage and recognize normal and abnormal descent 

       • Recognize and prioritize emergent conditions such as preeclampsia, eclampsia, and placental abruption. 

       • Understand the pharmacological management of pain in labor, including the use of epidurals and other analgesics. 

       • How to choose induction method (bishop score, prostaglandin, oxytocin, mechanical dilators, etc.)

     • Deliveries

       • Perform normal spontaneous vaginal deliveries, including delivery of fetal head, shoulders, body, collection of cord blood and cord segment 

       • Demonstrate active management of the third stage, including controlled cord traction for placental delivery and initiation of oxytocin at delivery of anterior shoulder 

       • Recognize and manage obstetric emergencies, including shoulder dystocia, postpartum hemorrhage, uterine rupture, and cord prolapse. 

         • Postpartum Hemorrhage 

         • Prevention and Mgmt of Postpartum Hemorrhage 

       • Assess for and repair straight forward 1st degree perineal lacerations and small vaginal or labial lacerations 

       • Start and / or complete birth certificate worksheets for patients where you are involved in the delivery

       • Expectation is to reach 30 deliveries by the end of the second rotation, so approximately 12-15 deliveries by the end of the first rotation

     • Postpartum

       • Thoroughly assess 1-2 postpartum patients per session and identify/manage common complications (acute blood loss anemia, endometritis, low urine output, abnormal vital signs)

       • Counsel patients on postpartum contraception 

       • Place contraceptive implants under direct supervision 

     • General

       • Understand the physiological changes of pregnancy and their implications for both mother and fetus. 

       • Recognize and manage common pregnancy-related conditions, such as gestational diabetes, hypertensive disorders of pregnancy, and hyperemesis gravidarum. 

       • Work effectively with obstetricians, midwives, anesthesiologists, pediatricians, and nursing staff. 

       • Communicate effectively with patients and their families, providing clear explanations and education about labor and delivery processes.

       • Maintain accurate and thorough documentation in the electronic medical record 

       • Apply evidence-based guidelines in the management of labor and delivery. 

       • Reflect on clinical experiences to identify areas for personal improvement. 

OB CHECKLIST: PRINT THIS OUT 

FHC: Patient care sessions per FHC wiki page. Generally there will be 2 sessions a week, on Thursday mornings and Friday afternoons, with the exception of the week of night float. One week you will work in Early Options clinic with Dr. Paladine on Thursday morning.  

QI/CMAS: see individual wiki pages

LECTURES: Attend all Thursday afternoon lectures. If you have an appointment or need to be excused, email Diana, Dr. Paladine, Dr. Strangas, and the sick line. 

ADMIN TIME: use this to do reading, complete the rotation exercise, or time to prepare for your Farrell sessions

NIGHT FLOAT

• Arrive to L&D @ 7:30pm, print OB service list and review with Green Attending (if there is one)

  • you will be assigned patients who had c/s and are scheduled for D/C in the AM and will need to round on these patients in the morning and discharge them

• Get the Green pager from the Green attending – you will cover gyn patients, post-op patients, and ER consults

• Discuss w/ Green attending how they want you to manage ER c/s (i.e. see the pt on your own first, then present; or go with the attending to the ED, etc.)

• Admit first scheduled induction, manage patient throughout induction and labor

• Be available to help with triage cases, especially when the floor is very busy or is understaffed. 

• Manage labor floor as per day Labor and Delivery expectations

  • • PGY1 Night shift Guide to Labor and Delivery.docx Specific tips and hints for nights 

Allen Labor and Delivery Checklist for Handoff 

•   Age G#P# at ## weeks admitted for ____________ on Date __________

•   Prenatal Care with __________________________

•  Labor Course:

•   Tracing Issues/Events during Admission/Safety Huddle Called?

•   Antepartum Issues/Chronic Medical Issues

• GBS

•  EFW (recent Ultrasound/Leopold)

•  Admission Consent Signed?

•   Immediate Postpartum Contraception/Sterilization?

•   Bias Concerns

•  PPH Risk

Formal evaluative assessments should be completed by the same cohort via shared Qualtrics survey.

