ObGyn and FM Intern Orientation and Survival Guide

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					Ob/Gyn and FM Intern Orientation and Survival Guide
(Medical Students - These are the interns duties for your information) There is a hierarchy within the residency. It is used to promote progressive decisionmaking capabilities while maturing in the training process. It is to be respected and utilized. Although the attending is ultimately responsible for whatever happens, he/she recognizes the importance of allowing residents the opportunity to make decisions and will often not intervene in the day-to-day decisions as they relate to patient care. Among residents, however, questions and management decisions should flow from first call/intern to second call and then chief. The chief resident may then confer with the generalist attending, the MFM or ONC attending. This fosters a learning environment and a sense of security. This flow of information is also bi-directional, and it is often necessary for the second call to “check behind” the intern. The second call will notify the chief of any changes in patient status and will inform the chief is his/her presence is needed. In the even of an emergency, the second call is epxected to directly notify the attending if the chief resident is not in-house. In clinic, a question may be taken directly to the attending, but conferring with the second or third year resident is encouraged, because valuable teaching and learning will occur (more on presenting to the attending later). If there is a situation where a junior resident receives an answer that he/she feels is inaccurate or is not in the best interest of the patient, that resident should ask the question again, stating his/her reservations. If it is still unacceptable, that resident may take the question to the next higher level without fear of penalty. Acronyms and abbreviations BTL- bilateral tubal ligation BSS- bedside sono ctx- contractions EGA-estimated gestational age EDC- est date of confiment (due date) FM-fetal movement EFW- est fetal weight GBS-group B strep FHT- fetal heart tracing LMP- last menstrual period LOF- leakage of fluid LTCS- low transverse c-section EBL- estimated blood loss LFI- live female infant LMI- live male infant IUFD- intrauterine fetal demise PPROM- premature preterm rupture of membranes SVD- spontaneous vaginal delivery VAVD- vacuum assisted vaginal delivery SVE- sterile vaginal exam SSE- sterile speculum exam SROM- sponteous rupture of membranes +/+/- Rh +, rubella immune, GBS neg TAH- total abdominal hysterectomy TVH- total vaginal hysterectomy BSO- bilateral salpingoophorectomy A&P- anterior and posterior repair PID- pelvic inflammatory disease TOA- tuboovarian abscess POC- products of conception

Clinic (OB)
Clinic begins at 9 am and runs until all patients are seen. Lunch does not begin until all the morning patients are seen. Before leaving for lunch make sure that there are no more patients to be put into rooms (even though all patients in rooms at noon may already be being seen). The afternoon session starts between 12:45 and 1:30 (depending on when the am patients finished) and runs until all patients seen in the afternoon. The on-call team

may be excused at 5pm or when their last patient is seen. The Ob residents may not leave until the Chief desktop has been cleared of phone calls- this is an intern responsibility and all patients must try to be reached before going home. The upper level ob residents do the labs and ultrasounds and the chief residents do the path and histology and paps. Prenatal care  We have a high-volume of Ob patients, both routine and high risk. High-risk days are typically Monday and Thursday mornings, when NST are easily done.  Schedule for visits for routine care:  Q 4 weeks up to 28 weeks  Q 2 weeks from 28-35 weeks  Q 1 week for 36-41 weeks  Biweekly for 41+ weeks- needs NST biweekly and weekly AFI  Patients need one nurse interview during their pregnancy- make sure this has been done  The first Ob visit is typically the NOBWU (new ob w/u). It should include a complete H&P, ultrasound to date the pregnancy and determine viability, Rx for PNV, schedule labs (more on this later), schedule sono if indicated, arrange PDC referral for high-risk.  Dating for a pregnancy should be based on first day of LMP. A first trimester US is the best way to confirm the EDC or to change her EDC. We do this in clinic. If she is mid-second trimester or 3rd trimester, then she should be sent ASAP to the hospital for a sono.  When to change a patient’s due date: <12 weeks- +/- 5 days difference in the LMP and sono 12-24 weeks- 10 days difference in LMP and sono 24-36 weeks- 15 days difference in LMP and sono >36 weeks- 21 days difference in LMP and sono TELL THE PATIENT HER DUE DATE AT THE FIRST VISIT- THIS IS HER OFFICIAL EDC UNLESS TOLD OTHERWISE!!!!! Routine labs, screens and ultrasounds  Prenatal panel- type and screen, T. pall, rubella titer, Hep B surface Ag, HIV, H/H, hbg electrophoresis, urine culture. Done at either the first dr visit or nurse interview  Pap, GC/CZ- done at the first dr. visit  All patients should try to have an office sono at the first visit to document IUP and EGA  Tetra screen (15-23 wk), first trimester Down’s screening (11-13wk), cystic fibrosis (any time)- all optional screens that charity care doesn’t cover. Needs to be offered and consent signed for accept and decline  Early glucola (16-18wk) for risk factors (>200lb, prior hx in preg, 1st degree relative)  Fetal movement first felt 16-24 weeks  Try to find fetal heart with doptone after 8 weeks  Start measuring fundal heights at 20 weeks. A normal fundal height is +/- 3 cm of EGA; if doesn’t correlate or lags or gains on EGA, needs sono to measure growth/AFI


