Family Medicine Obstetrical Rotation Overview Rotation Coordinator: David Harnisch, Sr. MD Residency Director: Jeffery Harrison, MD Clerical Support: Rita Smith Welcome to the FM-OB rotation! As a requirement of the Family Medicine program, Residents are required to do 40 deliveries during training—10 continuity deliveries and 30 non-continuity deliveries. This rotation gives residents the opportunity to learn appropriate obstetric care as they fulfill this requirement. The FM-OB team cares for patients from several sources: Red Team -- non continuity DOD (department of defense) patients Blue Team -- continuity DOD patients Green Team. -- non continuity patients seen at DOC Team Rojo -- non continuity patients seen at One World Continuities -- continuity resident patients from a variety of sources “Privates” -- continuity pts of the attendings (e.g. Drs Tibbels, Mathews etc.) While on the rotation residents see OB patients mainly in two clinics—Red Team clinics (numerous clinics and times) and the Green Team (Wednesday PM’s at DOC) while also continuing to see their own continuity clinics. The FM-OB team is composed of a staff physician (Primary), an OB consultant who can do cesareans (may also function as the Primary at times), the Rural Fellow, and the residents assigned to the FM-OB team (2 or 3 junior residents per month). Call Schedules: schedules are e-mailed at the beginning of the rotation. Any changes to the schedule should be communicated to and approved by the Rotation Coordinator (Dr. Harnisch) On weekends or holidays it is essential that you coordinate coverage with the Primary. It is also your responsibility to work with the attending in monitoring the work hour rules and not violate them. 1. No more than 30 consecutive hours of duty (not violatable) 2. 10 hours of rest between each 30 hours of duty 3. No more than 80 hours of duty per week (averaged over a one month rotation) 4. at least 1 day (24 hours) off of duty per week (averaged over each month) Residents are also expected to attend the OB conference on Mondays at Noon in the FM conference room; GYN conference at noon on Fridays in the FM conference room (except for the first Monday of the month when the OB staff meeting is held.); Grand Rounds, and Teaching Day Conferences. Rules and Responsibilities 1. Intern Week Day Duties (HO-1, M4/Sub-I accelerated track) a. Daily work hours Monday through Friday at 0700-1700 b. All Postpartum, laboring, and newborn patients should be rounded on and notes completed by 0730 c. Rounding responsibilities should be evenly distributed among the interns during the week. When an OB supervisor is on the service, it is their responsibility to make sure the work is split up evenly. d. Rounds with the attending on service begin at 0730 in the Consultation room on University L and D unless directed otherwise by the attending e. The primary responsibility for the interns is to cover the hospital for all triages, labors, C-sections, newborn exams, post partum care, and circumcisions. At least one intern should be physically present in the hospital during the day Monday through Friday for this purpose when at all possibility. f. Carry the 888-2162 pager. g. Keep the supervising resident and attending informed of events occurring on the service, consult with staff about possible procedures (epidurals, IUPCs, FSEs, etc. prior to performing them or having them performed), and examine patients after you discuss them with staff first as there may be additional procedures to perform or the staff may want to observe you during the exam. Always have a chaperone present for any exams (breast or pelvic.) i. Note—If you are an M4-Sub Intern, you must have a licensed physician supervising all genital/breast exams and cervical checks done in L and D—no exceptions h. Note that there are upper level residents in the hospital who can help you with some emergency and routine matters. These are the “mole” and/or the “supervisory” resident. The Smith-Berg-Tomich team also provides emergent consulting or surgical services if needed. i. Note that residents do not have admitting or discharging privileges. All admissions and discharges must be approved by the Primary. The primary will also approve all treatment plans and must be consulted on these issues. j. Note that occasionally residents will be called to see patients that they might not be delivering—e.g. other resident’s continuity patients. Please do not put the nurses or patients in the middle of confusing situations. If you are unsure as to what is needed when called by L and D, come in and sort it out in person. If there are negative trends that need attention, these can be sorted out once patient care is