The form is short; please solicit feedback from at least one individual you work with per session

Survey results are compiled by Dr. Grandelis and a composite evaluation will be shared at the end of the rotation. 

Regular feedback should be solicited on a frequent basis throughout the course of the rotation, with attention to feedback not only from attendings but also from midwives, nursing, and other team members. 

Family med medhub evaluations are completed by Dr. Strangas at the end of the rotation based on composite qualtrics survey results and incorporate feedback and observation from attendings outside the survey. 

Residents are expected to complete rotation evaluations on Medhub as well, which are compiled and anonymized, and reviewed every 6 months

Month 1 Questions (PRINT)

1. Orientation to L&D, Antepartum records, ACN practices, documentation in Eclipsys, triage form - PRINT THIS OUT!

2. Physical exam:  Leopold maneuvers, why is it important to estimate fetal weight? Cervical exams -

   •  Accuracy of Leopold

   • Cervical Exam Tips:

     • Effacement 0% is around the second DIP joint, 50% is around the first 

     • Carry around cervical dilation beads (super handy, each bead is 1 cm)

     • Keep a paper ruler in your badge to keep checking 5 cm vs 7 cm as needed

     • Following the posterior wall of the vagina till the end, then feel anteriorly for the cervix. Put pressure towards the rectum for comfort.

     • Drop your wrist/elbow into the bed for a better angle

     • When possible, feel for the baby's head and then find the lip of the cervix from there 

1. Introduction to suturing - basic vaginal anatomy review, practice on washcloth

• See AAFP article here: https://www.aafp.org/afp/2003/1015/p1585.html      AAFP review of perineal lacerations  

• Watch episiotomy repair video: http://www.operationalmedicine.org/Videos/Episiotomy.htm  

• Surgical knot tutorial if needed: https://www.youtube.com/watch?v=XHk_191uYP4  

2. Definition of Labor:  when is a patient in labor?  What criteria are used to admit? vs discharge vs ambulate? - https://www.aafp.org/afp/2015/0801/p202.html    AAFP review of perineal lacerations

1.  Accurate Dating of Pregnancy: how do we calculate; what are «good dates», what is the margin of error? Why is it important? - ACOG pregnancy dating

2.  mgmt of labor pain I; mgmt of labor pain II

3.  Postpartum hemorrhage (ALSO 4 Ts), including medications

   • Postpartum Hemorrhage ACOG 2017

   • Prevention and management of postpartum hemorrhage   

1.  Shoulder dystocia  (ALSO HELPERR mnemonic)

   • ACOG PB Shoulder Dystocia.pdf

   • AAFP 2004 Shoulder Dystocia 

2.  Review EFM and labor induction questions

3.  The P’s of labor dystocia (passenger, pelvis, power, psyche, also pain, "pladder"). What is a normal labor curve in stage 1 and stage 2? 

   • Zhang et al:  Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes

Important Reminders

• Every patient admitted to L&D for labor or IOL requires informed consent discussing the plan for management of labor, as well as associated risks.

• Consents are completed electronically. Please review the L&D Orientation PPT for further details on how to do this.

• Both Family Medicine & Emergency Room Medicine resident physicians are expected to verbally consent patients on admission.

  • • Please be sure to do several consents with an attending prior to consenting on your own.

• *** Of note, the attending provider (physician or midwife) is required to SIGN all consents.

  • • Once comfortable with the process, off-service residents should verbally consent patients admitted for labor and obtain the patient’s signature on the electronic consent form.

    • When this is completed, the resident should notify the attending physician or midwife that the consent form is ready for their signature.

• For the procedure, the resident should list something similar to the following:

  • • Management of labor, including augmentation and/or induction of labor (if applicable), cesarean delivery, injury to infant, and management of obstetric hemorrhage (including peripartum hysterectomy).

    • They should also include postplacental IUD, postpartum tubal ligation, management of shoulder dystocia as clinically indicated.