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Between 12-20 wks, record fundal height in weeks  12 weeks at pubic symphisis  16 weeks halfway to umbilicus  20 weeks at umbilicus 28 week panel- antibody screen, hct, T.pall and glucola; begin counseling on “kick counts” (at least 10 fetal movements in 2 hours is reassuring) Rhogam at 28 weeks for all Rh neg without positive antibody screen for Rh One ultrasound for normal pregnancies after 16 weeks (target before 20 weeks) Sign sterilization papers at 28 weeks- pink copy for patient and tell her to keep handy in case the hospital copy gets lost. Pt must be over 21 years old to sign and must have signed 30 days in advance for term delivery and 72hrs in advance for preterm delivery. Morbidly obese women may want to consider another form of contraception since this is very difficult in them. Check position at each visit 36+ weeks by Leopolds and then sono to confirm; if breech, offer external cephalic version or schedule c-section Counsel on signs/symptoms of labor each visit starting at 36 weeks

Prenatal Diagnostic Center Referral center for high risk pregnancies and for genetic counseling. Also does the first trimester Down’s screening. Check with an upper level if you think a person needs a referral and then gets scheduled through Pat Hale. High Risk Ob  Advanced Maternal Age (AMA)- older than 35 at the EDC. Needs to be offered genetic counseling and amniocentesis for chromosomes (optional)  Chronic HTN (CHTN)- elevated BP prior to 20 weeks. Also needs baseline PIH labs, 24hr urine for protein and creatinine clearance, EKG (if long standing). Biweekly testing at 32weeks  Diabetics- preexisting or gestational. Also needs hbg AIC, 24hr urine for protein and creatinine clearance, baseline PIH panel; ophthamology, nutrition and diabetic teaching referral; early PDC sono to r/o anencephaly or other lethal anomalies; month US for growth after 24 weeks; fetal echocardiogram at 20-22 weeks; biweekly testing 28-32 weeks; amnio at 37 weeks for poorly controlled diabetics and delivery  Previous preterm delivery- try to determine cause; if labor, determine need for cerclage, progesterone shots or BV screening. Biweekly testing Includes twice weekly NST (usually Mon/Thurs) and once weekly AFI Admitting from clinic Discuss all admissions with upper level resident/attending prior to sending patient to L&D. The upper level resident on L&D and the charge nurse need to be notified prior to pt going.

Scheduled C-sections  Determine how dating established- if adequate, then may post at 39weeks. If poor dating (3rd trimester sono, LMP and 2nd tri sono do not agree, etc), then pt may need amniocentesis for FLM prior to surgery.  Pt should be scheduled through Pat Hale for surgery date and pre-op appt; no routine c-sections on Friday if possible  H&P should be dictated by resident who sees the pt for pre-op  Pt brings the blue pre-op packet with them to the hospital  NPO after midnight  Discuss BTL prior to surgery. Optimally, pt will have signed VA medicaid papers at least 30 days in advance but this is not absolutely necessary for c-sections