ensured. k. There is a computer file on Blackboard that is used to generate a list of the team. The Residents will maintain this 2. Intern and upper level resident weekend duties a. Rounding and notes must be finished by 0730 unless a different time has been discussed with the on service attending physician. All patients on the service will be rounded on by the intern on call for the day or by the resident designated by the service attending. b. When there is an off service upper level resident (HO-2 or HO-2) who is on call on a weekend day, the rounding responsibility will still fall on the intern who is either coming off call or coming on call. (For example, an upper level resident is on call on a Saturday…then, the intern on call Friday night will round Saturday morning and check out to the upper level resident when rounds are completed. On Sunday, the intern coming on call will have rounding responsibility.) c. The weekend shift officially starts at 0730. 3. Weeknight call duties a. Weeknight call begins at 1700. all interns on service and the OB supervisor should meet shortly before 1700 for checkout b. Preferably, the on call intern carries the on call pager (888-2162) during the day. The will allow him to be well informed of the current situation with all patients. c. Any intern who has primarily managed a labor throughout the day is permitted to stay past 1700 to deliver this patient. This allows for continuity of care. Please use good judgment when staying late. The work hour rules are in effect unless a resident chooses to voluntarily waive them. d. On Tuesday and Thursday, the upper level residents on Advanced Pediatrics and Gynecology take OB call. This starts at 1700 with check out from the intern who was carrying the 888-2162 pager that day. It may be difficult for the upper level resident to be physically present at 1700 due to clinic responsibilities. Nevertheless, call does begin at 1700. Call for the upper level resident will end at 0700 at which time check out occurs either in person or on the phone. The upper level resident can stay to deliver patients for continuity of care purposes with attending approval. 4. Other responsibilities a. it should be noted that all call on the FP-OB service is “Home Call”. This means that if there are no actively laboring patients, triage patients, or issues with other patients on the service, then the on call resident does not need to be physically present in the hospital. However, the on call resident should always be ready to come to the hospital within 30 minutes of being called no matter what you are doing. b. Residents are required to see patients in the Red Team clinic at Offutt AFB and at Green Team Clinic at DOC. Residents are absolved of these responsibilities if there are inpatient duties that would give them unique experiences (such as deliveries), but they then are required to contact the attending manning the Red Team or the Green Team Clinic and let them know what’s going on. c. All interns will have continuity clinic once a week for a half day. This should never be during a post call afternoon (if at all possibility). This is an RRC (Residency Review Committee) requirement. This responsibility supersedes all other responsibilities with the exception of a laboring continuity OB patient. d. Resident call schedule is “built” by Dr. Harnisch (Rotation Coordinator) 5. Continuity OB patients a. A “continuity” OB patient is defined as an OB patient followed by a resident or staff physician throughout her pregnancy with the intent of delivering her and providing post partum and newborn care. b. All “continuity” OB’s will be triaged by the FP-OB service. This allows all residents to minimize conflicts with their rotations. Perhaps more importantly, it allows the interns the opportunity to learn. These patients should be staffed with the on service or on call attending physician. The “continuity” resident should be informed of their patient’s hospital course. c. Once a “continuity” OB patient is admitted to the hospital for labor or other complications, the “continuity” resident becomes fully responsible for their patient’s care. The “continuity” resident should come to the hospital promptly after their patient is admitted. (Residents may be permitted to finish their “continuity clinics” or other duties prior to reporting to manage their patient at the discretion of the on call attending.) d. All rounding and discharge responsibilities for the “continuity” OB and her newborn fall on the “continuity” resident. This should be accomplished by 0800 daily. The “continuity” resident should staff their patients with the on service or on call attending physician. 