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					                    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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