Hospital Care (OB)
Rounds  8 am on in the lobby conference room (7 am on Fridays). 8 am in the 6th floor L&D conference room on weekends.  Be prepared to give a brief overview of the patients you saw in the am: --yo G-Pppd/pod # s/p SVD/LTCS, doing well (or having whatever complication). If a patient is going home that day, then we need certain information for RRC stats.  -baby’s weight, delivering resident and attending and any complications  All pts that the interns see must also be seen by an upper level (a note is not always written by the upper level).  All pts, except routine SVDs, are seen in the evening as well (may start rounding after 12 noon for pm rounds)  Interns usually start with routine SVDs and see progressively more difficult patients, such as c-sections and gyn patients. They are NOT to see transfer patients (by order of Dr. Dennis). Patient Lists Can be printed through SMS at any nurse’s station. Go to Print Nurse Station Census (option 8); units are 6EST 7CTR 7WST and sometimes 7EST. Y to occupied beds, W sequence and 1 copy only Our patients are identified by our attendings (Arner, McCuin, Ellsworth, Stacey, Hillard, Williams, Li, Dennis, Scribner and Waller-Smith) L&D Responsibilities  Management of the low-risk laboring patient and triage are the intern’s main responsibilities. This is done under the direct supervision of the upper level OB resident. They should know everything that is going on.  A vaginal exam should NEVER be done without a nurse present, and the 2nd call resident should preferably be present also.  All triage patients must also be seen by the upper level resident after the intern has evaluated them. Upper level residents are responsible for preterm (24-37wk) triage pts. Interns are welcome to see them, but management should come from the upper level.

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The upper level resident will be the primary surgeon except for BTLs and D&Cs. FM residents are encouraged to scrub for C-sections as these deliveries count for their numbers. Upper level residents are responsible for the ER calls; interns are to follow the residents while they evaluate the patients. 7th floor calls may go either to the upper or first year residents. Interns should update the upper level on things that need management. Interns should not manage gyn onc or antepartum patients- calls need to be redirected to the upper level. “Pound calls”- ie. The Ob Emergency Pager. See Next section

Pound Calls Pt’s are instructed to call the Ob Dr. On Call to discuss any questions or concerns they have outside of regular clinic hours. Operators will notify you of the patients name and connect you with them  Obtain the pt’s EDC, phone number and where they are seen for their prenatal care  Complaints and above info need to be recorded on the yellow phone triage sheets for legal purposes and reviewed by the upper level. They may also be recorded in Centricity  If the caller is someone other than the pt, ask to speak to the pt directly to obtain the most accurate information.  This is not a 24-hr ob/gyn chat line; pts with routine gyn questions are urged to call clinic during hours, but if they feel they need to be seen immediately, direct them to the ER  Ob pts with concerns should be come to the ER (triage pt’s enter through the ER and should be instructed as such) for decreased fetal movement greater than 28 weeks, bleeding, cramping, contractions, or leaking fluid. When in doubt, they should be seen sooner than later.  Narcotics are not to be phoned in. If a pt requires this level of pain control, they should be seen through the ER.  Calls should be answered expeditiously, but if you are in the middle of a delivery or surgery, have the nurse call the operator and hold the calls until later. Remember to call back ASAP. These calls should not be ignored, and if the operator feels you are not calling back fast enough, your upper level will be called. Common Pound-call Questions Use the big black Ob phone triage notebook in the call room Leaking fluid- anyone with possible ruptured membranes should come in. If it leaks only when she coughs/sneezes, then likely urine. She can wear a pad for a few hours and if it’s soaked, then needs to come in for eval. Decreased fetal movement- less than 10 movements in 2 hours after 28 weeks. Lie down, eat a snack, drink some fluid and if above criteria not met, then needs to be evaluated Bleeding- spotting at term is ok. Bleeding like a period needs to be evaluated immediately. If first trimester and not accompanied by cramping, may be normal, but monitor for worsening. Explain to pt that some miscarriages are inevitable, and there is