6. Cesarean section patients a. We have four staff physicians currently who perform C-sections—Drs. Finley, Harnisch, Simmons, and King. One of these four staff physicians is almost always on call for “OB back-up.” b. In the event that a patient is being considered for a C-section, the “ob Back up” is contacted. The team will then work together to determine if a C-section is necessary c. If a patient is in fact taken for C-section, a system exists for “c-section” call. HO-4’s and other residents interested in doing c-sections are on this list and take call accordingly. One of the HO-4’s typically will organize this. The on-call resident for c-sections is informed and called when a c- section may be necessary. d. If the patient is a “continuity” OB, then the “continuity” resident’s role in the cesarean will be decided by the cesarean capable physician. If the “continuity” resident would like to be the primary surgeon and the attending physician agrees that he is qualified based on previous experience or other factors, then the “continuity” resident can take primary. e. The resident who is the primary surgeon on the case must dictate an operative note, take primary responsibility for the patient, address all post operative issues, round on the patient daily, do the discharge summary, and make arrangements for follow up. If for some reason the primary resident surgeon cannot do the above, he must make arrangements for a fellow upper level resident to do so. f. In the case of a planned c-section, all the above rules apply. 7. Rural Fellow: the duty of the rural fellow is to supervise the service and teach junior residents. They will participate in rounds on patients each day and attend teaching rounds with the staff physician. They may also help cover Red Team clinics. They carry pager 888-1597 and will coordinate CDs, NST’s, AFIs and other procedures. The fellow has first option on CDs. 8. The “Primary”—conducts morning rounds and teaching while supervising the triage of patients in L and D and the clinics. This attending will attend all deliveries and will serve as a coordinator for women needing NST’s or other procedures. He will also be responsible for the primary training in the nursery in the care of our neonates 9. The OB Consultant is a Cesarean capable physician who can serve as consultant in high risk cases or help to provide operative vaginal delivery capabilities. Please note the OB/GYN department has a physician in house 24/7 who is CD (cesarean delivery) capable. They also have Perinatologists available for consultative management. Any patient admitted to the FM-OB service with isoimmunization, IDDM, severe preeclampsia or Eclampsia, PPROM < 34 weeks, preterm labor unresponsive to one intravenous agent, preterm cervical ripening or preterm induction of labor, or IDDM in pregnancy who are admitted for diabetic control, must be seen by an OB/GYN Charting Admissions: Standard admission forms are available in the chart. Patients may be seen in the hospital for observation for 4 hours before admission orders need to be made. Labor notes: Patients in labor should be seen at least every two hours until delivery. All notes should be dated and timed. Rounding: Rounds are conducted daily with the attending physician at an agreed upon time. All patients should be seen and notes written before rounds. If a patient is a continuity OB for another resident in the program, that resident should see the patient and write the note and the FM-OB should review the note and any labs prior to rounds unless other arrangements have been made with the continuity provider for the FM-OB intern to follow the patient. Dictation: 1) H&P’s need dictated for patients going to C-section. SVD’s do not need a dictated H&P. 2) Short OP notes should be written for all C-sections and an OP note should be dictated. 3) Delivery notes need to be written and dictated for all SVD’s and vacuum or forceps assisted deliveries. 4) Discharge summaries are needed all for patients who have delivered. 5) Circumcision’s need dictated but no note needs to be written. (see attachment) 6) Soap notes should be written on all patients seen in the Red Team clinic. FMC clinic visits should have a written and dictated note. See attachment to this packet for templates for appropriate notes and dictations. Neonatal Circumcision Dictation Template (Work Type 95) PREOOPERATIVE DIAGNOSIS Parental desire for circumcision POSTOPERATIVE DIAGNOSIS Parental desire for circumcision OPERATION Neonatal circumcision STAFF SURGEON ___________________ RESIDENT SURGEON ___________________ ANESTHESIA ____________ block with 1% lidocaine without epinephrine ESTIMATED BLOOD LOSS Minimal. FINDINGS Normal male penis. PROCEDURE Circumcision was done in