OB Rotation: Month 2

Rotation Goals

The goal of the second OB month is to establish competence in safe management of normal labor and delivery in uncomplicated prenatal patients. By the end of this rotation residents should demonstrate competence in performing a normal vaginal delivery; performing procedures associated with normal labor such as amniotomy, cervical balloon placement, FSE placement, and IUPC placement; monitoring progress of labor and fetal well being; identifying patients with indications for labor induction and making shared decisions on method and timing of labor induction; and responding to urgent and emergent clinical situations common on labor and delivery. Residents are also expected to begin learning to repair vaginal lacerations and to perform these under supervision.  

The second month on Labor and Delivery is also an opportunity to explore if and how prenatal care and obstetric care fit into your plans for future practice. It is a chance to examine perinatal care with a critical eye and to consider what is done well and where the practice of medicine has room to grow to be more patient centered and more equitable. 

Before Your Rotation Begins:

❏       Review the weekly schedule

❏      Call room 5-4-3 (do not share)

❏       Scrub room / clean utility: 2-4-3-0

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

ROTATION GOALS

MONTH 2

• Inpatient obstetric care

• Prenatal care

Rotation Expectations:

The goal of this rotation is to establish competence in safe management of normal labor and delivery in uncomplicated prenatal patients. By the end of this rotation residents should feel comfortable and demonstrate competence in performing a vaginal delivery; performing procedures associated with normal labor such as amniotomy, cervical balloon placement; FSE placement, and IUPC placement; monitoring progress of labor and fetal well being; identifying patients with indications for labor induction and making shared decisions on method and timing of labor induction; and responding to urgent and emergent clinical situations common on labor and delivery, including but not limited to precipitous delivery, intrapartum fetal distress, and postpartum hemorrhage. Residents are also expected to begin learning to repair vaginal lacerations and to perform these under supervision. 

This rotation is also a chance to gain proficiency with counseling around long-acting contraception, and with placing the contraceptive implant. The Allen Hospital has available both IUDs and the implant. While post-placental IUD placement during delivery is a distinct procedure from office IUD placement, implant placement is the same procedure whether it occurs in the hospital or in the office. Competency with implant placement is not a rotation specific requirement for L+D but remains a program requirement that may be met during the OB rotation. Residents must have previously completed the official Merck training prior to placing Nexplanon implants. https://www.nexplanontraining.com/ 

Finally, the second month on Labor and Delivery is an opportunity to explore if and how prenatal care and obstetric care fit into your plans for future practice. It is also a chance to examine perinatal care with a critical eye and to consider what is done well and where the practice of medicine has room to grow to be more patient centered and more equitable.  

The final week of the rotation is primarily outpatient, with a focus on ambulatory maternity care, both at Farrell and at Perinatal clinic. 

L&D DAY:

1. Arrive to L&D 7:20am (rounds start promptly at 7:30am) --> print Labor board list

2. Manage labor floor including:

   1. • Managing normal and abnormal labor progress

      • Triaging patients and staffing them with FM attending, OB attending, and / or CNM if present

      • Choosing induction method (bishop score, misoprostol, mechanical induction, etc.)

      • Learning management of hypertension in pregnancy (gHTN, PEC, etc.)

      • Managing intrapartum pain

      • Planning for delivery of GDMA1 and glycemic control in prenatal patients and during labor 

      • Management of obstetrical emergencies (Cat2-3 tracing, STAT c/s, shoulder dystocia, PPH, etc.)

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

           • Postpartum Hemorrhage AAFP 2017.pdf   

           • STAT c/s – usually for >5 mins of fetal distress (bradycardia on FHT), maternal distress. Help nursing/physicians with transporting patient safely to the OR within 3 minutes of decision. Assist team in any way – informing OR of STAT section, informing team members, transporting patient to OR, disconnecting/connecting monitoring monitors, providing ACLS support if needed, or bringing blood from blood bank

      • Management and monitoring of labor progress in admitted patients -ACOG Approaches to Limit Intervention During Labor and Birth

      • Complete exams for labor course, with confirmation by attendings when necessary

      • Monitoring and analyzing EFM in laboring patients

      • Consents for admitted patients 

      • Complete birth certificate forms as needed for cases you participate in

FHC:  Check the orange schedule. Generally there will be 2 sessions a week, on Thursday mornings and Friday afternoons during the first half of the rotation, followed by a week of night float with no FHC sessions. The final week of the rotation is exclusively outpatient. 

NEXPLANON: After board rounds, check in with the Green attending, NP, or CNM rounding on postpartum to see if there are any patients who need Nexplanon placement that day 

LECTURES: The expectation is for residents to attend Thursday didactics unless on L+D nights. If you have an appointment or need to be excused, email Diana, Dr. Paladine, Dr. Strangas, and the chiefs.

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 MD – you may 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 first, then present vs go with the attending to the ED, etc.)

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

• Manage labor floor as per day L&D

FARRELL SESSIONS (FINAL WEEK)

• Focus on prenatal care and apply lessons from L+D to prenatal and postpartum practice

• Meet with Dr. Strangas the Monday morning to review your prenatal panel and discuss panel management in prenatal care

• You will work with regular FHC sessions, with the OB/gyn at Farrell (Dr. Swapna Nalgonda), Dyad clinic for postpartum care, and rotate to the perinatal high risk clinic as well. 