usually nothing that can be done to prevent them, but should go to the ER if bleeding greater than 1 pad/hr. Contractions- if preterm and more than 6/hr, then needs immediate evaluation. If less frequent, she should drink a large glass of water, lie down and monitor ctx. If term, then she should wait until the are every 3-5 minutes, increasing in intensity and have been occurring for at least an hour. If a pt is unable to complete sentences while you are talking to her, then it may warrant coming in. OB Triage It’s the obstetrical ER- #89897. Prior to 20 weeks, they are evaluated in the main ER, but you may be called to evaluate a pregnant patient down there. You will be called to evaluate pt’s prior to 24 weeks and at term. If they are preterm, you will see them with your upper level. After eval, call the upper level to check out to them.  All NST’s must be approved by an upper level prior to pt discharge; all pt’s greater than 28 weeks need a reactive NST prior to discharge  Always verify the pt’s EDC by her records; many pts will tell you the wrong due date and this may change their medical care; records can be obtained from clinic by security  Labor evaluation includes a digital exam to assess dilation. If she is in latent labor, she may walk (if reactive NST) or be sent home on therapeutic rest  SROM evaluation involves a SSE for pooling, nitrazine and/or ferning. This is performed prior to a digital exam  Bleeding exam involves and ultrasound to verify the position of the placenta prior to SSE and an SSE if previa is ruled out. The ultrasound also reassures the pt that the baby is ok  Decreased fetal movement exam involves an NST  Nausea/Vomiting involves a UA to check for dehydration and IVF and antiemetics as indicated. Once a pt is tolerating po, she may be discharged Documentation is done on Centricity as “Hospital Procedure” type. Things that must be documented include gestational age, G’sP’s, complaint, pt vitals, FHTs, exam findings, and which upper level approved the pt’s discharge. It is then sent to the Generic Attending desktop without your signature. Admission Indications  Cervical change (ie labor)  Nonreassuring fetal surveillance  Spontaneous rupture of membranes  Pts who are >40wks- case by case basis  Other preterm patients with problems (high BP, pyelonephritis, bleeding, etc) Admission H&P For laboring patients, the first line is the most important: --yo (race) G-P- with an LMP of – giving an EDC of --- confirmed by (or changed by) a --- week ultrasound, for an EGA of ---. Pt presents with --- (ctx, VB, LOF, decr FM, etc). SROM at – am/pm. PNC began at –wks. Pregnancy complicated by ---.

PMH: should include ob/gyn history (paps, STDs, past preg and delivery info) PSH, Meds, Allergies, Social and family hx Labs- GBS status PE: vitals, general Heart, lungs, abd (should include fetal lie by Leopold’s and EFW!!), extremities SVE- dilation/effacement/station/position of fetal head SSE- pooling, ferning, nitrazine BSS- confirm fetal position and fetal weight Assessment- active labor, ruptured membranes, NRFS, etc Plan: Admit and plan per resident Review the “routine labor orders” to become familiar with them. Labor Patients  Check patients every 2 hours when in labor; if not in labor yet, needs a note q 2 hours to document fetal heart tracing, contraction pattern and vitals  Check patients if change in FHT- decelerations, variables  Check patients if she is feeling rectal pressure or large amounts of bloody show (or if the nurse asks you to)  Effacement refers to the length of the cervical canal; 100% effaced means the lower uterine segment is the same thickness as the cervix  Station is where the presenting part is in the vagina/pelvis. “0” station is when the bony presenting part is at the level of the ischial spines and + or – refers to distal or proximal to the ischial spines  Position is which direction the occiput is pointing. LOA- left occiput anterior is most common, but may be occiput posterior, or occiput transverse. Difficult to determine at less than 4 cm dilation.  Check your exam with the wooden dilation board at the nurse’s station.  Epidurals, IV pain meds, pudendal blocks are all acceptable pain control options for patients  Epidurals usually after labor well-established but may be sooner if needed  IV meds q 1 hr until close to time to delivery (have narcan available for baby)  Pudendals usually just for pushing Labor Note S: comfortable, unconfortable, etc. Preeclampsia symptoms O: vitals FHTs- baseline, presence of accelerations/decelerations, variability Toco (dynomometer)- frequency and strength of contractions SVE- dilation /effacement/station/ position Time of AROM/SROM and color of amniotic fluid; placement of FSE or IUPC should be noted A: progressing, not progressing, etc P: expect SVD, proceed to C-section, start pitocin, etc