the normal fashion with a Gomco clamp size _________ COMPLICATIONS None CONDITION Infant stable in newborn nursery PATOLOGY None Dr ____ was present for the entire procedure. Recommended Readings/ Resources 1. ALSO binder 2. Obstetrics: Normal and Problem Pregnancies, Fifth Ed.; Gabbe, Niebyl, Simpson 3. Gynecology and Obstetrics 2006 Edition; Current clinical strategies medical book; Chan 4. Neonatal circumcision: Risks and benefits; Uptodate, Shoemaker 5. AAFP Monographs: FP Essential 292, Pregnancy Care, September 2003; Choby FP Essential 291, Newborn Care, August 2003 Goals To have us state that you are competent to perform a procedure, you must meet certain minimum standards. Some of you will pick things up a little quicker, some a little slower. Just don’t quit and by the end of your 2 or 3 years here you can meet most of these standards for basic OB. The operative vaginal delivery and cesarean deliveries will take more work. Procedure Number of procedures needed to be considered “credentialable” Circumcision 5 (five)—of a single method. 5(five) for each method of circumcision Spontaneous Vaginal Deliveries 25 (twenty five) Operative Vaginal Deliveries 15 (fifteen) Cesareans 25 (twenty five) as the primary surgeon (skin to skin) Colpos 20 EMB’s 3-5 IUD insertions 1-2 Please note that I do realize that our numbers here would make this difficult to get all the way to OVD’s and this is done intentionally. Experience is the key in the world of Obstetrics. I fully believe that if a resident wants to go farther that they should be back with us for a least one extra month of obstetrics and probably more. If you want c/s privileges and/or forceps privileges then you may well have to embark on an extra year of training (or at lease some extra months of training). Presenting All patients should be presented as followed: Age, G/P, race (not continent of origin), cultural background if appropriate (e.g Hsidic Jew), female at # weeks EGA as determined by LMP or US done at # weeks. She presents with c/o of… (describe complaint as per “admit h and p” description (ctx, bleeding etc.) Describe evaluations and interventions. Finally don’t forget your second patient—the baby (Fetus is a Latin word meaning baby). You should describe the baby’s position (breech, cephalic, transverse), estimated fetal weight, and baseline heart rate along with whether the heart rate is reactive or not and any unusual fetal cardiac changes or patterns. An example would follow: Mary Smith is a 24 yo black female G2 P1001 at 29 + 2 weeks by LMP confirmed by a 12 week ultrasound who presents to labor and deliver with a complaint of irregular uterine contractions for 12 hours. Monitoring shows contractions every 4-10 minutes. Sterile speculum exam was done and showed negative nitrazine, fern, and pooling. GC, chlamydia, and group b strep cultures were collected and sent. KOH and wet prep were done and are negative. Cervical exam was done and was long, thick, and closed. Ultrasound exam shows adequate fluid with an AFI of 14, baby in the cephalic position with a posterior placenta, estimated fetal weight is 1200 grams, baseline fetal heart rate is 140 and the heart rate is reactive. Patients must be presented in this logical manner. Use the ultrasound machine in evaluating patients. You should be able to do an AFI, detect FHM, find the placenta, and determine fetal position. Use the ultrasound to verify your Leopold maneuvers. All patients who present, get cervical exams (unless their complaint is not obstetrical or gynecologic; unless they have preterm premature rupture of the membranes; or unless they have placenta previa or other second or third trimester bleeding of uncertain etiology All of your exams must be counterchecked by an experienced nurse or physician (staff or resident Postpartum patients (s/p vaginal delivery) must have six aspects of their care commented on: (1) rH status (and the baby’s status if applicable), (2) rubella status (3) initial and final hemoglobins (4) family planning methods (5) breast or bottle feeding (6) 6 immunizations should be offered or at least patients evaluated for their need—Hep B, DTaP, Varicella, Flu, Pneumococcal, and Rubella—these evals should be documented Post-op patients (s/p cesarean delivery) must have the above six aspects commented on plus the following six subjective items, seven physical exam items, and the four labs/meds: Subjective (1) pain control (pain controlled with what (po, iv, im med, pca, epidural, etc) and how well controlled (2) diet (NPO, clears, regular) (3) bowel function (flatus, bowel sounds, bm) (4) bladder function (void spontaneously, foley, suprapubic catheter) (5) ambulation (6) use of incentive spirometry