*** References are in the reading lists for the OB1 rotation. ***

1)  List three contraindications to breastfeeding, three infant benefits, and three maternal benefits.

2) A.A. is a 24yo woman G1P1, now two days s/p an uncomplicated NSVD.  She has questions about postpartum contraception

*An evidence-based source for this question is the CDC Medical Eligibility for Contraception guidelines, available online or as a free app.*

•  If she wants to use OCPs, when can she start?  What if she is breastfeeding vs. not breastfeeding?

• When can she have an IUD inserted?

•  What are the three criteria that must be true for her to rely on the lactational amenorrhea method (LAM)?

•  Can she use estrogen-containing contraception if she had high blood pressure during pregnancy?

3)      B.B. is a 33yo woman G2P1 at 9 weeks EGA here for a first prenatal visit.

•  How much weight should a normal weight woman gain in pregnancy?  What about an obese woman?

•  List three maternal consequences and three neonatal or long-term consequences in the child of excessive weight gain in pregnancy.

•  What can you do in the office to make sure your patient gains the right amount of weight in pregnancy?

You will conduct 3 prenatal chart reviews during the rotation, of patients late in the 2nd or early in the 3rd trimester of pregnancy. You will receive patient MRNs from Dr. Strangas at the beginning of the rotation, and are expected to review the patient by the end of the rotation according to the chart review template attached. 

To conduct the chart review, it is easiest to the use the "OB Tools" function in Epic. Unfortunately this can only be done through an open encounter, which can by achieved by opening a new Documentation encounter. 

Prenatal Chart Review Template 

1. Review common complications of pregnancy: hypertensive disorders and gestational DM

   1. 1. GDM AAFP article (direct access GDM AAFP 2015 )

      2. Review NYP prenatal protocols - when is delivery at MSCHONY required?

      3. Cases Requiring Booking at MSCH 10-22-18 (1).docx

1. Common postpartum complications:

   • postpartum care (wind, water, walking, wound, womb) - https://www.aafp.org/afp/2019/1015/p485.html (authored by Drs. Strangas and Paladine!)

   • Postpartum Hemorrhage (primary and secondary)ACOG Practice Bulletin PPH

   • breastfeeding difficulties - BFing support and resources

1. Review labor onset outside range of “norm” (<37 wks and >40 wks). PTL, PPROM, post dates

   1. ACOG Practice Bulletin on Preterm Labor.pdf

   2. ACOG Practice Bulletin on PROM.pdf  

   3. ACOG Practice Bulletin on Late term and post term pregnancies.pdf  

general prenatal care

❏      AFP Update on Prenatal Care 2014: https://www.aafp.org/pubs/afp/issues/2023/0800/prenatal-care.html

❏      Antepartum Protocol

❏      ultrasound in pregnancy

❏      ACOG practice bulletin: ACOG Practice Bulletin

❏      gestational diabetes

❏      Screening, Diagnosis, and Management of Gestational Diabetes: https://www.aafp.org/pubs/afp/issues/2023/0900/gestational-diabetes.html

❏      also review the NYP gestational diabetes protocol on the wiki 

❏      weight gain in pregnancy

❏      http://www.nationalacademies.org/hmd/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx

❏      pain relief during labor

❏      AFP Labor Analgesia 2012: https://www.aafp.org/pubs/afp/issues/2021/0315/p355.html

❏      birth plan

❏      BirthPlan.pdf

Now that you have an understanding of basics of labor and delivery, you have an opportunity to explore different ways of providing prenatal care, and take a critical eye to ways in which obstetrics engages with health inequities. These readings are intended as an introduction to perspectives other than that of the hospital, be it public health, news media, or individual experience. They are perspectives are not exclusive, and residents are encouraged to seek out further reading and experiences as able. There are often ways in which attempts to provide quality clinical care can cause or perpetuate harm to patients or populations; it is important that we are open to the possibility that we, as part of the medical establishment, are part of the problem if we are to meaningfully advance health equity and provide quality care. 

• Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproducti.pdf

• Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis - The New York Times.pdf

• America is Failing its Black Mothers _ Harvard Public Health Magazine _ Harvard T.H. Chan School.pdf

• A Litany for Survival, by Naomi Jackson.pdf

There are also other modes of providing quality care. Centering Pregnancy is a proprietary group prenatal model employed by many practices. The University of Michigan has developed multiple prenatal care models, driven by the pandemic, that include traditional prenatal care, a hybrid virtual / in person model, and group prenatal care

• Centering pregnancy and birth equity: BirthEquity_IssueBrief__Oct9th2019.pdf

• https://www.centeringhealthcare.org/what-we-do/centering-pregnancy

• University of Michigan MiPATH: https://www.umwomenshealth.org/mipath-prenatal-patient-resources#mipath

  • ACOG Redesigning Prenatal Care: ACOG Prenatal Care Initative 

 Residents are expected to complete rotation evaluations on Mehhub which are anonymous and will be reviewed every 6 months.