Delivery  Attended by student, intern, upper level, attending and nursery (NICU and chief PRN).  A resident should push with the patient and give encouragement  The intern is responsible for delivery, assisted by the upper level, unless it is premature and then the intern will assist the upper level. The student usually gets to deliver the placenta, until the intern has adequate deliveries, then the intern is responsible for teaching the student how to do a delivery.  Try to be as neat as possible and observe sterile technique; count sponges and needles with the nurses and try not to drag towels and suture across non-sterile fields  Nurses appreciate efforts to help them clean up afterwards Delivery Note- you will often find that an attending has written a comprehensive note on a patient but it’s always a good idea for the delivering resident (or student) to also write a note to show continuity of care SVD/VAVD/FAVD of a LFI/LMI at --- weeks from --- position (OA, OT, OP) (If an operative vaginal delivery was done- VAVD/FAVD- then a reason must be given) AGPAR/weight/EBL Resident, attending Anesthesia/analgesia- epidural, spinal, local (perineal block, pudendal block), IV, none Perineum- perineal laceraton, MLE, labial laceration and what was used to repair Placenta- spontaneous vs manual extraction, intact, 3/2 vessels Complications- shoulder dystocia, 4th degree laceration, etc Disposition- mom and baby doing well in room, baby to NICU, etc NICU/neonatology Called for the following deliveries: -OR deliveries, including c-sections and double setups -multiple births -preterm or postdates (<37wk, >42 wk) -meconium-stained fluids -no prenatal care -per request of delivering doc/nurse, depending on maternal /fetal condition -at edge of viability- 22-23 weeks; try to contact them as early as possible for consult Post Partum/Post Op note S: complaints, amount of lochia, pain, breast/bottle feeding, birth control plan, BM quality (if 3rd or 4th degree laceration) or flatus (if C/s) O: vitals (make sure range of BP for preeclamptics) and Tm/Tc for chorio/post op Heart/lung/abd- fundus above/below umbilicus, firm/tender, +BS Wound- clean, dry, intact, no erythema Extr- pulses, edema, DTR (if preeclampsia) A: --yo G-P- PPD/POD #, s/p SVD/LTCS secondary to --, doing well P: continue postpartum/post-op care (or whatever the plan may be)

Operative Note Pre Op Dx: IUP at –weeks, (indication for c-section) PostOp Dx: same Procedure: primary vs repeat LTCS/ classical c-section Surgeons/attending Anesthesia- type and dr. Findings- LMI/LFI wt, APGARs, cord pH, anatomy Complications EBL (usually 700-1000ml) Disposition- mom and baby doing well in recovery, baby to NICU, etc Review the routine C-section orders to become familiar with them. Discharge Orders SVD- 24-48 hr postpartum; c-sections 48-72hr if without complications        D/C to home, verbal order per (whichever attending will write a d/c note) Follow up in 4-6 weeks (4 weeks if BTL planned, 1 week if preeclampsia) Pelvic rest (nothing in vagina) x 6 weeks No lifting anything heavier than baby x 6 weeks (if c-section) Prescriptions on chart (motrin if SVD, add lortab/percocet for c-sections) Rubella or rhogam if indicated Endometritis precautions: fever greater than 101, chills, abdominal pain, worsening cramping, heavy foul-smelling lochia  Bleeding should last 2-6 weeks but may last longer; quarter-sized clots OK  Not breast-feeding- tight bra, cold compresses, cabbage leaves, no stimulation  Breast feeding- heating pad, nurse on demand or q 2 hr, pump inbetween to relieve pressure (engorgement will improve over 2-7 days as mom and baby synchronize) If coming back for IUD or BTL we strongly encourage an alternate/interim form of contracpetion. IUDs and BTLs are both done 8 weeks postpartum but pt’s need to be seen before then, and may start ovulating as soon as 2 weeks postpartum if not breastfeeding (and breastfeeding is not a reliable form of contraception). We have sample OC packs on 7th floor. Depoprovera can be given prior to leaving the hospital if bottle feeding and 2 weeks later if breast feeding. Discharge Dictations The most important patients to have immediately dictated are the transfer patients, however, interns should not be seeing these patients. Everyone other than routine term SVD need a discharge dictation (preterm or complicated SVD, c-sections, gyn and other surgery patients). Please see Dr. Williams dictation format to avoid the “orange pen”. All discharge dictations are preferably done the DAY of discharge. Discharge Dictation “This is Dr. ___ ____ dictating the discharge summary on Ms. ____ ____ (name, MR#, date of admission and date of discharge and date of dictation)