Physical (1) VS with Tmax (highest temp over past 24 hours) and Tc (current temp) (2) I’s and O’s for patients on mag and certain selected surgical patients (3) Pul (CTA) (4) Cor (RRR with Murmur) (5) Abd (ND, NT, Pos BS) (6) Wound (CDI) (7) Extremities (neg homan’s) Pertinent Labs/Meds (1) Hemoglobins (2) Mag levels (3) Antibiotics (4) Pathology findings Finally, I’ve posted for you below, my rules of medicine and pager numbers and phone numbers. Harnisch 888-0824 Finley 888-0802 Simmons 888-2682 Jarzynka 888-5436 Wheatley 8881243 Babbe 888-2441 Mathews 888-1252 Smith 888-0813 Harrison 888-2962 OB Intern 888-2162 Rural Fellow 888-1597 Tibbels 888-3849 King 888-0829 Steffanie Bowen 294-9242 Red Team Office 294-9423 and 294-1451 Melanie Heyd (Offutt Peds Clinic Nurse) 294-4482 Tracey Biles (Blue Team Nurse) 294-9296 Pediatric Nephrology (Helen Lovell, MD) 20 mg/kg amox for pelviectasis and 6-8 week follow up. Pager is 888-3012. office phone is 559-7344 Dr. Harnisch’s Rules of Medicine 1. Treat others as you would like to be treated and as you would treat a family member 2. There’s more than one way to skin a cat! 3. Never be an interesting medical case! 4. When all else fails listen to the patient. 5. Trust but verify 6. Never say never. Never say always. 7. Never turn your back on a pushing multip. 8. Less is more. 9. Control and support 10. Anyone can take care of the easy patients. 11. It’s the patient’s baggage, let them carry it. 12. There’s no clock in Obstetrics. 13. Avoid the avoidable, because you cannot avoid the unavoidable Appendix A. Using the pager. A. To have a pager ring to another pager, follow these steps: a. Dial the original pager i. E.g. 888-2162 b. As soon as the “voice” answers, dial zero i. E.g. “0” c. Then “enter your access code” (= the last four of the original pager) i. E.g. “2162” d. Then enter “16” e. Then enter “6” f. Then enter the pager number you wish to have the original pager transferred to and follow the number with the “#” symbol. g. Repeat step “f” Appendix B. Obstetrical services. OBSTETRICAL SERVICES AT UNMC The Family Medicine obstetrical service will provide the resident with an obstetrical experience at Nebraska Medical Center. The resident will be responsible for the prenatal work-up, prenatal care, labor and delivery management, and post-partum care of each of their assigned patients. A Family Medicine faculty physician will be on-call for admissions and deliveries. Residents should discuss patients presenting for prenatal care with the faculty staffing their respective clinics. The faculty on-call for the Family Medicine obstetrical service must be notified when any patient presents to Labor and Delivery or when a resident is considering admission of an obstetrical patient. A staff physician must be present for deliveries and will see your patients daily while they are hospitalized. The OB/GYN service will be consulted as necessary for their advice and expertise according to NMC Policy AD-05. All FM OB patients presenting to labor and delivery will be evaluated by the on call FM OB Intern (pager 888-2162) and will be presented to the Family Medicine attending on call and to the patient’s personal family physician. If a resident or staff is on leave, it is their responsibility to arrange cross-coverage for their patients. Family Medicine newborns are the responsibility of the Family Medicine primary/continuity physician. That physician is responsible for the evaluation, admitting orders, H&P, and daily notes. The Family Medicine OB attending staff will examine all FM OB newborns and supervise their daily newborn care. Parents who wish to have their male infants circumcised must sign a circumcision permit after the procedure is explained by the resident. Residents will have supervision by a staff physician on all circumcisions. MILITARY CONTINUITY OBSTETRICS AT EBC The Family Medicine Residency Clinic will provide USAF residents with an obstetrical continuity experience at Ehrling Bergquist Clinic. The resident will be responsible for the prenatal work-up, prenatal care, intrapartum and postpartum management and care of each of their assigned patients. FM staff physicians will be available for precepting all clinic visits and for every delivery and are ultimately responsible for all OB patient care. The resident should discuss all patients presenting for prenatal care with the faculty in the clinic or the staff on-call at night. The FM attending on-call must be notified when any patient presents to Labor and Delivery or when a resident is considering admission of an obstetrical patient. A staff physician will be present for deliveries and will see your patients daily while they are hospitalized. The