Example Script for Labor Consent

First start by asking if any questions or concerns regarding the process, so that you can address in your counseling

"To start, we will need to do an exam to see if the cervix is dilated. This will give us more information about the best methods to use for your induction. Most likely, we will need to help prepare the cervix for labor. We call this cervical ripening and it is accomplished, ideally, by doing two things at the same time.

First, we will give you a pill approx. every 2h called misoprostol to help the cervix start to soften, dilate and thin out. Second, we will attempt to place a balloon through the cervix and inflate it to also help the cervix dilate and thin out. It is safe to use both methods at the same time and also the most efficient way to get you into labor.

The balloon can be left in place for up to 12 hours and usually comes out sooner. You can still move around and use the bathroom normally with the balloon in place. The balloon is very low risk and safe for both you and baby. Most patients experience intense cramping with placement, which usually improves after 15-20min. Once the balloon comes out, you should be around 4-5cm dilated. - exclude this the first paragraphs up to here if induction is not required (i.e., patient presents in labor or has a favorable cervix based on the BISHOP score.

At some point, we may start a medicine called Pitocin to help the contractions become stronger and closer together, and we may break the bag of water to help labor progress as well if it does not break on its own.

You may choose to get an epidural during labor. This is by far the best option for pain control. You can get an epidural whenever you choose, and research has shown that timing of epidural placement does not affect labor progress. Some patients get it very early on, and others will wait until they are more advanced in labor or before we break the water or start pitocin. Any time is fine. The other options available are not very effective, so we generally do not offer them, but we can discuss them if you are interested.

There are risks associated with labor and delivery, even for patients who are young and healthy. First, there is a risk of heavy bleeding after delivery, sometimes requiring a blood transfusion. This cannot always be predicted, so it is important that we ask every patient if they are ok receiving a blood transfusion should they need it. Would you be ok with this? Can discuss risks of blood transfusion here, if time.

In the case of heavy bleeding, there are many medications we can administer and procedures we can do to help stop bleeding. The last resort, if the amount of bleeding is life-threatening and has not responded to other interventions, would be to perform a hysterectomy, or remove the uterus. This is extremely rare and we only mention it so that you are fully informed.

There is also a risk of infection. Some patients develop an infection in the uterus during labor, which is treated with antibiotics through the IV. You would also receive antibiotics for prevention of infection should you need a cesarean section. Some reasons we may recommend a c-section include: if labor is not progressing normally or if we are concerned about your baby not being able to tolerate labor.

Whether you have a vaginal delivery or a c-section, there is a risk of injury to surrounding organs/structures. For example, some patients need stitches after a vaginal delivery. During a c-section, we rarely see injuries to other organs in the abdomen (the intestines, bladder, tubes that bring urine from kidneys to bladder). If there is an injury during surgery, we fix it then, sometimes with the help from other types of surgeons. Rarely, people will need a second procedure to fix an injury that was not noticed during the c-section.

Lastly, whether you have a vaginal delivery or c-section, there is a risk of injury to baby. Again, this is exceedingly rare, and nearly all injuries get better on their own without intervention (nerve injuries or small cuts from instruments are the most common). We take great care to protect your baby from injury, but it can happen on rare occasions despite our best efforts."

At this point, you can reaffirm that these complications (especially injury to surrounding organs and to the baby) are quite rare.

Will also need to consent for tubal ligation and post-placental IUD placement desiring these forms of contraception. You will also need to counsel on shoulder dystocia for high risk patients (EFW > 4,000g or patients with diabetes). Please ask the attending provider to review these with you prior to consenting the patient.