ADMISSION HISTORY: PAST MEDICAL HISTORY (incl Ob/gyn hx) PAST SURGICAL HISTORY FAMILY HISTORY SOCIAL HISTORY ALLERGIES MEDICATIONS ADMISSION PHYSICAL EXAM PERTINENT LABS ADMISSION DIAGNOSES (list these 1, 2, 3…) HOSPITAL COURSE (does not need to be hr by hr, but summarize) DISCHARGE DIAGNOSES (needs to be a diagnosis, not a list of symptoms) PROCEDURES DONE WHILE IN HOSPITAL DISCHARGE MEDICATIONS LAB DATA (needing outpt followup) To accomplish a good discharge summary: 1. Review the whole chart for essential information 2. Establish all the admission diagnoses- write them down on a scrap of paper 3. All admission diagnoses must be explained in your H&P summary 4. Go through the chart and note all the discharge diagnoses 5. All treatments and procedures that are utilized during the admission must have a diagnosis 6. Summarize the sequence of events, but do not dictate a series of diagnostic studies that were done and do not just read the progress notes into the dictation line! 7. All Dicharge Diagnoses that are Different from the admission diagnoses must have an explanation in the summary 8. Don’t forget discharge medications

GYN pearls
The gyn service is a new block this year. The goal is to ensure continuity of care and an increase in the OR time for ob/gyn residents. There will be between 5-8 OR days a month. These will be every Wednesday and every other Thursday. The OR starts at 8:30 on the first 3 Wednesdays of the month and at 7:30 every Thursday and the 4th and 5th Wednesdays of the month. Op Note PreOp Diagnoses: pelvic pain, fibroids, stress urinary incontinence, undesired fert PostOp Diagnoses: ?same, vs findings during surgery Procedure: TAH, TVH, BSO, TOT, LOA, diagnostic laparoscopy, etc Surgeons: primary, assistants Attending: Anesthesia: type and administering doctor/nurse anesthetist EBL Fluids

Findings Complications Disposition Post Op Orders Transfer to 7th floor, admit to Dr. ---- (attending) Diagnosis Condition – guarded, stable, etc Vitals- q 1 hr x2, q 2 hr x2, then q 4 hours Allergies Activity- bed rest Nursing- foley to gravity, SCDs in place until ambulating, incentive spirometer to bedisde (please instruct in use) Call HO for T>100.4, pulse >120, resp >30, urine output less than 60cc/2 hours, BP >160/90, less than 90/40 Diet- ice chips, may advance to clears (depends on the surgery) IVF- LR at 150cc/hr Meds- PCA pump (has check-off orders in PACU), any home meds that need to be restarted, hormone replacement if needed Labs- usually none needed Post-op check Done about 4 hours after surgery. If at night, the OR team should check out the pertinent information to the floor team and what time post op check is needed. S: Pt alert, nausea controlled, pain controlled O: Vitals, urine output over X hours Heart, lung, abd exam. Examine wound bandage to make sure no leaking of blood A: POD #0 or 1, s/p “procedure” P: continue post-op care IVF Primer Indications for IVF- cannot tolerate PO, immediately post-op, maintain IV access in pt with poor veins and need for possible IV access, medication dosing FLUID Serum NS ½ NS ¼ NS 3% saline LR Sodium 135-145 154 77 38.5 513 ` 130 Potassium 3.4-4.7 0 0 0 0 4 Chloride 98-108 154 77 38.5 513 109 Bicarb 22-31 0 0 0 0 28

General fluid management  Initial post-op: isotonic fluid at 100-150cc/hr with intent to fill up vascular space and losses from NPO/bowel prep/blood loss/intraop fluid losses.

 Stable post-op (>24hr) change to hypotonic fluid with K; ½ NS with 20mEq KCL at rate to maintain urine output  Continuation of LR or NS may yield metabolic acidosis; most patients correct for this but be careful in debilitated pts or those with other medical comorbities.  Prolonged NPO (more than 48hr, less than 7d) need D5 added to prevent protein catabolism: D51/2 NS with 20mEq KCL at 125cc/hr. Watch BMP for evidence of electrolyte imbalances and correct as indicated  Extended NPO (>7d): assess nutrition status, start TPN if expected return of oral intake not expected for another 5 days.  Hospitalized with observation: heplock if need continous possible access. If poor veins, can use lowest rate needed to keep vein open (KVO). Stop all unnecessary IVF when able.

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