OB/GYN service will be consulted as necessary for their advice and expertise according to NMC Policy AD-05. OB/GYN AT EBC All residents will complete a minimum of two months of obstetrical care and one month of gynecological training during the Family Medicine residency. The required training for obstetrics will be two months at Nebraska Medical Center, and a one-month rotation at the Nebraska Medical Center or EBC. There are electives in OB/GYN at the NMC, EBC, and at Fort Carson, Colorado Springs, Colorado, for residents requesting additional training. For those wanting to do OB in practice an additional month of OB will be required at one of these elective sites. The elective at Colorado Springs is highly recommended. The OB experience at NMC will involve time spend on the Family Medicine OB service and/or time on the Obstetrical service. The OB experience on the Obstetrical service will focus mainly on low-risk routine prenatal care, though there is exposure to the high risk Maternal Fetal Medicine patients; and routine vaginal deliveries. The Family Medicine OB service experience will focus mainly on low risk prenatal care with some high risk Obstetrical exposure and training on the FM OB service. Routine vaginal deliveries and Assisted Vaginal deliveries are taught and surgical training focused primarily on cesarean delivery experience. An experience sheet (part of the evaluation form) will be filled out on all first-year residents to document their proficiency at various OB skills while in Labor and Delivery, and will abide by the ACGME guidelines for resident work hours. Home-call is to be exercised when there are no patients in labor or in need of antepartum evaluation. All patients needed evaluation on labor and delivery require the presence of the on-call resident to come in for the evaluation. The resident will be responsible for the management and delivery of patients in labor and delivery, management of post-partum patients, and consultations from our various referral clinics. Upper level residents will complete a one month Gynecology rotation at EBC during their Family Medicine residency. This will include one half-day of clinic experience per week at the DOC as well as one evening STD clinic per week at Baker Place. They will have exposure to a broad array of outpatient gynecological problems, with exposure to colposcopy both at EBC and at DOC. All call will abide by the ACGME guidelines for resident work hours. Residents will be allowed to leave their rotational services to attend their private continuity OB deliveries at the NMC after they’ve made arrangements with their rotational attendings. Residents on the OB and GYN rotations will be allowed 2 weekdays and 2 weekend days of vacation per month if they are not covering Home Call for Labor and Delivery during months where there is only one intern on the OB service. Vacation requests must be received at least 2-4 weeks before the beginning of the rotation to be considered. OB SERVICE CALL POLICIES The OB intern call (888-2162) is covered and split equitably amongst the residents assigned to the service with supplementation for night call from residents on services with no night call of their own (e.g. the GYN rotation and the Advanced Pediatrics rotations). Please refer to the OB call rules located on our resident web page. Residents need to come in for all patients seen in triage, though they do have the option of personally contacting the “Mole” or supervisory resident or the patient’s continuity provider to come in for these patient triages. If a patient is in house, in labor, then a resident physician must be in house to care for her. We will be using the home call system to be a learning experience in “telephone medicine”—so each time you are called by the nursing staff you must get an adequate history to relay to the staff on call: for example, the staff will want to know… A concise presentation with— G’s and P’s, EGA VS Complications Lab results Past obstetrical history You will have to call staff on every patient before they leave the hospital. If you suspect an emergency situation (nurses may have already done so) call staff immediately. Also residents taking home call—for OB the standard of care is being able to get to the hospital within 30 minutes—if you live too far away you may need to make other arrangements to stay closer to the hospital. ADVANCED OBSTETRICAL ROTATION/FT CARSON, COLORADO This rotation has been developed to provide clinical training for Family Medicine residents in obstetrics. The specific nature of this rotation is to obtain additional experience in obstetrical deliveries for second and third year residents. Residents will cover the Labor and