Updated October 1, 2024 by Grandelis

❏       General: Spontaneous Vaginal Delivery AFP 2015: http://www.aafp.org/afp/2015/0801/p202.pdf  

❏       Ob-gyn residency bite size didactics for review (Audubon-bons): https://www.obgyn.columbia.edu/audubon-bons 

❏       Fetal monitoring:

• Intrapartum Fetal Monitoring (with examples).  AFP 2009: http://www.aafp.org/afp/2009/1215/p1388.html

• Macones GA et al.  The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring (summary of fetal monitoring terminology): http://dbbs.wustl.edu/curstudents/Documents/Markey/2008%20NICHD%20EFM%20_%20Macones.pdf

• Management of Category II Tracings:  Intrapartum management of category II fetal heart rate tracings: towards standardization of care

❏       Labor induction/postdates :

• Common Questions about Late-Term and Post-term Pregnancy: http://www.aafp.org/afp/2014/0801/p160.html

• ACOG labor induction 2009:  ACOG Induction of Labor 2009

❏       Postpartum hemorrhage (includes active management of the third stage of labor)

• Prevention and Management of Postpartum Hemorrhage.  AFP 2007:http://www.aafp.org/afp/2007/0315/p875.html   

❏       Pre-eclampsia/ hypertension

• Hypertensive Disorders of Pregnancy: http://www.aafp.org/afp/2016/0115/p121.html

❏       labor dystocia

• Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660040/

• Preventing the First Cesarean Delivery: http://www.slideshare.net/AshaReddy2/preventing-the-first-cesarean-delivery  

❏       shoulder dystocia/ macrosomia

• Shoulder Dystocia.  AFP April 2004 (includes HELPERR mnemonic): http://www.aafp.org/afp/2004/0401/p1707.html

❏       Breastfeeding

• Strategies for Breastfeeding Success, AFP 2008: http://www.aafp.org/afp/2008/0715/p225.html

• Lactmed app (drug safety in breastfeeding women): http://toxnet.nlm.nih.gov/help/lactmedapp.htm

• Wellstart self-study modules: http://www.wellstart.org/Self-Study-Module.pdf

❏       postpartum contraception

• CDC recommendations for postpartum contraception: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm?s_cid=mm6026a3_w

• CDC contraception app: https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewSoftware?id=595752188&mt=8

❏       Group B Strep

• CDC 2010 guidelines: http://www.cdc.gov/groupbstrep/guidelines/guidelines.html

❏          Committee Opinion No 782 on prevention of GBS disease in newborns

❏       Prevent GBS app (free from the CDC): https://itunes.apple.com/us/app/prevent-group-b-strep-gbs/id689290789

Common Triage Complaints

• Rupture of Membranes: I think my water broke

❏       To do:  sterile speculum exam, look for pooling, nitrazine, ferning; sterile vaginal exam after to check dilation/effacement/station

• Vaginal Bleeding

❏       To do: assess for trauma, painful or painless bleeding, recent sex, mucous-like d/c or frank blood (may be mucous plug)

❏       Search OB sonos for evidence of previa BEFORE ANY VAGINAL EXAMS (if previa, no vaginal exam)

❏       Sterile speculum exam, then vaginal exam

❏       Order coags to r/o DIC in cases of abruption

• Decreased Fetal Movement

❏       To do: 20 mins min of FHT and tocometry + kick counter for mom to mark fetal movement

❏       Ultrasound to measure AFI (oligo = cause of decreased FM)

• Contractions

❏       To do: 20 mins min of FHT and toco

❏       Assess tracing for regularity and frequency of contractions

❏       Sterile vaginal exam to evaluate for active labor

• Vaginal Discharge

❏           To do: assess for safe sex practices, h/o STDs, multiple partners, most recent sexual intercourse

❏       Speculum exam: collect sample for wet prep, r/o ROM, examine d/c (green/frothy, cottage cheese, +whiff, etc.)

❏       Vaginal exam: look for cervical motion tenderness, dilation/effacement/station

• I think I’m in labor

❏       To do: keep on FHT and toco

❏       Assess for ROM -> If no, proceed with SVE;

❏  if yes/unsure, proceed with SSE (examine for ROM with pooling, ferning, nitrazine), then perform SVE

❏       Assess regularity and frequency of CTX

❏       If in active labor (6cm +), present pt to attending, consent for delivery, admit and place admission orders, collect labs, discuss pain control options, update handoff and board note

❏       Sometimes pts in latent labor (<5cm) are admitted for pain control if they live far from hospital

• smart phone apps