Delivery area, and, if time permits, the resident may assist the OB/GYN Clinic in seeing patients. This will greatly increase residents’ clinical experience. Residents will be under the supervision of Army OB/GYN physicians for training purposes. Lodging has been obtained for participating residents at 3340 Quail Lake Road, Apt. 114, Colorado Springs, CO 80906, telephone number (719) 579-0671. prior to the resident’s arrival on rotation, copies of the following information must be faxed to Dr. Brian Crisp at Fax # (719) 526-7850: up-to-date NRP, CPR, and ALSO cards. COVERAGE OF CONTINUITY DELIVERIES Continuity in obstetrical care is a practice that is often unique to our specialty. This manner of medical practice recognizes the importance to (1) patient care, (2) the patient- physician relationship, and (3) requirements for resident education. Due to variable resident responsibilities and unavoidable conflicts with call and supervisor responsibilities, the following protocols for Family Medicine continuity OB are provided: 1. The intention of these provisions is to provide residents and patients the maximum reasonable opportunity for contact continuity throughout pregnancy, labor, and delivery. However, this goal must be flexible in the face of conflicting availability, responsibilities, and emergencies. These protocols are not meant to micromanage, nor supersede sound medical judgment, professionalism, or ethical responsibilities. These guidelines are meant to specify agreed-upon responsibilities when resident continuity obstetrical care conflicts with other call schedules. 2. it is recognized that a Primary may not be immediately available for the following reasons: a. in-house call at i. NMC ii. Children’s MH b. Vacation/moonlighting/out-of-town rotations c. Illness d. Not responding to pager 3. When a Family Medicine obstetrical patient (“OB”) comes to the hospital, the resident (“primary”) to who that patient has been assigned through their continuity Family Medicine clinic is responsible for that patient’s evaluation and care. At the Primary’s discretion, the initial evaluation may be taken care of by another resident (“Secondary”), if that resident chooses to extend the courtesy. 4. Residents on call should notify the appropriate rotation supervisors or staff of their patients’ estimated date(s) of confinement in advance if there is a potential of a conflict with call. If the patient is scheduled for induction or cesarean section, arrangements should be made with the rotation supervisors or staff as soon as possible. 5. An intern Primary should ideally coordinate with another resident (Secondary) for OB coverage for dates when the primary will be on call. When an intern (or any house officer taking in-house call in a non-supervisor capacity) Primary’s OB comes in for evaluation/admission while that Primary is on call or in the midst of rotation responsibilities, the Primary must still communicate with Labor and Delivery regarding the status of the patient and immediate orders (monitor, etc.) 6. The on-call civilian Primary’s responsibility is to call the FM OB staff to notify them of their patient and pertinent history. 7. If the patient is subsequently sent home or discharged after a short (<3 hour) period of observation, the on call resident (2162 resident) will document the visit, order any tests, arrange for follow up and notify the Primary of such. 8. If the patient needs to be admitted for observation or for delivery, the participation of the 2162 resident will be to call the Primary in to assume control and management of the patient. Appendix C. Samples of notes 1. Outpatient OB visit a. S) patient without complaint. Positive fetal movement. Denies HA/vis change or edema. (o) See 533 (an USAF form) or See ACOG form (a) IUP at 33 weeks (p) fetal kick counts. Preterm labor precautions and preeclampsia precautions given. 2. Labor progress note a. S) list any patient complaints. Comment on adequacy of pain control and on how it’s being controlled (e.g. “Pain well controlled with epidural”) (o) VSS/A Pit at 10 mIu /min. FHTs 140 and reactive. Cervix is 5/75/+1 (a) term, IUP, AROM’d (p) AMOL (active management of labor) 3. Delivery note (courtesy of UNMC OB/GYN department) a. “On (delivery date, time) this (age, race) female under (epidural, pudendal, local, no anesthesia) delivered a viable (male/female) infant weight ______lbs with APGAR scores of (1-10) and (1-10) at 1 & 5 minutes. Delivery was via (SVD, LTCS, classical CS, vacuum, forceps) to a sterile field. (nuchal cord reduced.) infant was (bulb, wall) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (pediatrician, nurse). (cord blood/pH sent for analysis.)(Intact, fragmented, meconium stain) placental with (2, 3) vessel cord delivered (spontaneously, with manual extraction) at (time). Amount of (IV oxytocin, IM methylergonovine) given. (uterus, cervix, vagina, rectum) explored and (midline episiotomy, #th degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient taken to RR in stable condition. Infant taken to (NBN, NICU) in stable condition. Dr. (name of attending) present for entire delivery. 4. Postpartum notes a. PPD (not post-op)(these are for primarily for vaginal deliveries but may be modified for surgical deliveries) i. Comment on pain control, lochia, breast vs bottle, desiring of circ, tolerating diet, ambulating, urinary and bowel function, contraception desires. (o) VSS/a (T current and T max). heart, lungs, abdomen (fundus at or below umbilicus, and firm, nontender or appropriately tender), incision CDI (clear dry intact), extremities (edema, Homan’s neg/pos) (D/c IVF and IV)(increase ambulation, regular diet)(check H and H—home with Iron supplements if Hb less than 10) (Rh status) (rubella status) (GBS status) (a) ppd # (p)give plan b. Post-op note i. Patient without/with complaint (elaborate). Pain well controlled with (state what’s being used.) tolerating (state type) diet. Ambulating? Voiding? Bowel function? Using incentive spirometry? (o) rubella status, gbs status, rh status. Give vs including t max and t current. List I’s and O’s. Pul. Cor. Abd. Wound. Extremities. Hb. List any other labs (mag level, placental to path, ABG results, culture results). List contraceptive choice/family planning options. (a) POD # (p) saline lock IV. d/c IV. d/c pca. Start percocet. Advance diet. Patient may shower. Encourage ambulation. Encourage IS use. d/c foley 5. Cesarean note (courtesy of “Obstetrics Gynecology and Infertilty, 10th Edition, John David Gordon MD”) a. PREOPERATIVE DX: (1) 40 week IUP (2) failed IOL (3) fetal intolerance of labor. POSTOPERATIVE DX: same PROCEDURE: PLTCD via Pfannensteil SURGEON:----- ASSISTANT:-------- ANESTHESIA:Epidural/intrathecal/GETA COMPLICATIONS:-------- - EBL: 800 cc FLUIDS: 1500 cc crystal UOP: 300 cc clear urine at end of the procedure INDICATIONS: 20 yo G1P0 at 40 weeks, induced for 40 weeks, late decels with oxytocin, maximum dilation 2 cm. FINDINGS: male infant in cephalic presentation. Thick meconium with none below the cords. Pediatrics present at delivery, apgars 6/8, weight 2980 g. normal uterus, tubes, and ovaries. PROCEDURE: The patient was taken to the operating room where epidural anesthesia was found to be adequate. She was the prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt. A pfannensteil skin incision was then made with the scalpel and carried through to the underlying layer of fascia with the bovie. The fascia was incised in the midline and the incision extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then grasped with the Kocher clamps, elevated, and the underlying rectus muscles dissected off bluntly. Attention was then turned to the interior aspect of this incision which, in a similar fashion, was grasped, tented up with the Kocher clamps, and the rectus muscle dissected off bluntly. The rectus muscles were then separated in the midline, and the peritoneum identified, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the vesicouterine peritoneum identified, grasped with the pick-ups and entered sharply with the Metzenbaum scissors. This incision was then extended laterally and the bladder flap created digitally. The bladder blade was then reinserted and the lower uterine segment incised in a transverse fashion with the scalpel. The uterine incision was then extended laterally with the bandage scissors. The bladder blade was removed and the infant’s head delivered atraumatically. The nose and mouth were suctioned with the DeLee suction trap, and the cord clamped and cut. The infant was handed off to the waiting pediatricians. Cord gases were sent. The placenta was then removed manually, the uterus exteriorized, and cleared of all clots and debris. The uterine incision was repaired with 1-0 chromic in a running, locked fashion. A second layer of the same suture was used to obtain excellent hemostasis. The bladder flap was repaired with 3-0 vicryl in a running stitch and uterus returned to the abdomen. The gutters were cleared of all clots, and the peritoneum closed with 3-0 vicryl. The fascia was reapproximated with ) vicryl in a running fashion. The skin was closed with staples. The patient tolerated the procedure well. Sponge, lap and needle counts were correct times two. 2 grams of Cefotetan was given at cord clamp. The patient was taken to the recovery room in stable condition.
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